First Human Totally Endoscopic Robotic-Assisted Sutureless Aortic Valve Replacement

The Perceval Sutureless Bioprosthetic Aortic Valve: Evolution of Surgical Valve Technology

OBJECTIVE

The surgical treatment of aortic stenosis continues to evolve, and sutureless aortic valve replacement (SUAVR) is an emerging technology. With the Perceval S (Corcym, London, UK) as the only true sutureless valve on the market, the objective of this review is to analyze the current literature on Perceval S. Focusing on valve design and deployment as well as applications of the technology for challenging pathology, clinical outcomes are assessed, including a comparison with transcatheter AVR (TAVR).

METHODS

PubMed and MEDLINE were searched by 3 authors for studies analyzing SUAVR from inception to May 19, 2023.

RESULTS

SUAVR facilitates minimally invasive surgery and offers an alternative strategy for patients with small aortic annuli. It also has a time-saving advantage for patients who require complex operations. SUAVR results in excellent long-term morbidity, mortality, durability, and hemodynamic function. In comparison with conventional surgical AVR (SAVR), SUAVR does have a greater risk of postoperative pacemaker implantation; however, increasing user experience and refinements in implantation technique have contributed to reductions in this outcome. SUAVR results in morbidity and mortality that is similar to rapid-deployment AVR. Midterm outcomes are superior to TAVR; however, further robust investigation into all of these comparisons is ultimately necessary.

CONCLUSIONS

SUAVR bridges the gap in technology between SAVR and TAVR. The application of this exciting technology will undoubtedly grow in the coming years, during which additional investigation is paramount to optimize preoperative planning, valve deployment, and reintervention strategies.

Endoscopic Aortic Valve Replacement: Initial Outcomes of Isolated and Concomitant Surgery

BACKGROUND

The applicability of totally endoscopic surgical aortic valve replacement (AVR) in multivalve operations is unknown. This study describes an approach and perioperative outcomes of totally endoscopic isolated and concomitant AVR using various valve types.

METHODS

A total of 216 patients (114 male; mean age, 71.3 ± 11.3 years) underwent totally endoscopic AVR from May 2017 to October 2022 in a tertiary care center. The 3-port technique was used: a 3- to 4-cm main port without rib spreading, a 10-mm 3-dimensional endoscopic port, and a 5-mm left-hand port with femoral cannulations. Sutures were hand tied with a knot pusher. Descriptive analyses compared perioperative outcomes between patients with or without concomitant procedures.

RESULTS

Of 216 patients, concomitant surgery was performed in 33 (15.2%) patients. Of the 33, 21 (63.6%) had a concomitant mitral procedure. A stented bioprosthesis was implanted in 165 (76.3%) patients, a mechanical valve in 22 (10.2%) patients, and a rapid deployment or sutureless valve in 29 (13.4%) patients. Median operation time and aortic cross-clamp time were 175 minutes (interquartile range; 150-194 minutes) and 78 minutes (interquartile range; 67-92 minutes) for isolated AVR, respectively. Thirty-day mortality occurred in 1 patient (0.5%). Two patients (0.9%) had conversion to sternotomy. Major neurologic events occurred in 3 patients (1.4%). The major adverse event rate was similar between patients with or without concomitant procedures.

CONCLUSIONS

Endoscopic AVR can safely address concomitant valve diseases.

Robotic-Assisted Solutions for Invasive Cardiology, Cardiac Surgery and Routine On-Ward Tasks: A Narrative Review

Robots are defined as programmable machines that can perform specified tasks. Medical robots are emerging solutions in the field of cardiology leveraging recent technological innovations of control systems, sensors, actuators, and imaging modalities. Robotic platforms are successfully applied for percutaneous coronary intervention, invasive cardiac electrophysiology procedures as well as surgical operations including minimally invasive aortic and mitral valve repair, coronary artery bypass procedures, and structural heart diseases. Furthermore, machines are used as staff-assisting tools to support nurses with repetitive clinical duties i.e., food delivery. High precision and resolution allow for excellent maneuverability, enabling the performance of medical procedures in challenging anatomies that are difficult or impossible using conventional approaches. Moreover, robot-assisted techniques protect operators from occupational hazards, reducing exposure to ionizing radiation, and limiting risk of orthopedic injuries. Novel automatic systems provide advantages for patients, ensuring device stability with optimized utilization of fluoroscopy. The acceptance of robotic technology among healthcare providers as well as patients paves the way for widespread clinical application in the field of cardiovascular medicine. However, incorporation of robotic systems is associated with some disadvantages including high costs of installation and expensive disposable instrumentations, the need for large operating room space, and the necessity of dedicated training for operators due to the challenging learning curve of robotic-assisted interventional systems.

