atrial fibrillation is associated with significant morbidity and mortality , and for some patients it may be the cause of particularly bothersome symptoms . over the last two and a half decades , surgical treatment of atrial fibrillation with the cox maze procedure
a number of variations of the operation have been developed to allow for its adaptation to a minimally invasive technique .
these have included the use of cryoablation through a minithoracotomy , and more recently a robotic approach . with widespread use of echocardiography , asymptomatic cardiac valvular lesions are found with some frequency .
mobile masses associated with left - sided heart valves are particularly worrisome because they present a risk of embolization of tumor or its associated thrombus .
although the majority of these valvular lesions will be found upon resection to be benign fibroelastomas , surgical excision is recommended to avoid the potentially catastrophic complications of cerebrovascular accident , retinal artery occlusion or cardiac event .
this patient , a 58 year - old woman with a history of hypertension , dyslipidemia , and an uncharacterized bleeding disorder , experienced uncomfortable paroxysms of atrial fibrillation .
these occurred two to three times per week , and were accompanied by chest pressure , dizziness , and palpitations .
the episodes persisted despite medical therapy first with flecainide and then with propafenone . during evaluation for a possible catheter ablation procedure
she was found , by transesophageal echocardiography , to have a mobile mass on the left coronary cusp of the aortic valve measuring 0.6 by 0.7  cm .
( figures 1 and 2 ) the remainder of her echocardiographic evaluation was remarkable only for mild mitral valve regurgitation .
chest and abdominal cta revealed no anatomic contraindication to a minimally invasive surgical approach with retrograde femoral artery perfusion .
because of the history of easy bleeding and bruising , hematology consultation was obtained , but no identifiable defect of coagulation was identified . after informed consent was obtained the patient was brought to surgery , general anesthesia induced , and lung separation accomplished with an endobronchial balloon catheter .
venous drainage for cardiopulmonary bypass was established using a 17 fr catheter ( medtronic inc , minneapolis mn ) placed percutaneously in the right internal jugular vein and a 24 fr catheter ( avalon laboratories , rancho dominguez ca ) directed through the right common femoral vein to the right atrium .
arterial return was accomplished with a 21 fr catheter directed proximally through the right common femoral artery , and a 10 fr pediatric aortic cannula ( medtronic inc , minneapolis mn ) directed distally in the right superficial femoral artery to provide lower extremity perfusion .
right chest incisions for the robotic ports were placed anterior to the anterior axillary line ( aal ) at the 3 intercostal space ( ics ) , posterior to the aal at the 6th ics , and at the 5th ics along the midclavicular line .
a working port incision of 5  cm length was placed along the 4th ics crossing the aal .
a chitwood aortic clamp was brought through the 2nd ics at the midaxillary line , and the aorta was cross - clamped .
antegrade cardioplegia was administered via the aortic root and intermittent retrograde cardiplegia was given via a coronary sinus catheter ( edwards lifesciences , irvine ca ) placed percutaneously via the right internal jugular vein .
the davinci surgical robot ( intuitive surgical , sunnyvale , ca ) was docked , a 30 degree up - oriented scope utilized , and the aorta opened transversely above the right coronary artery . the mobile mass on the left coronary cusp of the aortic valve was visualized ( figure 3 ) .
the mass was excised by shaving it off the aortic valve , and the aorta was closed with a 4 - 0 cardionyl suture ( peters , paris france ) in running to - and - fro fashion . on pathologic evaluation , the diagnosis of papillary fibroelastoma confirmed ( figure 4 ) . the biatrial maze procedure was performed as previously described by rodriguez and colleagues .
the left atriotomy incision was placed anterior to the right pulmonary veins in longitudinal fashion .
two minute applications of the cryomaze probe ( ats medical , plymouth mn ) were utilized to create the left atrial lesions at   140 to   160 degrees c. a box lesion was begun from the inferior edge of the atriotomy along the floor of the left atrium , then anterior to the left pulmonary veins ( figure 5 ) .
the box was completed by creating a lesion from the superior edge of the atriotomy along the roof of the left atrium , the anterior to the pulmonary veins to connect with the first lesion .
( figure 6 ) the mitral lesion was made from the inferior edge of the box lesion to the p3 portion of the mitral annulus .
the mirror image of this lesion was made on the epicardial surface and over the coronary sinus by placing the probe in the oblique pericardial sinus ( figure 7 ) .
one minute applications of the cryoprobe were utilized . a linear lesion from the lateral aspect of the superior vena cava to the inferior vena cava
a lesion connecting this line to the right atriotomy incision was placed , completing the  t-shaped set on the right atrial wall ( figure 9 ) .
endocardial lesions were then made from the medial edge of the atriotomy to the 2 o'clock position on the tricuspid annulus ( figure 10 ) and from the 10 o'clock position to the right atrial appendage ( figure 11 ) .
warm blood was administered as the atriotomy was closed , and once the heart began to beat , the crossclamp was removed .
a bipolar right ventricular temporary pacing wire was placed , the robot undocked , and the patient was weaned from bypass in normal sinus rhythm with normal right and left ventricular contractility by transesophageal echo .
initial post - operative course was uneventful , but on postoperative day six the patient fell , with subsequent development of a significant periorbital hematoma which required operative evacuation . despite this , she was able to be discharged on post - operative day seven , and promptly returned to her usual activities .
her symptoms of atrial fibrillation resolved completely , and she remains in sinus rhythm two years post surgery .
over the last decade and one half , refinements in robotic cardiac surgery have enabled its use to extend beyond a few pioneering centers   to more widespread application .
the surgical robot is now used routinely to repair mitral valves , close atrial septal defects , create ablative lesions for atrial fibrillation , and remove intracardiac masses and tumors .
robotic resection of an aortic valve papillary fibroelastoma has been described , but we believe this is the first description of such a resection concomitant with a biatrial maze procedure .
papillary fibroelastomas represent the minority of primary tumors of the heart , but the vast majority of tumors of the cardiac valves . they may be found on any of the heart valves , do not exhibit the potential for malignant transformation , and are usually not symptomatic .
most commonly they are found incidentally when patients undergo echo - cardiography for a different indication , as was the case in our patient . despite the benign nature of papillary fibroelastomas ,
when present in the left heart these lesions have been shown to present a risk of embolism with central nervous system accident , cardiac injury , or end - organ malperfusion , and prompt surgical removal is recommended .
the presence of paroxysmal atrial fibrillation in this patient presented the opportunity to perform one surgical procedure that would address both conditions .
feasibility of the concomitant performance of robotic mitral repair and a maze procedure using cryoablation has previously been demonstrated .
the successful outcome of the case described here suggests that a robotic approach can similarly be utilized for the infrequent patient who presents with atrial fibrillation and a lesion of the aortic valve .
 
 abstract : cardiothoracic surgeons have utilized the surgical robot to provide a minimally invasive approach to a number of intracardiac operations , including tumor resection , valve repair , and ablation of atrial arrhythmia . 
 we report the case of a 58 year - old woman who was found to have a mobile mass on her aortic valve during evaluation of atrial fibrillation . 
 both of these conditions were addressed when she underwent a combined robotic biatrial maze procedure and excision of the mass , which proved to be a papillary fibroelastoma of the aortic valve . 
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