This is a very extensive sx and I havent seen this before. Please, if anyone can help me or at least provide me their thoughts, i would apprecaite it so much.

Robotic assisted:
1. Repair of the patent foramen ovale.
2. Lateral commissuroplasty.
3. Triangular resection of anterior leaflet A2 region.
4. Trapezoid resection of posterior leaflet in the P1-P2 region.
5. #35 ATS annuloplasty band insertion.
6. Minithoracotomy

The patient's right groin was exposed for femoral arterial and venous
cannulation. Next, the port incisions were made for insertion of the robotic ports that is the camera 2 cm lateral to the nipple in the 4th intercostal
space and few centimeters above the anterior axillary line approximately 4 cm
below the camera port ,the working portwas inserted. The right arm was
inserted at the anterior axillary line in the 5th intercostal space and the 3rd
intercostal space just at the level of the camera, the left _arm____ port was
inserted. The left atrial retractor insertion site was made in the 5th
intercostal space approximately 2 cm medial to the nipple. Once that was done, the patient was heparinized and the arterial and venous cannulation was performed using Seldinger technique under TEE guidance. Next, the Endo
occlusion balloon was floated. However, it was difficult to position the
balloon into the ascending aorta secondary to the patient's anatomy. We had to briefly go on bypass to position the balloon in the ascending aorta.

The robot was docked and the next step was to proceed with the dissection of the pericardial fat and the pericardial dissection. However, the patient would not tolerate one-lung ventilation at all and was desaturating in the low 80s. Therefore, cardiopulmonary bypass was instituted and we proceeded with the resection of the fat pad around the pericardium. It may be noted that the diaphragm was extremely large and diaphragmatic stitch was inserted still however, it was obstructing the view once in a while. We were more or less keeping it on the side with the help of the right instrument arm.. Again, there was an extensive pericardial fat all along the lateral surface,
completely hiding the pericardium itself. Once the fat dissection was done,
pericardium was opened and retracted using Ethibond sutures. It should also be noted the patient had lung adhesions down to the pericardium and had to be dissected out before we did the pericardiectomy. Once the pericardium had been opened and retracted as mentioned above, we proceeded with the cross clamping. Using the Endo occlusion balloon, the aorta was cross clamped and the patient was given antegrade cardioplegia and from then onwards, he was given cold blood cardioplegia in a retrograde fashion every 20 minutes. The patient was cooled to 28 degrees. A left atriotomy was performed and valve was visualized. The intraoperative TEE demonstrated the patient had prolapse of the P1 and P2 and A2, and a PFO was visualized as wellas well. There were chords broken in both P1, P2 and in the A2 area. In addition, there was prolapse of the lateral commissure as well. The valve was extremely dilated and large. Intraoperatively, direct visualization of the mitral valve demonstrated a floppy appearance and redundant tissue all around the atrium and the valve itself as well. Initially. we proceeded with a trapezoid resection of the P1 and P2 area, that was repaired. The valvuloplasty was then performed using a
running CN Gore-Tex CV4 suture. Once that was completed, the lateral
commissuroplasty was performed using the CV4 Gore-Tex as well. The A2 prolapse initially was not evident, however, on further visualization, it was clearly seen and as confirmed by intraoperative TEE done earlier as well. The A2 lesion was then dissected using a triangular resection as well and repaired
with Gore-Tex CV4. Next, valve was sized and a 35 mm ATS band was found to be appropriate. It may also be noted the patient had a patent foramen ovale, which was initially repaired with 4-0 prolene as well. The 35 mm ATS band was secured to the annulus with the help of U clips. However, it may be noted just while we were done with approximately 90% of the ring implantation, the patient had sudden gush of blood from the ventricle and on exploration, it was found that the Endo occlusion balloon had ruptured and was not holding pressure at all. The patient was cooled down to 25 degrees, was given retrograde cardioplegia at that time, but then that retrograde balloon ruptured as well. At that time the camera port incision was joined with the working port and making a minithoracotomy.
Next, a cross clamp was placed in the proximal ascending aorta. The ATS band implantation was completed with 2-0 Ethibond. The atriotomy was then closed using 3-0 Prolene running suture. The patient was placed in Trendelenburg position and the cross clamp was removed. The patient was then gradually weaned off from bypass and protamine was given to reverse heparin. The patient was sequentially decannulated and all cannulation sites were secured as needed.