Outcomes of robotic and endoscopic combined aortic and mitral valve surgery: experience from National Taiwan University Hospital

Abstract

Background: Minimally invasive approaches in cardiac surgery have transformed the field by reducing surgical trauma and improving recovery outcomes. The lateral approach, using robotic and endoscopic technologies, offers superior visualization for complex procedures, such as combined aortic and mitral valve surgery. Addressing concurrent pathologies in the aortic and mitral valves increases procedural complexity, requiring precise techniques and optimal patient selection.

Methods: This retrospective, single-center study evaluated adult patients who underwent robotic or endoscopic combined aortic and mitral valve surgery between January 2015 and November 2024. Data on patient demographics, perioperative details, and postoperative outcomes including complications, mortality rates, and improvements in New York Heart Association (NYHA) functional status were analyzed.

Results: A total of 67 patients were included, with 8 undergoing robotic and 59 endoscopic procedures. No mortality or conversion to open surgery was observed. Postoperative complications were minimal, with a low infection rate of 1.5% and an atrial fibrillation rate of 26.8%. Over 85% of patients experienced significant improvement in NYHA functional status.

Conclusions: Robotic and endoscopic combined aortic and mitral valve surgery using the lateral approach is safe and effective, yielding excellent outcomes in a well-selected patient population.

Keywords: Robotic valve surgery; combined aortic and mitral valve surgery; endoscopic cardiac surgery; lateral approach; minimally invasive cardiac surgery.

Figure 1

Surgery set-up. (A) The robotic setup demonstrates the placement of the working port, robotic arm ports, and camera port. The patient is positioned supine with the right chest elevated, and the ports are arranged to optimize access to the aortic and mitral valves via the lateral thoracic approach. (B) The endoscopic setup illustrates the arrangement of the working port and camera port in the right anterior thoracic space, with patient positioning and anesthesia protocols similar to the robotic setup. This configuration facilitates minimally invasive access for combined aortic and mitral valve surgeries.

Figure 2

Aortic valve exposure using traction sutures. (A) The robotic approach. (B) Endoscopic approach. The three-suture traction technique optimizes exposure for aortic valve surgery. Upward traction: a suture placed at the left-right commissure is directed upward and secured to the upper pericardium. Rightward traction: a suture at the right-noncoronary commissure is pulled towards the diaphragm, improving lateral exposure. Downward traction: a suture at the left-noncoronary commissure is directed downward toward the working port.

Figure 3

NYHA Sankey diagram. This diagram visually represents the transitions in NYHA functional class for patients following robotic and endoscopic double valve surgery. Each pathway’s width corresponds to the number of patients experiencing that transition, emphasizing the improvement or consistency in functional outcomes postoperatively. NYHA, New York Heart Association.