Robotic Surgery for Triple Valve Insufficiency: A Case Report

A 63-year-old woman was referred to our institution for surgical treatment of triple valve (aortic, mitral, and tricuspid) insufficiency and underwent a robot-assisted endoscopic procedure. Three intercostal ports were placed in the right lateral chest for robotic instruments and a retrograde cardioplegic cannula, and a 5 cm thoracotomy was made for the procedure, which was a mitral valve repair with neochords and ring annuloplasty, an aortic valve replacement with bioprosthetic valve, and a ring tricuspid annuloplasty. Surgery was successfully achieved without blood transfusion or any complications.

Sternal-Sparing Surgical Options in Combined Aortic Valve and Coronary Artery Disease: Proof of Concept

OBJECTIVE

The standard management of concomitant aortic valve (AV) and coronary artery disease has been coronary artery bypass and AV replacement (AVR). With the advent of minimally invasive options, many isolated lesions have been successfully managed using a sternal-sparing approach. In our institution, patients with isolated AV disease are offered minimally invasive surgical or transcatheter AVR, and those with isolated coronary artery disease are routinely managed with robotic totally endoscopic coronary artery bypass or percutaneous coronary intervention. Various combinations of these techniques can be used when a sternal-sparing posture is desired because of patient risk or preference. The aim of this study was to review the outcomes in patients with combined AV and coronary disease who were managed using sternal-sparing approaches.

METHODS

We reviewed the records of 10 patients in our minimally invasive surgical database who presented with concomitant AV and coronary artery disease and underwent combined sternal-sparing management of these 2 lesions using various combinations of minimally invasive approaches.

RESULTS

Four patients had totally endoscopic coronary artery bypass and minimally invasive AVR at the same time, 2 patients underwent transcatheter AVR followed by totally endoscopic coronary artery bypass, and 4 patients underwent minimally invasive AVR with percutaneous coronary intervention. There was no 30-day mortality. The duration of postoperative surgical hospital stay was 3.1 ± 0.9 days.

CONCLUSIONS

Sternal-sparing approaches in combined AV and coronary artery disease are feasible with patient-specific treatment selection of minimally invasive techniques.

Robot-Assisted Aortic Valve Replacement - First Clinical Report in Japan

BACKGROUND

Robot-assisted valve surgery represents the latest development in the field of minimally invasive approaches. Robotic assistance may provide greater visualization, enhanced dexterity, and greater precision than traditional mini-thoracotomy aortic valve replacement.

METHODS AND RESULTS

Aortic valve replacement operations using the da Vinci Xi Surgical System (Intuitive Surgical Inc., Sunnyvale, CA, USA) were performed on 2 patients, 1 with severe aortic insufficiency and the other with aortic stenosis. Both patients had an uneventful postoperative course and were discharged without any adverse events.

CONCLUSIONS

Robot-assisted assisted aortic valve replacement appears feasible and safe in limited cases.

Rapid-Deployment Aortic Valve Replacement: Patient Selection and Special Considerations

Sutureless or rapid deployment valves in the setting of aortic valve replacement (AVR) is an emerging surgical technique using the transcatheter valve technology, which may lead to reduction in cross-clamp time and potentially better hemodynamics compared to a stented bioprosthetic valve. The absence of subannular pledgets results to excellent hemodynamic performance with reduced turbulent flow and larger effective orifice area. However, complications from both surgical and transcatheter AVR may still occur and impact survival. The incidence of paravalvular leakage and permanent pacemaker implantation are not low. Although technical modifications can improve these outcomes, there is a learning curve effect. Therefore, technical and anatomical considerations as well as better patient selection are paramount for better outcomes. In this review, we discuss the use of sutureless or rapid deployment valves in setting of (1) complex procedures, (2) minimally invasive AVR, and (3) small aortic annulus. The advantage of sutureless or rapid deployment valves in terms of mortality remains to be clarified; therefore, it is necessary to accumulate long-term outcomes in an appropriate patient cohort.

