Combined robot-assisted mitral valve plasty and Nuss procedure via small ports

Surgical strategies for mitral valve diseases associated with pectus excavatum: a narrative review of approaches and outcomes

OBJECTIVES

To develop a decision-making framework for the surgical management of coexisting mitral valve (MV) prolapse and pectus excavatum, addressing the challenges posed by anatomical complexity and functional compromise.

METHODS

A narrative review of reported cases involving coexisting MV prolapse and pectus excavatum was conducted. Each case was analysed to evaluate the characteristics, personalized surgical strategies and operational details, with a focus on the associated benefits and risks. Additionally, surgical strategies were classified, and process management approaches were explored to guide treatment planning.

RESULTS

The management of coexisting MV prolapse and pectus excavatum was categorized into three tailored approaches: (i) isolated chest wall reconstruction for cardiac decompression in patients with preserved valvular function; (ii) standalone MV repair or replacement for severe regurgitation with mild-to-moderate skeletal deformity (Haller index <3.5) and (iii) single-stage combined procedures for complex presentations (Haller index ≥3.5). A framework for personalized treatment pathways was proposed, incorporating factors such as deformity severity, surgical history and haemodynamic status to optimize approach selection.

CONCLUSIONS

The integration of innovative surgical techniques and minimally invasive approaches offers the potential for safe and effective outcomes. A personalized, anatomically stratified approach is essential for optimizing treatment strategies in patients with this complex comorbidity.

Sternal lifting technique for patients with sternal depression during robotic mitral repair

INTRODUCTION

Traditional surgical methods have been difficult for patients with chest wall deformities, but the use of the Electrical Sternum Lifting System (ESLS) has made the surgery easier.

MATERIALS AND SURGICAL TECHNIQUE

Patients with a sternum-to-vertebral distance of less than 80 mm on preoperative computed tomography (CT) scan routinely underwent sternal lift using the ESLS. The ESLS was effective in securing the operative field while suspending the sternum, allowing adequate observation of the left atrium, left ventricle, and the mitral valve, and safe mitral valve plasty. The use of the lifting device did not interfere with the robot arms, and the space between the sternum and vertebrae was widened with only a 3 mm wound to move the mitral valve surface in the sagittal plane, making the repair easy and accurate under robotic assistance. The effort to attach the ESLS was not difficult, and the postoperative cosmetic outcomes were excellent. Sixty-three out of 1002 patients (6.3%) underwent sternal elevation using ESLS. There were 19 males and 44 females with a mean age of 50.9 ± 14.0 years. The average of sternum-to-vertebral (S/V) distance was 72.4 ± 8.9 cm. Two patients had S/V distance of more than 80 mm but ESLS was used because of scoliosis.

Combined minimally invasive repair of pectus excavatum and robotically assisted mitral valve repair: A case report and considerations

INTRODUCTION

Severe pectus excavatum (PE) is considered a relative contraindication to robotic cardiac surgery and information is lacking on surgical solutions to allow for a robotic approach in this setting.

OBJECTIVE

We present a case of concomitant minimally invasive treatment of severe PE with initial pectus correction with Nuss bar insertion followed by robotically assisted mitral valve repair.

METHODS

A multidisciplinary team planned and executed the operation. Thoracoscopic assessment at the onset of the case demonstrated mediastinal exposure was inadequate for robotic repar without PE correction. Forced sternal elevation demonstrated sternal laxity sufficient to provide adequate exposure. Nuss bars were placed and robotic repair proceeded uneventfully.

RESULTS

The patient underwent successful concomitant minimally invasive PE and robotically assisted mitral repair.

CONCLUSION

Successful combined minimally invasive pectus repair and robotic mitral valve can be achieved if sufficient chest wall laxity is present on forced sternal elevation and access sites are planned properly in a multidisciplinary approach.