Case Report
A 56-year-old woman, without previous systemic disease, visited our
out-patient department for worsening shortness of breath for two months.
A grade II/VI systolic murmur was noted over the 2nd left parasternal
border. Jugular vein engorgement was also noted. Transthoracic
echocardiogram showed a huge mobile tumor in the right ventricle,
originating from the TV and extending into the pulmonary trunk. The
tumor stalk, about 12 mm in diameter, was connected to the anterior
tricuspid leaflet and its chordae tendineae. The tumor occupied the
right ventricular outflow tract and nearly obstructed the pulmonary
valve. The estimated tumor volume based on computed tomography (CT) scan
was 69.36 cm3, with a maximum diameter of 41 mm
(Figure 1). An urgent operation was conducted for unstable hemodynamic
status.
The operation was performed using a totally endoscopic, robot-assisted
approach. After the induction of general anesthesia, the patient was
intubated smoothly. A central venous catheter and 6.5-Fr introducer
sheath were placed into the right internal jugular vein. A 2-cm oblique
right groin incision was made for peripheral cannulation. After systemic
heparinization, the patient’s femoral artery was cannulated (19 Fr) for
systemic retrograde perfusion. Adjunctive distal femoral perfusion was
done using an 8-Fr arterial cannula (Medtronic, Minneapolis, MN).
Bicaval venous drainage was initiated through the right internal jugular
vein (17 Fr) and femoral vein (23 Fr). Cardiopulmonary bypass was
established. A camera port (7 mm) was introduced into the fourth
intercostal space (ICS) at the right midclavicular line. The left and
right robot arm ports (7 mm) were placed in the second ICS at the
midclavicular line and sixth ICS at the anterior axillary line. The
assisting port (7 mm) was placed in the fourth ICS at the right
parasternal border. The Da Vinci Xi surgical system (Intuitive Surgical,
Inc, Sunnyvale, CA) cart was docked. A 11.5-mm endoscopic trocar port
(ThoracoportTM, Medtronic, Minneapolis, MN) was placed
at the right fourth ICS. A transthoracic Chitwood cross-clamp (Scanlan
International, Minneapolis, MN) was placed at the right fourth ICS at
the mid-axillary line. A cardioplegia delivery pig-tail catheter was
inserted through the second ICS at the right parasternal border directly
into the ascending aorta. Right pericardiotomy was done. After aortic
cross-clamping, myocardial protection was achieved using antegrade cold
crystalloid cardioplegia with histidine-tryptophan-ketoglutarate
solution (30 cc/kg; Custodiol HTK; Köhler Chemie GmbH, Bensheim,
Germany). The heart was decompressed by bi-caval snare. Right atriotomy
was done. Atrial retractor was applied through the assisting port, and
the TV was exposed.
When exploring the tumor, the anterior leaflet of the TV was incised
perpendicularly in the midline. The tumor stalk, about 12 mm in
diameter, connects the ventricular side of the anterior leaflet and
associated papillary muscle. Hence, the tumor was excised en-bloc with
the associated leaflet and papillary muscle tip. It was placed in a
wired endo bag (UNIMAX, Taipei, Taiwan (R.O.C.)) inserted from the
working port. Then, the tumor was cut into pieces by the morcellator and
sucked out without debris sputtering (Figure 2)(Supplemental material).
The anterior leaflet was repaired with CV-5 sutures. One CV-5 artificial
cord was applied between the residual papillary muscle and corresponding
leaflet edge. A 28-mm annuloplasty ring (MC3, Edwards Lifescience,
Irvine, CA) was applied with 10 sets of Cor-knots (LSI SOLUTIONS,
Victor, NY) fixation (Figure 3). Normal sinus rhythm resumed after
aortic clamp off. The patient weaned off bypass without inotropes. The
aortic clamping time was 121 min, and the total cardiopulmonary bypass
time was 175 min.
Extubation was done two hours after the surgery. The patient was
transferred to the general ward on the next day and was discharged
uneventfully on the fourth postoperative day.