Benefits of robotically-assisted surgery for complex mitral valve repair

Abstract

Objectives: To determine whether robotic mitral valve repair can be applied to more complex lesions compared with minimally invasive direct mitral valve repair through a right thoracotomy.

Methods: We enrolled 335 patients over a 9-year period; 95% of the robotic surgeries were performed after experience performing direct mitral valve repair.

Results: The mean age in the robotic versus thoracotomy repair groups was 61 ± 14 vs 55 ± 11 years, respectively (P < 0.001); 97% vs 100% of the patients, respectively, had degenerative aetiologies. Repair complexity was simple in 106 (63%) vs 140 (84%), complex in 34 (20%) vs 20 (12%) and most complex in 29 (17%) vs 6 (4%) patients undergoing robotic versus thoracotomy repair, respectively. The average complexity score with robotic repair was significantly higher versus thoracotomy repair (P < 0.001). The robotic group underwent more chordal replacement using polytetrafluoroethylene and less resections. All patients underwent ring annuloplasty. Cross-clamp time did not differ between the groups, and no strokes or deaths occurred. More patients undergoing robotic repair underwent concomitant procedures versus the thoracotomy group (30% vs 14%, respectively; P < 0.001). The overall repair rate was 100%, with no early mortality or strokes in either group. Postoperative mean residual mitral regurgitation was 0.3 in both groups, and the mean pressure gradient through the mitral valve was 2.4 vs 2.7 mmHg (robotic versus thoracotomy repair, respectively; P = 0.031).

Conclusions: Robotic surgery can be applied to repair more complex mitral lesions, with excellent early outcomes.

Keywords: Minimally invasive cardiac surgery; Mitral valve repair; Right thoracotomy; Robotic surgery.

Figure 1:

Patient selection flow chart. Patients undergoing sternotomy or concomitant aortic valve repair, tricuspid valve repair or coronary artery bypass grafting were excluded from the evaluation. Included patients who underwent minimally invasive mitral valve repair through a right thoracotomy were divided into 2 groups, 1 undergoing robotically assisted mitral valve repair (robotic) and 1 undergoing minimally invasive direct MVr. CABG: coronary artery bypass grafting; MVr: mitral valve repair.

Figure 2:

Institutional trends in the operative approach to mitral valve repair by era. The bar graph describes the use of robotically assisted mitral valve repair (blue sections), minimally invasive mitral valve repair through a right thoracotomy (orange sections) and median sternotomy (grey sections) over time in our institution. The black line indicates the ratio of right thoracotomy for mitral valve repair during the study period. MVr: mitral valve repair.

Figure 3:

(A) Port placement and the service port; (B) annuloplasty with running mattress sutures using barbed suture; (C) loop technique; (D) maze procedure using a cryoablation device.

Figure 4:

Comparison of mitral valve repair complexity. C1: simple repair; C2: complex repair; C3: most complex repair.

Figure 5:

Comparison of preoperative and postoperative mitral regurgitation stratified by repair complexity and approach. C1: simple repair; C2: complex repair; C3: most complex repair. *P < 0.001.