robotic surgery on aortic heart valves?

Question

information of techniques

Answer 1

Minimally Invasive and Robotic Surgery
Robotic Mitral Valve Repair
Maze Surgical Atrial Fibrillation Ablation
Laser Removal of Pacer Wires

Thanks to minimally invasive procedures perfected here at the Cardiovascular Center, heart surgery doesn’t have to be as disruptive or painful as it once was. In traditional heart surgery, surgeons make full chest incisions, which involves cutting through muscle and bone tissue, to gain access to the heart.



Minimally invasive heart surgery is performed through a small incision. The incision is only about 3 inches instead of the 6 to 8 inches required for traditional heart surgery. The result is including less pain after surgery, dramatically reduced recovery time and a shorter hospital stay. The surgeons at the Cardiovascular Center are national leaders in robotic and minimally invasive cardiac surgery.



Cardiovascular Center surgeons use minimally invasive procedures, including robotic-assisted surgery, whenever it is appropriate to the patient's diagnosis and condition. Minimally invasive procedures offered here include mitral valve repair and replacement, maze atrial fibrillation ablation, aortic valve repair/replacement and coronary artery bypass surgery.

The other colleague has also answered nicely benefits from both these topics.

Answer 2

I do not know any robotic surgery techniques on aortic heart valves



Aortic valve repair

In the past few years, aortic valve repair has become an option for patients with bicuspid aortic valve disease and other conditions of the aortic valve. Aortic valve repair is performed less often and is more technically difficult than mitral valve repair; however, the majority (2/3), of leaky bicuspid aortic valves can be repaired with good results.


Advantages: The heart's natural anatomy is preserved and patients do not need to take any blood thinner medications.
Drawbacks: The surgery is technically difficult. This procedure is not an option for stenotic valves - only leaky aortic valves. Although a repaired valve can possibly last a lifetime, about 20 to 25 percent of patients will require a valve replacement within ten years. In the best case scenario, the repaired aortic valve would behave like the original well-functioning bicuspid valve.

Aortic valve replacement

In 2002, there were 1,007 aortic valve replacements at The Cleveland Clinic Foundation, with bioprosthetic valves accounting for 74%, homografts 10%, mechanical valves 9%, and Ross Procedures 1%.

From 1990 to 2000, the choice of valve replacements indicated by the Society of Thoracic Surgery (STS) Registry for patients less than age 60 years with aortic valve disease was: mechanical valve in 77% of patients, bioprosthetic valves in 13%, homograft valves in 5%, and Ross procedure in 5%.

In 2002, despite the increased complexity of cases and rate of re-operations, the overall operative mortality (rate of death as a result of surgery) for valve procedures was 2.1%, far below the reported national average. Primary valve (excluding reoperations) mortality was 1.9%. The majority of young patients with aortic valve disease have a lower risk than the average risks cited here.

Mechanical Valve Replacement
mechanical valve

Mechanical valves are made totally of mechanical parts, which are non-reactive and tolerated well by the body. The bileaflet valve is used most often. It consists of two pyrolite (qualities similar to a diamond) carbon leaflets in a ring covered with polyester knit fabric.

Advantages: Mechanical valves are very sturdy. They are designed to last a lifetime. Re-operations for mechanical failures or tissue in-growth are uncommon.

Drawbacks: Due to the artificial material involved, patients who receive these valves will need to take a blood-thinner (anticoagulant) medication for the rest of their lives. Blood thinners are medications (such as warfarin or Coumadin) that delay the clotting action of the blood. They help prevent clots from forming on the valve prosthesis; such clots can cause a heart attack or stroke and disturb the valve function.

Bioprosthetic valve replacement
bioprosthesisBiological valves (also called tissue or biological valves) are made of tissue, but they may also have some artificial parts to provide additional support and allow the valve to be sewn in place. Biological valves can be made from pig tissue (porcine), cow tissue pericardial (bovine), or pericardial tissue from other species.

Advantages: In comparison to the mechanical valve, the bioprosthetic valve does not require patients to take blood thinners, unless they have other conditions (such as atrial fibrillation) that require these medications.

Drawbacks: Studies on the PERIMOUNT pericardial valve show that in a 40 year old patient, these valves have a 50 percent chance of lasting 15 years or longer, without decline in function. In younger patients, these valves will not last as long, but still last longer than previous generations of bioprostheses. In older patients they will last longer. Durability of present generation pericardial valves and homografts are very similar Click here to learn more.

Homograft (also called allograft) valve replacement
homograftA homograft is an aortic or pulmonic valve that has been removed from a donated human heart, preserved, antibiotic-treated, and frozen under sterile conditions.

