Robotic Mitral Valve Surgery with Intracardiac Ultrasound Guided Septal Myectomy.

Abstract Hypertrophic obstructive cardiomyopathy requires surgical myectomy when heart failure symptoms persist despite best medical therapy. Minimally invasively myectomy with robotic surgery can be performed in experienced centers allowing for surgical correction of accompanying mitral valve pathologies. The extent of myectomy is important to relieve left ventricular outflow tract obstruction while care should be taken to prevent iatrogenic ventricular septal defects or heart blocks caused by excessive removal of septal tissue. We report the use of intracardiac ultrasound during robotic surgery to intraoperatively assess the myocardium before and after myectomy to increase the safety of this procedure. Hypertrophic obstructive cardiomyopathy (HOCM) is a genetic myocardial disease characterized by thickened myocardium and obstruction of the left ventricular outflow tract (LVOT). 1 Patients with symptoms of heart failure resistant to drug treatment are candidates for surgical septal myectomy. Conventionally performed through a midline sternotomy, septal myectomy can be carried out via transapical, transaortic, or transmitral approaches. The transmitral approach allows surgical treatment of the concomitant mitral valve pathology through a left atriotomy. Robotic septal myectomy can be performed in experienced centers with results comparable to the classical sternotomy approach with the added benefits of minimally invasive surgery. 2 Excessive removal of septal tissue can result in a heart block or a ventricular septal defect while an inadequate myectomy can leave a high gradient in the LVOT. Intracardiac ultrasound can assist the surgeon in performing a safe and adequate myectomy. We describe our technique for intracardiac ultrasound guided robotic septal myectomy in a patient with HOCM and infective endocarditis.