Robotic Atrial Septal Defect Repair and
Endoscopic Treatment of Atrial Fibrillation
Michael Argenziano and Mathew R. Williams
Computer (robotic) enhancement has emerged as a facilitator of minimally invasive cardiac surgery and
has been used to perform portions of intracardiac procedures via thoracotomy incisions. This report
describes the use of the da Vinci surgical system in two totally endoscopic (“closed chest”) cardiac
operations: atrial septal defect closure and pulmonary vein isolation of atrial ﬁbrillation. ASD closure:
Fifteen patients underwent repair of a secundum-type atrial septal defect or patent foramen ovale by
a totally endoscopic approach, utilizing the da Vinci robotic system. Cardiopulmonary bypass (CPB)
was achieved peripherally. Cardioplegia was administered via the distal port of the arterial cannula
after endoballoon inﬂation. Via three port incisions in the right chest, the entire operation including
pericardiotomy; bicaval occlusion; atriotomy; atrial septopexy; and atrial closure was performed by a
surgeon seated at a computer console. A fourth 15 mm port was utilized for suction and suture passage
by a patient-side assistant. In one case, a recurrent shunt was identiﬁed and repaired on POD 5. Median
ICU length of stay (LOS) was 20 hours, and median hospital LOS was 4 days. Atrial ﬁbrillation surgery:
This report also describes the pathway that we have pursued in the development of a totally endo-
scopic operation for atrial ﬁbrillation. Beginning with animal models, we tested various ablative energy
sources; methods of ablation; and minimally invasive approaches. This work has led to the develop-
ment of a variety of minimally invasive surgical approaches including a totally endoscopic, robotically
assisted beating heart procedure for the treatment of atrial ﬁbrillation.
© 2003 Elsevier Inc. All rights reserved.
Key words: Robotic surgery, atrial septal defect, atrial ﬁbrillation.
n the past decade, the face of cardiac surgery
has been changed by a number of advances,
most notably the development of minimally inva-
sive techniques, including minimally invasive di-
rect coronary artery bypass (MIDCAB), off-pump
coronary artery bypass (OPCAB), and minimal
access valve surgery. Initial attempts to perform
cardiac operations through small incisions were
hindered by the absence of appropriate accessory
technology, such as visualization systems, retrac-
tors, stabilizers, and alternate methods of vascu-
lar cannulation and cardiopulmonary bypass.
With the development of these technologies, sur-
geons have been increasingly able to perform
complex cardiac procedures, including coronary
artery bypass, mitral and aortic valve replace-
ment, and atrial septal defect (ASD) closure,
through smaller-than-traditional incisions. None-
theless, in many cases, the extent to which inci-
sion size has been reduced by these minimally
invasive approaches has been matched by a cor-
responding increase in technical difﬁculty and
operative time—and a potentially decreased
safety margin— due to the constraints imposed
by limited or incomplete cardiac exposure.
Computer (robotic) enhancement has emerged
as a potential facilitator of minimally invasive
surgical procedures. Initially, this technology was
utilized to maximize visualization of intracardiac
structures by providing enhanced (including
voice-activated) endoscopic camera control.
More recently, robotic surgical systems have per-
mitted the manipulation of surgical instruments
through limited thoracic incisions.
describes the next step in this progression: the
performance of atrial septal defect repair entirely
through thoracoscopic port incisions. Torracca
and colleagues have recently reported a small
series of patients undergoing this operation in
Our series of robotic ASD repairs sup-
plements this experience and represents the ﬁrst
U.S. application of robotic technology for totally
From the Division of Cardiothoracic Surgery, Columbia University
College of Physicians and Surgeons, New York, NY.
Address reprint requests to Michael Argenziano, MD, 177 Fort
Washington Avenue, Milstein Hospital, Room 7-435, New York, NY.
© 2003 Elsevier Inc. All rights reserved.
Seminars in Thoracic and Cardiovascular Surgery, Vol 15, No 2 (April), 2003: pp 130-140