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In this chapter we describe indications, robot-assisted set-up, and approach for performing a leaflet edge-to-edge mitral valve repair. Although this method is not our primary repair technique, it has simplified robot-assisted repairs in patients with complex bileaflet disease and others with significant comorbidities.

Idiopatic hypertrophic subaortic stenosis (IHSS) is a type of obstructive cardiomyopathy that causes aortic outflow tract obstruction during systole. Moreover, the anterior leaflet can be shifted toward the hypertrophied septum creating, more outflow obstruction and concomitant mitral insufficiency. Traditional IHSS has been treated surgically through the aortic valve. In this chapter, we describe a robotic trans-atrial left approach to perform a large septal myectomy with concomitant mobilization of anterior papillary muscle and mitral valve reconstruction. Robotic methods provide ideal septal and valve exposure as well as superior visualization and ergonomic access.

Cardiac tumors occur rarely, however, can cause devastating complications including stroke, syncope, myocardial infarction, and cardiac dysfunction. These tumors should be removed surgically to prevent the above complications. Traditionally, these have been extirpated through a sternotomy approach. This chapter describes robotic minimally invasive methods for removing cardiac myxomas and fibroelastomas. Because of safety and patient comfort, the robotic approach has become surgical therapy for cardiac tumors at our institution.

In this chapter we detail the approaches used at both of our institutions to perform robotic mitral valve replacements. Herein, we describe the robotic setup as well as associated complexities of mitral valve replacement using the da Vinci™ robotic surgical system. Outcomes have been excellent and are described in this chapter.

In this chapter we detail systematic approaches to performing robotic mitral valve repairs. Particular attention is given to techniques for repairing both simple and complex anterior and posterior leaflet pathology. Herein, we describe the robotic setup as well as instruments and new suturing techniques used in performing robotic mitral valve repairs.

The development of a successful robotic cardiac surgical program requires both a close association and synergy between many hospital personnel. The thought often is that the major components include only the lead surgeon and operating room staff. However, cooperation among many other individuals is essential for ideal program development. Other programmatic considerations relate to economic commitments, clinical synergy, and cardiology support as well as the firm belief that robotic surgery is advantageous to patients. This chapter describes a step-wise approach for beginning a vibrant and safe robotic cardiac surgical program. Herein, serial guidelines are suggested as these strategies have been shown to be effective for success for many programs. The importance of team synergy and group training cannot be over emphasized prior to deploying a robotic surgical program.

Mitral valve annular calcium presents a significant problem when performing a repair. Extensive calcium, that circumscribes the entire annulus or invades either the ventricle or leaflet surfaces, precludes minimally invasive or robotic repair strategies, and a sternotomy should be used for extensive debridement to promote safety and efficacy. Nevertheless, isolated islets of calcium often are encountered when repairing degenerative mitral valves and in this situation robotic techniques can be used for annular debridement and reconstruction. This chapter describes robotic methods to repair mitral valves in the presence of limited leaflet or annular calcium.

The Cox-Maze III operation is the gold standard in the treatment of atrial fibrillation. With the advent of different energy sources (radiofrequency, microwave, and cryothermy) and less invasive approaches (i.e. minimally invasive access and different lesion sets) have been tried at different centers with lesser rates of sinus rhythm restoration when compared to the Cox-Maze III. At our institution we have attempted to reproduce the Cox-Maze III without sacrificing the lesion set while combining the robot assisted minimal access techniques with early results similar to the Cox-Maze III procedure.

Surgeons performing robotic assisted cardiac surgery must master different cannulation strategies as well as different techniques to assure proper cardiac arrest and myocardial protection. In this chapter, we will review the current available cannulation and perfusion techniques as well as their pitfalls.