<div>Echocardiography: Images</div><div>Successful robotic mitral valve plasty for isolated clefts of both
anterior and posterior mitral valve leaflets</div><div>Running title: Robotic MV plasty for isolated clefts of MV</div><div>Norihiko Ishikawa1, Go Watanabe1, Kazuto Miyata2, Sayaka Shigematsu2,
Takafumi Horikawa1, Ryuta Seguchi1, Ryuta Kiuchi1, Shigeyuki Tomita1,
Toshiya Ohtsuka1</div><ol><li>NewHeart Watanabe Institute, Department of Cardiovascular Surgery</li><li>NewHeart Watanabe Institute, Department of Anesthesia</li></ol><div>Corresponding author</div><div>Norihiko Ishikawa, MD PhD</div><div>NewHeart Watanabe Institute</div><div>3-19-11 Hamadayama, Suginami, Tokyo 168-0065, Japan</div><div>Tel: +81-33311-1119, Fax: +81-33311-3119</div><div>E-mail: iskwnrhk@gmail.com</div><div>Keywords: robot, mitral valve, cleft, minimally invasive, mitral
regurgitation</div><div>Abstract</div><div>Double clefts of both the anterior and posterior leaflets are extremely
rare. A 21-year-old female with mitral valve regurgitation was admitted
to our institute, and real-time three-dimensional transesophageal
echocardiography revealed a cleft in the posterior mitral valve leaflet
and an additional partial cleft in the anterior leaflet.
Totally-endoscopic mitral valve plasty using surgical robot with direct
suturing of both clefts, and annuloplasty were performed successfully.
This is the first report of robotic totally-endoscopic mitral valve
plasty for mitral regurgitation due to double clefts of the anterior and
posterior mitral valve.</div><div>A 21-year-old female patient with a history of mitral valve
regurgitation was admitted to our institute for surgery. She was being
followed up at another hospital with a diagnosis of functional mitral
regurgitation (MR) following detection of a heart murmur when she was in
kindergarten.</div><div>Her functional capacity was NYHA class II. She was in sinus rhythm with
a ventricular rate of 67 bpm. Transthoracic echocardiography revealed
dilatation of left heart chambers with a left ventricular ejection
fraction of 54%, along with severe mitral regurgitation. Real-time
three-dimensional transesophageal echocardiography (3D-TEE) revealed a
cleft in the posterior mitral valve leaflet and an additional partial
cleft in the anterior leaflet (Figure 1). After confirming the
echocardiographic findings, we decided to perform robot-assisted
minimally-invasive surgery.</div><div>Totally-endoscopic mitral valve plasty using the da Vinci surgical
system (Intuitive Surgical, Inc., Sunnyvale, CA) with direct suturing of
both the anterior and posterior clefts using expanded
polytetrafluoroethylene sutures, and annuloplasty with a 29-mm
annuloplasty band were performed (Figure 2). Operative time,
cardiopulmonary bypass time and cross-clamp times were 225, 156 and 56
minutes, respectively. No blood transfusions were required and her
postoperative course was uneventful.</div><div>Comment</div><div>To our knowledge, this is the first report of robotic totally-endoscopic
mitral valve plasty for severe mitral regurgitation due to double clefts
of the anterior and posterior mitral valve.</div><div>Not only are clefts of the posterior leaflet rarely reported, but double
clefts of both the anterior and posterior leaflets are extremely rare
and only a few such cases have been described so far<sup>1</sup>.
The mechanism of development of congenital mitral valve clefts is not
fully understood<sup>2</sup>, although it might be related to
abnormal embryological development of endocardial cushion tissue.</div><div>Pre-operative 3D-TEE was very useful in identifying the clefts in the
anterior and posterior mitral valve leaflets as an additional anatomic
lesion, and was essential for planning the surgical procedure.</div><div>Surgical treatment options for mitral valve clefts with severe MR range
from plasty to replacement<sup>2</sup>. Usually, direct suturing
of the isolated cleft is preferred over mitral valve
reconstruction<sup>3</sup>. However, if direct suturing is not
feasible, mitral valve repair is preferable to valve replacement in
adults. In our case, we opted for simple direct closure of both clefts
with annuloplasty via small ports using a surgical robot.</div><div>References</div><div>1. Mohammadi S, Bergeron S, Voisine P, et al. Mitral valve  cleft in
both anterior and posterior leaflet: an extremely rare anomaly. Ann
Thoracic Surg. 2006;82:2287-2289.</div><div>2. Du X, Hung C, Wan Z. Successful mitral valve repair for severe mitral
regurgitation caused by isolated cleft of the posterior leaflet. Int J
Cardiol. 2011;150:48-49.</div><div>3. Perier P, Clausnizer B. Isolated cleft mitral valve: valve
reconstruction techniques. Ann Thorac Surg. 1995; 59: 56-59.</div><div>Figure legends</div><div>Figure 1. Real-time three-dimensional transesophageal echocardiography
image showing clefts in both the anterior and posterior mitral valve
leaflets</div><div>Figure 2. Intraoperative view of the mitral valve from the left atrium</div><div>A: Clefts of the anterior mitral leaflet (white arrow) and the posterior
mitral leaflet (black arrow) are visible.</div><div>B: Robotic direct closure of the posterior cleft was performed.</div><div>C: Robotic direct closure of the anterior cleft was performed.</div><div>D: Annuloplasty was performed using an annuloplasty band.</div>