Robotic mitral valve repair in National Taiwan University Hospital: 10-year results

Abstract

Background: With the help of robotic surgical systems and their 3-dimensional, high-resolution imaging, mitral repair with long shaft instruments and endo-wrist functionality has become a feasible reality. Patients benefit from maintained thoracic cage integrity, reduced surgical trauma, and faster return to normal functional activity. We describe National Taiwan University Hospital's 10-year experience with robotic-assisted mitral valve repair procedures for repairing mitral regurgitation.

Methods: We performed a retrospective observational cohort study of patients undergoing robotic-assisted mitral valve repair for severe mitral regurgitation at National Taiwan University Hospital. Between January 2012 and September 2022, 450 consecutive patients underwent robotic mitral valve repair with or without additional cardiac procedures. All procedures were completed by a single surgical team.

Results: Four hundred and fifty patients, with 272 (60.4%) isolated mitral repairs and 178 (39.6%) combined additional (one or more) cardiac procedures were performed. The Euroscore II estimate mortality was 3.1%±2.7%. The average cardiopulmonary bypass (CPB) time was 124±42 minutes, and the average operation time was 165±51 minutes. Perioperative and 30-day mortality was observed in one (0.22%) patient. Mean intensive care unit stay was 26.5±26.0 hours. Postoperative stroke was observed in one (0.22%) patient and new-onset atrial fibrillation was observed in 71 (15.78%) patients. All patients were in less than mild mitral regurgitation and 422 (93.78%) had none or trace regurgitation at discharge. Freedom from moderate mitral regurgitation was 97.6%, and freedom from mitral valve reoperation was 98% at 10 years.

Conclusions: With standardized robotic procedures and non-compromised repair techniques, excellent short-term outcomes and long-term valve repair durability can be achieved in experienced centers.

Keywords: Robotic mitral repair; mitral repair; robotic cardiac surgery; robotic surgery.

Figure 1

Ports location and settings of operation room. (A) Port location. The 3 cm working port is located in the 4^th intercostal space with a soft tissue protector. Tissue protector (black arrow). The right arm is in the 6^th intercostal space (red arrow) at right anterior axillary line, left arm is in the 3^rd intercostal space (yellow arrow). Left atrial retractor port is in the 4^th intercostal space (white arrow) between working port and sternal margin. (B) Overview of robotic setting. The whole view of robotic arms machine docking and the cardiopulmonary bypass machine is on the right side of the picture, the trans-esophageal echocardiography is located in the left side of the picture.

Figure 2

Mitral valve repair techniques. We use anatomical lesion sets to determine repair strategy. Before an operation, the lesion should be determined by echocardiography. The repair techniques are adopted according to the lesion location. Artificial chords are used in the prolapsed posterior leaflet and anterior leaflet without good secondary chordae for transferring. Chordae shortening techniques are adopted to shorten the elongated chords in the leaflet margin.

Figure 3

Mitral valve repair techniques in Barlow’s disease. The repair strategy for Barlow’s disease is a combination of all techniques described according to the lesion set. With huge prolapsed redundant posterior leaflets, we use artificial chords to relocate to the annular plane and close all indentations and clefts to make for good coaptation. The anterior leaflets are shortened if necessary, followed by commissural closure and annuloplasty ring fixation.

Figure 4

Console time, operation time, cardiopulmonary bypass time in the first 30 isolated mitral valve repair patients. In the first operation, the surgical time was more than 450 minutes and console time was 385 minutes. With continuous efforts on standard steps and team setup, the operation time can be less than 200 minutes in less than 10 isolated mitral valve repair cases.

Figure 5

Freedom from more than moderate mitral regurgitation.