Historical evolution of robot-assisted cardiac surgery: a 25-year journey

Many patients and surgeons today favor the least invasive access to an operative site. The adoption of robot-assisted cardiac surgery has been slow, but now has come to fruition. The development of modern surgical robots took surgeons close collaboration with mechanical, electrical, and optical engineers. Moreover, the necessary project funding required entrepreneurs, federal grants, and venture capital. Non-robotic minimally invasive cardiac surgery paved the way to the application of surgical robots by making changes in operative approaches, instruments, visioning modalities, cardiopulmonary perfusion techniques, and especially surgeons' attitudes. In this article, the serial development of robot-assisted cardiac surgery is detailed from the beginning and through clinical application. Included are references to the historical and most recent clinical series that have given us the evidence that robot-assisted cardiac surgery is safe and provides excellent outcomes. To this end, in many institutions these procedures now have become a new standard of care. This evolution reflects Sir Isaac Newton's famous 1676 quote when referring to Rene Descartes, "If have seen further [sic] than others, it is by standing on the shoulders of giants".

Totally Endoscopic Robot-Assisted Aortic Valve Replacement and Complex Mitral Valve Repair: The Lateral Approach

A 76-year-old male patient was referred to our institution with moderate-to-severe aortic and mitral insufficiency. The patient underwent totally endoscopic robot-assisted aortic valve replacement and mitral valve repair. In this article, we present our lateral approach to the robotic double valve surgery.

Benefits and Pitfalls of the Perceval Sutureless Bioprosthesis

Objective: To highlight the main target points covered by clinical studies on the Perceval sutureless valve for surgical aortic valve replacement (SAVR) and raise a point of discussion for further expansion of its use when compared with stented bioprostheses (SB) and transcatheter aortic valve replacement (TAVR).

Methods: We reviewed clinical trials and retrospective studies published up to date and compared the outcomes in terms of mortality, myocardial infarction (MI) stroke, paravalvular leak (PVL), permanent pacemaker implantation (PPI), bleeding and long-term outcomes.

Results: Clinical studies showed that 30-day mortality ranged from 0–4% for Perceval and 2.9–7% for TAVR. The incidence of PVL (Perceval 1.9–19.4 vs. TAVR 9–53.5%), PPI (Perceval 2–11.2 vs. TAVR 4.9–25.5%), stroke (Perceval 0 vs. TAVR 0–2.8%), MI (Perceval 0 vs. TAVR 0–3.5%), were all higher in the TAVR group. Compared to other SB, mortality ranged from 0–6.4% for Perceval and 0–5.9% for SB. The incidence of PVR (Perceval 1–19.4 vs. SB 0–1%), PPI (Perceval 2–10.7 vs. SB 1.8–8.5%), stroke (Perceval 0–3.7 vs. SB 1.8–7.3%) and MI (Perceval 0–7.8 vs. SB 0–4.3%) were comparable among the groups. In patients with a bicuspid aortic valve, mortality rate was (0–4%) and PVL incidence was (0–2.3%). However, there was a high incidence of PPI (0–20%), and stroke (0–8%). Long-term survival ranged between 96.7–98.6%.

Conclusions: The Perceval bioprosthesis has proved to be a reliable prosthesis for surgical aortic valve replacement due to its implantation speed, the reduced cardiopulmonary bypass time, the reduced aortic cross-clamp time and the shorter intensive care unit and hospital length of stay.

3D-endoscopic assisted concomitant mitral and aortic valve surgery

Minimally invasive cardiac surgery (MICS) is commonly used to treat degenerative mitral regurgitation. Totally endoscopic approach has emerged as an attractive alternative procedure especially for young patients and has been described in isolated mitral and aortic valve settings. Totally endoscopic double valve procedure, including mitral and aortic valves, extends this treatment option to be offered to a broader patient population. We describe our approach to performing totally endoscopic concomitant aortic and mitral valve procedure, which has overcome unique technical hurdles and has yielded favorable outcomes.