Advantages: Homografts are ideal valves for aortic valve replacement, especially when the aortic root is diseased or endocarditis (infection) is present. Homograft is the best and safest option for patients with severe infections causing aortic valve and root destruction and abscesses. This is particularly true if the infected valve is a prosthetic valve. The heart's natural anatomy is preserved or restored, and patients do not need to take any blood-thinner medications after surgery.
Drawbacks: The availability of homografts can be a drawback. In addition, this type of surgery is technically difficult. Homograft valves are expected to last about 15 to 20 years. Like bioprosthetic valves, homografts are not as durable in younger patients.

Ross Procedure (also called Switch Procedure)

The Ross operation is usually performed on patients younger than ages 40 to 50 who want to avoid taking the blood-thinning medication, Coumadin, after surgery. During this procedure, the patient's normal pulmonary valve is removed and used to replace the diseased aortic valve. The pulmonary valve is then replaced with a pulmonary homograft. The immediate success rate in the operating room is very good, which means that most of the patients intended to have a Ross operation do leave the operating room with a successfully completed Ross operation and well-functioning valves.

The Ross operation is not performed when operative findings contraindicate the procedure, or when the pulmonary valve does not appear normal on the echocardiogram or on inspection. The procedure may also be abandoned when any other technical issues are present.

In 2002, 5 Ross procedures were done by Dr. Gosta Pettersson. The mean age of the patient was 33 and the patients ranged in age from 26 to 44. All patients survived the procedure and valve function was restored.
The Ross Procedure

Step 1: Measurement of the aortic and pulmonic valves Step 2: The aorta and pulmonary artery are opened and the aortic and pulmonary valves are carefully inspected to determine if the Ross is an appropriate procedure.

Step 3: The diseased aortic valve is removed. Then, the pulmonary valve (autograft) is removed and placed in the aortic position. Step 4: The autograft in sutured in place and the coronary arteries are re-attached.

Step 5: A pulmonary homograft is attached to the right ventricle outflow tract. Step 6: The aorta is attached to the autograft and the pulmonary artery is attached to the homograft - the procedure is complete.

Advantages: The pulmonic valve is anatomically very similar to the aortic valve and could be an ideal substitute for the aortic valve. The new aortic autograft is a living valve and it will grow as the child or adolescent grows, making this a good option for young patients. The blood flows with less pressure through the pulmonary valve than the aortic valve, therefore a homograft valve could last longer in the right-sided pulmonary valve position. The risk of thromboembolic complications (blood clots, stroke) and the risk of valve infection is very low, lower than for any alternative valve prosthesis. The hemodynamic performance makes the Ross operation an attractive alternative for athletes. The pulmonary autograft valve has a good chance of being a life-lasting solution for the aortic valve. Our qualified guess is that this is going to be the case in 50% of Ross procedure patients.

Drawbacks: The Ross procedure is a technically difficult and long surgery, as it requires two valve replacements. Therefore, this procedure is only recommended for young patients who would tolerate a long surgery time. The pulmonary autograft valve is transplanted from the low pressure pulmonary circulation over to the aortic high pressure system. The valve cusps are strong enough to withstand the systemic pressure, but the pulmonary artery wall does dilate when exposed to systemic pressure, occasionally enough to cause the autograft valve to leak. The risk of requiring re-operation for a leaking autograft valve is about 10 percent within 10 years after the operation. The Ross procedure is not recommended for patients with tissue defects (such as Marfan syndrome) or for patients who have an abnormal pulmonary valve. The pulmonary homograft in the pulmonary position could also fail; the most common mode of failure is that it becomes stenotic. The risk of requiring replacement of the pulmonary homograft is about 10 percent 10 years after the procedure.

The Ross procedure should only be performed by very skilled and experienced surgeons, particularly interested in the operation.

Who makes the final decision?

Choosing the best surgery for you requires a frank and open conversation with your physician regarding your own personal risks and benefits for each surgical option. Then, you and your cardiologist should choose the best surgeon to perform the operation. The surgeon should have experience in performing the procedure and good surgical outcomes. The final decision is made by the surgeon, and this may not occur until the surgery itself, when the surgeon is able to view the diseased valve.

A note about minimally invasive aortic valve surgery.....

Minimally invasive surgery allows surgeons to perform aortic valve surgery with smaller incisions. In 2002, about 65 percent of aortic valve surgeries at The Cleveland Clinic were performed with minimally invasive techniques. Click here to learn about minimally invasive valve surgery.