Anesthetic considerations in robotic mitral valve surgery

Abstract

The robotic approach to cardiac surgery offers patients numerous potential advantages compared with a traditional sternotomy approach including shorter hospital length of stay, reduced pain, fewer blood transfusions, and a quicker return to normal daily activities. At the same time, robotic cardiac surgery requires that the anesthesiologist employs several subspecialty skillsets in order to provide optimal care for these patients. Multiple different regional anesthesia techniques may be used to improve analgesia, reduce opioid dosages, and facilitate rapid extubation at the conclusion of the case. Several peripheral cannulation strategies for cardiopulmonary bypass (CPB) exist and the anesthesia team may assist with percutaneous cannulation of the superior vena cava (SVC) or positioning of an endo-pulmonary vent. Similarly the anesthesiologist may be asked to percutaneously cannulate the coronary sinus for retrograde cardioplegia delivery. The need for one-lung ventilation (OLV) and heavy reliance on transesophageal echocardiography (TEE) occupy much of the anesthesiologist's attention during these cases. Variations in institutional practice exist. Reviews of current practice and future studies may help refine the anesthetic approach to robot-assisted cardiac surgery.

Transversus Thoracis Muscle Plane Block

“…A number of analgesic approaches have been used in robotic-assisted mitral valve surgery, including intrathecal opioids, local anesthetic infiltration, thoracic epidural catheter placement, intercostal nerve block, and paravertebral nerve block [23]. Other regional techniques include US-guided pectoralis blocks (Pecs I and Pecs II) and the serratus plane (SP) block.…”

Tips and Pitfalls in Robotic Mitral Valve Surgery

“…In establishing the peripheral cannulation, the venous drainage for cardiopulmonary bypass is obtained by a placement of cannula, usually via the right femoral vein and right internal jugular vein. It is essential to introduce cannula under a transesophageal echocardiography to avoid the risk of extravasation, migration of the cannula, or other types of complications [15]. Arterial cannula is usually inserted to the right femoral artery.…”

Anaesthetic Issues in Robotic-Assisted Minimally Invasive Surgery

“…Mitral valve repair has also been performed robotically, with favourable early and mid-term results 105 . The patient is typically positioned in 30 degree left lateral decubitus, with the right arm secured at a level below the posterior axillary line to facilitate additional exposure to the right chest 91,106 . The right arm is often flexed at the wrist and elbow, limiting the ability to use the right radial artery for arterial line placement due to dampening of the arterial waveform 106 .…”

“…The right lung is deflated and a capnothorax is established. In addition to the robotic port sites, a right inframammary incision is required 91,106 . De-airing of the heart is more difficult in the absence of a sternotomy but can be facilitated with the use of transoesophageal echocardiography 106 .…”