 |
|
| AATS/NHLBI: Cardiothoracic Surgery Exploring Collaborative Clinical Research Opportunities |
|
Title and Author Robotic Mitral Repair: Structural Re-engineering ThroughImage Fusion "Blueprint" ModelingW. Randolph Chitwood, Jr., M.D. Abstract Mitral valve repair was adoptedby a few centers in the United States around 1984. Despite proven patient benefits, further penetration was slow, and by 2007, the mean repair rate was only 41%. Training may be the root cause of slow adoption as most repair planning was/is predicated upon the surgeon�s qualitative judgment, experience, and facility in translating an arrested heart repair strategy into a well-engineered three-dimensional dynamic result. For many surgeons the inability to make this translation precluded repair over replacement, even using preoperative 2-D echocardiographic guidanceto help definefunctional and pathologic valve components. Other barriers have been poor valve exposure and ergonomic access, as well as demanding complex repair techniques.The da VinciTM robotic system (tele-manipulation) was FDA approved for mitral valve surgery in 2002, and addresses many of these problems with repairs. A third-generation device now provides HD-3D magnified vision, enhanced ergonomics, motion-filtration, and on-screen echocardiographic registration. A number of reference centers now perform robotic mitral valve repairs in over 95% of cases. However, many surgeons have had poor robotic repair outcomes, and moreover, the adoption of these facilitatingtechniques has been slow. The author proposes that this mitral repair "gap", using robotic devices,may be closed by developing: 1) Surgical "blueprints" with the ability to translate 3-D echo (or MRI and CT) models into the surgeon�s console to guide repair strategies byimage fusion and 2) Surgical team training simulatorswith the ability to emulate "real-time" mitral repair operations in 3-D digital platforms with predictive (metrics) models. Surgical team training has been shown to be essential for the best outcomes in robotic surgery, butnew tools are needed to train teams outside of the operating room. Development of a surgical "blueprint"requires the amalgamation of several technologies.Engineering principals may be applied to optimize repair strategy. Finite-element echo studies suggest that structural leaflet stress reduction results by achieving anannular "saddle shape" (hyperbolic paraboloid) with leaflet billowing (parabolic paraboloid). Moreover, pathologic types may be determined before surgery using these methods. By being able to obtain this information instantaneously, valve reconstructions could provide an ideally engineered structural repair. Current research is being done to measure different mitral valve aspects digitally using robotic "touch-mapping". To simplify repair techniques and reduce the intraoperative cognitive load, the nexus of valve modeling, planning, and less aggressive repair technologies,coupled with improved team training, may close the "robotic mitral valve repair gap" for surgeons and patients. Key Research Gap Requiring NHLBI Leadership Develop 3-D imaging overlay "blueprints" in the robotic platform, designed to provide the best structural engineering to create reproducible valve repairs and recapitulate "analog real time" robotic repairs into 3-D digital simulation to train surgeons. Key Citations 1: Chandra A, Salgo I, Sugeng L, Weinert L et al., Characterization of degenerative mItral valve disease using morphologic analysis of real-time three-dimensional echocardiographic images: objective insight into complexity and planning of mitral valve repair. Circ Cardiovasc Imaging 2011:4:24-32.2: Chitwood WR, Rodriguez E, Chu MWA, Hassan A. et al. Robotic mitral valve repairs in 300 patients: a single-center experience. Jour Thoracic Cardiovasc Surg 2008;136:436:436-41 3: Salgo IS, Gorman JH, Gorman RC, Jackson BM et al. Effect of annular shape on leaflet curvature in reducing mitral leaflet stress. Circ 2002;106:711-717 |
We Model Excellence |
|
Copyright © 2012 American Association for Thoracic Surgery
All rights reserved. IMPORTANT REMINDER: The preceding information is intended only to provide
general guidance and not as a definitive basis for diagnosis or treatment in any particular case.
It is very important that you consult a doctor about any specific medical problem or question.
All rights reserved. IMPORTANT REMINDER: The preceding information is intended only to provide
general guidance and not as a definitive basis for diagnosis or treatment in any particular case.
It is very important that you consult a doctor about any specific medical problem or question.