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.