Robot -Assisted Mitral Valve Repair via Right Mini-Thoracotomy in a Patient with a History of Cardiac Surgery via Median Sternotomy: A Case Report and Technical Considerations

The human heart is a resilient organ, but when it requires a second operation, the path to fixing it becomes fraught with danger. For decades, the standard way to reach the heart for surgery has been to cut through the breastbone, a method known as a median sternotomy. While effective, this approach leaves behind a landscape of internal scar tissue, or adhesions, that can fuse the heart to the chest wall. When a patient needs a third surgery, or even a second one after a long gap, reopening that breastbone carries a terrifying risk: the surgeon might accidentally tear the heart or major blood vessels while trying to peel them away from the old scars. This reality has forced doctors to look for other ways in, specifically through the side of the chest, avoiding the breastbone entirely. The challenge, however, is that working through a small opening on the side is incredibly difficult for the human eye and hand, requiring a level of precision that traditional tools struggle to achieve in such a cramped, scarred environment.

A team of surgeons at Osaka Metropolitan University recently demonstrated that a high-tech solution can navigate this treacherous terrain. They successfully repaired the heart valves of a seventy-five-year-old woman who had undergone a heart surgery thirty years prior. The patient had developed heart failure because her heart valves were leaking, a condition caused by the stretching of the rings that hold the valves in place. Because her previous surgery had been done through the breastbone, the team knew that cutting through that bone again would be hazardous. Instead, they turned to a robotic system, the da Vinci Xi, to perform the repair through a small incision on the right side of her chest. This approach allowed them to bypass the dangerous scar tissue entirely, reaching the heart from a fresh angle where the anatomy was clear and safe.

The procedure began with careful planning. Before the surgery, the medical team used advanced imaging to map the patient's chest, ensuring that the blood vessels in her legs and neck were healthy enough to serve as entry points for the machines that would circulate her blood while her heart rested. Once the patient was under anesthesia, the surgeons inserted tubes into her neck and groin to connect her to a heart-lung machine. This machine took over the job of pumping blood and delivering oxygen, allowing the heart to stop beating so the surgeons could work on it. The robotic system was then set up through a five-centimeter cut between the ribs on the right side of her chest. Three robotic arms, equipped with tiny cameras and surgical tools, were inserted to give the surgeon a magnified, three-dimensional view of the inside of the heart and the freedom to move with extreme delicacy.

Inside the chest, the surgeons faced the expected challenge of scar tissue from the operation thirty years earlier. Using the robotic arms, they carefully peeled away just enough of the adhesions to expose the ascending aorta, the large artery that carries blood out of the heart. This was a critical step; the robotic system provided a clarity of vision that made it possible to separate the heart from the chest wall without causing damage. Once the area was clear, they clamped the aorta and delivered a cold solution to stop the heart and protect the muscle. The surgeons then opened the left side of the heart to inspect the mitral valve and the right side to check the tricuspid valve. Both were leaking because the rings holding them had stretched, but the flaps of the valves themselves were intact.

The repair involved tightening these rings to stop the leaks. The surgeons placed a new, artificial ring around the mitral valve and another around the tricuspid valve, sewing them into place with fine sutures. They also closed a small pouch on the left side of the heart called the left atrial appendage, a common step to prevent blood clots in patients with irregular heartbeats. Throughout the operation, the patient's body temperature was kept cool at thirty degrees Celsius to protect her lungs and brain. The entire process took just under five hours, with the heart being stopped for ninety minutes. The amount of blood lost was minimal, and the surgeons were able to confirm immediately that the valves were working correctly, with only tiny, insignificant leaks remaining.

After the surgery, the patient recovered quickly. She was taken off the breathing machine within fifteen hours and spent two days in the intensive care unit. By the time she was discharged fifteen days later, her heart function had improved significantly, and the leaks in her valves were no longer a concern. This case shows that for carefully selected patients, using a robot to repair heart valves through the side of the chest is a safe and viable option, even when they have had heart surgery before. The success of the operation relied on three key factors: detailed imaging before the surgery to ensure the approach was safe, the ability of the robot to see and work around old scar tissue with minimal disturbance, and a careful strategy to protect the heart and lungs during the procedure. While this approach is not suitable for every patient, it offers a powerful alternative to the risks associated with reopening a previous breastbone incision, proving that technology can help surgeons navigate the most complex of medical histories.