Robotically assisted minimally invasive mitral valve surgery

A propensity matched comparison of robotic vs. traditional minimal access approach for mitral valve repair with concomitant cryoablation

Background

Atrial fibrillation (AF) occurs frequently in patients with mitral valve disease. Results of cryoablation concomitant with either minimally invasive video-assisted [minimally invasive mitral valve surgery (MIMVS)] or with robotic-assisted (RMV) mitral valve surgery have previously been separately reported. However, there are up-to-date no studies comparing the two procedures in terms of safety, efficacy, and mid-term follow-up.

Methods

Between January 2017 and March 2022, 294 patients underwent MIMVS, and 187 patients underwent RMV at our institution. After 1:1 propensity score matching using 22 preoperative variables, the study included 104 patients. Group 1 (MIMVS) included 52 patients operated on between 2017-2022 using a minimally invasive video-assisted right-sided mini-thoracotomy. Group 2 (RMV) included 52 patients operated on between 2019-2021 using a robotic-assisted approach. Early and mid-term outcomes were assessed, including maintenance of sinus rhythm. Follow-up was 100% complete at a median follow-up of 2 years.

Results

For the entire propensity matched cohort, the median EuroSCORE II was 3.14 [interquartile range (IQR), 1.93-4.99], the median age was 68 (IQR, 61-74) years, and two thirds of the patients were male. Most (72.1%) underwent mitral valve surgery, and 26.9% had an additional tricuspid procedure. Only four patients underwent mitral valve replacement (3.8%). The majority (87.5%) received a left-sided atrial Maze and 12.5% a bi-atrial Maze. The left atrial appendage was occluded in 72.1% cases. Overall, there were no significant differences between the two propensity matched groups in baseline demographics or intra-operative characteristics. Similarly, there were no significant differences in the post-operative short and mid-term outcomes between the two groups. There were no in-hospital or 30-day deaths. At the mid-term survival was similar between groups, log-rank test P=0.056. Maintenance of sinus rhythm at follow-up was 76%.

Conclusions

Mitral or double valve repair with concomitant cryoablation can be safely performed with either a MIMVS or RMV approach. Both methods demonstrated outstanding early and mid-term outcomes.

Totally endoscopic mitral valve repair without robotic assistance: A case report

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Robotic TEMVR is the most advanced level of MICS.

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We have performed TEMVR using no robotic system.

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The used equipment included MICS instruments and a 3D Endoscopic system.

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We improved mitral valve exposure techniques and surgical port placement.

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We used sutures as a left atrial retractor to expose mitral valve.

Introduction

Totally endoscopic mitral valve repair (TEMVR) is the highest level of minimally invasive cardiac surgery (MICS). It brings many benefits to patients but the downside is that a robotic system is always required. The deployment of robotic surgery is very complicated and expensive. Therefore, we improvised, making it possible to perform TEMVR without the aid of a robotic system.

Presentation of case

A 66-year-old male patient presented with severe mitral valve regurgitation due to posterior leaflet prolapse. He was treated with TEMVR without robotic assistance. No chest incision was over 1.2 cm. The repair techniques included posterior leaflet resection and annuloplasty with ring implantation.

Discussion

A midline sternotomy is still the standard approach for mitral valve repair. In recent years, MICS has gradually replaced conventional surgery with the most advanced strategy being totally robotic mitral valve repair. However, complex surgical techniques and high cost make it less accessible for the majority of patients. Instead of using robot, we improved mitral valve exposure techniques, surgical port placement and therefore were able to perform TEMVR with MICS instruments.

Conclusion

TEMVR without robotic assistance is a safe, effective and cost-efficient procedure, which can be adopted in most cardiac centers.

Minimally Invasive Mitral Valve Surgery III: Training and Robotic-Assisted Approaches

Minimally invasive mitral valve operations are increasingly common in the United States, but robotic-assisted approaches have not been widely adopted for a variety of reasons. This expert opinion reviews the state of the art and defines best practices, training, and techniques for developing a successful robotics program.

Conditional long-term survival following minimally invasive robotic mitral valve repair: a health services perspective

BACKGROUND

Conditional survival is defined as the probability of surviving an additional number of years beyond that already survived. The aim of this study was to compute conditional survival in patients who received a robotically assisted, minimally invasive mitral valve repair procedure (RMVP).

METHODS

Patients who received RMVP with annuloplasty band from May 2000 through April 2011 were included. A 5- and 10-year conditional survival model was computed using a multivariable product-limit method.

RESULTS

Non-smoking men (≤65 years) who presented in sinus rhythm had a 96% probability of surviving at least 10 years if they survived their first year following surgery. In contrast, recent female smokers (>65 years) with preoperative atrial fibrillation only had an 11% probability of surviving beyond 10 years if alive after one year post-surgery.

CONCLUSIONS

In the context of an increasingly managed healthcare environment, conditional survival provides useful information for patients needing to make important treatment decisions, physicians seeking to select patients most likely to benefit long-term following RMVP, and hospital administrators needing to comparatively assess the life-course economic value of high-tech surgical procedures.

Videoscope-assisted cardiac surgery

Videoscope-assisted cardiac surgery (VACS) offers a minimally invasive platform for most cardiac operations such as coronary and valve procedures. It includes robotic and thoracoscopic approaches and each has strengths and weaknesses. The success depends on appropriate hardware setup, staff training, and troubleshooting efficiency. In our institution, we often use VACS for robotic left-internal-mammary-artery takedown, mitral valve repair, and various intra-cardiac operations such as tricuspid valve repair, combined Maze procedure, atrial septal defect repair, ventricular septal defect repair, etc. Hands-on reminders and updated references are provided for reader's further understanding of the topic.

Robotic mitral valve repair in infective endocarditis

BACKGROUND

Robotic mitral surgery is the most common robotic cardiac procedures. However, in mitral endocarditis the repair become more challenging especially in minimally approach. We applied robotic surgery in mitral endocarditis repair and reviewed our surgical methods and results.

PATIENTS

From January 2012 to December 2013, 12 patients with mitral endocarditis in National Taiwan University Hospital were operated via robotic assisted repair. Age of them was among 21 to 65 years old, mean 43.

RESULTS

The vegetation involves anterior leaflet in 3, posterior leaflet in 8 and commissural leaflet in 4. Mean cardiopulmonary bypass time is 124 minutes and cross clamp time is 89 minutes. There was no stroke and no operation death. Mitral valve repair technique including anterior leaflet patch augmentation in 2, direct closure of rupture hole on anterior leaflet in one, plication commissural leaflet in 2, and artificial chordae in 10. There was no mitral regurgitation detected immediately after weaning of cardiopulmonary bypass. All of them got free-from-regurgitation or -stenosis rate was 100% at one-year follow.

CONCLUSIONS

Although mitral infective endocarditis is complex and difficult to repair, robotic mitral repair in infective endocarditis is feasible. Even in the complex repair group, the cardiopulmonary bypass time is not prolonged and the result is good.