Complex robotic correction for complex degenerative mitral valve disease.

The gold standard treatment of degenerative mitral valve disease remains surgical repair. The classic repair described by Dr. Carpentier (1) with leaflet resection and annuloplasty remains the primary technique for mitral repair. Other techniques such as the “American correction” (2) or artificial chordae have been introduced with similar success rates. Innovations in surgical approach over the past 20 years have led to the development of minimally invasive access to the mitral valve. Fifteen years ago, Dr. Chitwood pioneered the use of the da Vinci Robotic Surgical System (Intuitive Surgical, Inc., Sunny Vale, California, USA) for mitral valve repair (3,4). His excellent outcomes and those of others led to an increased utilization of the robotic approach to the mitral valve (1-10). Robotic correction of mitral regurgitation was initially limited to less complex mitral valve pathologies. However, with improvement in technologies and experience, complex repair of degenerative mitral regurgitation is possible. A 44-year-old gentleman was referred with asymptomatic severe mitral regurgitation. His past medical history was unremarkable except for osteoarthritis of the hip. Physical examination was normal except for a grade V holosystolic murmur in the left fifth intercostal space (ICS) radiating to the axilla. Transthoracic echocardiography (TTE) demonstrated severe mitral regurgitation, severe bileaflet prolapse, predominantly involving the posterior leaflet with flail of the anterior leaflet and evidence of ruptured chordae. Left and right ventricular function were normal. The rest of the cardiac work-up was normal, demonstrating no coronary artery disease and absence of peripheral vascular disease. Surgical techniques