Robotic Aortic Valve Replacement: First 50 Cases

BACKGROUND

Existing management challenges in selecting transcatheter versus surgical aortic valve replacement (SAVR) include bicuspid stenosis, low clinical risk, horizontal valve position, aortic insufficiency (AI), and need for concomitant procedures or mechanical valves. To address these gaps, we present our early experience with fully robotic-assisted aortic valve replacement (RAVR).

METHODS

Between January 2020 and February 2021, 50 consecutive RAVR operations were performed utilizing a 3-4 cm lateral mini-thoracotomy three-port technique with transthoracic aortic clamping, similar to our robotic mitral platform. Conventional SAVR prostheses were implanted with interrupted braided sutures in all cases.

RESULTS

Median age was 67.5 years, BMI was 29, calcified bicuspid disease was present in 28/50 (56%), and severe AI in 8/50 (16%). Ejection fraction was 54.8±8.4% (mean±SD), and STS PROM was 1.54±0.7%. Mechanical prostheses were used in 16/50 (32%), and 7 required concomitant procedures including Cox-Maze (3), left atrial appendage clipping (1), aortic root enlargement (2), mitral repair (1), and left atrial myxoma excision (1). Median times for cardiopulmonary bypass, cross-clamp, valvectomy, annular sutures, and aortotomy closure were 166, 117, 4, 20, and 31 minutes, respectively. All times plateaued after the initial five cases. Most patients (42/50, 84%) were extubated in the operating room, and the remainder (8/50, 16%) within 4 hours. There was no 30-day operative mortality or stroke. All had 30-day echocardiography demonstrating no valvular or perivalvular abnormalities.

CONCLUSIONS

RAVR appears to have procedural safety and short-term outcomes to rival alternatives. Incremental experience may facilitate the safe performance of concomitant procedures as deemed necessary.

Robotic resection of an aortic valve fibroelastoma using a right lateral approach

BACKGROUND AND AIM OF THE STUDY

Robotic technology provides excellent visualization and surgical precision and it is reaching maturity in cardiac surgery, although mostly confined to mitral surgery and coronary revascularization. Robotic aortic valve surgery (rAVS) has not been sufficiently developed, and experience is extremely scarce.

METHODS

We present a robotic resection of a papillary fibroelastoma on the aortic valve using a totally thoracoscopic right lateral approach.

RESULTS

This technique provides excellent exposure, facilitates patient recovery and improves cosmesis.

CONCLUSIONS

rAVS has tremendous potential and many patients may benefit in the future. The lateral approach used in our case may offers advantages over others previously attempted and may also facilitate adoption of rAVS by teams currently performing robotic mitral surgery.

Early Clinical Experiences of Robotic Assisted Aortic Valve Replacement for Aortic Valve Stenosis with Sutureless Aortic Valve

Robotic assisted aortic valve surgery is still challenging and debatable. We retrospectively reviewed our cases of robotic assisted aortic valve replacement utilizing sutureless aortic valve with following surgical technique: 3 ports, 1 for endoscope and 2 for the robotic arms were inserted in the right chest and da Vinci Si robotic system (Intuitive Surgical, Sunnyvale, CA, USA) was adapted to these ports. Cardiopulmonary bypass was initiated through peripheral cannulations. A vent cannula was placed through the right superior pulmonary vein and a cardioplegia cannula in the ascending aorta. After cardioplegic arrest following aortic cross-clamp, the aortic valve was exposed through a clam shell aortotomy. Valvectomy along with decalcification was performed. Next using 3 guiding sutures the Perceval S valve (LivaNova, London, UK) was parachuted down and deployed. After confirming valve position, the aortotomy was closed. There were no major complications during the procedures and no conversion to sternotomy. Exposure of aortic valve was of high quality. Valvectomy required assistance with long scissors by the bedside surgeon for excision of the severely calcified valve cusps and effective decalcification of annulus. Postoperative convalescence was uncomplicated except for postoperative atrial fibrillation in 1 patient. Robotic assistance in aortic valve procedure enabled excellent exposure of the aortic valve and improved manipulation and suturing of the aortic annulus and aorta. There needs to be improvement of instrumentation for valve debridement and removal of calcium from the annulus. In addition, the sutureless valve technology contributes to the feasibility and the efficacy of this procedure.