Establishing a robotic aortic valve replacement program in Spain: growing opportunities for Europe

Abstract

Background: The natural history of aortic valve disease commonly eventuates in percutaneous or open surgical treatment. Percutaneous treatment has been expanding its indication from high-risk patients to low- and moderate-risk patients; however, there are certain groups of patients who are not good candidates for percutaneous treatment, such as those with bicuspid valve disease or pure aortic regurgitation patients. Robotic surgery, as an evolution from traditional approaches, has been gradually expanding its indications in cardiac surgery. The use of a lateral approach, common to robotic mitral procedures, may become a valid alternative for several patients undergoing aortic valve procedures. The aim of the present study was to evaluate and discuss the characteristics, challenges and early results of a newly created robotic aortic valve replacement program.

Methods: This was a retrospective study analysing prospectively collected data of all patients who have undergone robotic aortic valve replacement (RAVR) in Hospital Clínic Barcelona from December 2021 to October 2024.

Results: Since December 2021, 25 consecutive patients have undergone RAVR. Sixty-eight percent of the cohort were males and the median age was 66 years [interquartile range (IQR), 58.5-71.8 years]. Severe aortic stenosis was the predominant lesion in 76% of patients, and degenerative calcification was the aetiology in 52% of patients. Median cardiopulmonary bypass time was 129 minutes (IQR, 113-145.5 minutes) and median ischemic time was 91 minutes (IQR, 78-105 minutes). Three patients required a re-exploration for bleeding, which was performed through the same approach, and one patient suffered an ischemic cerebro-vascular accident (CVA) with complete recovery. Median intensive care unit (ICU) length of stay and hospital length of stay were 1 and 4 days, respectively.

Conclusions: Our initial experience shows that expanding a robotic program to include RAVR is feasible, safe, and can provide excellent clinical outcomes in selected patients.

Keywords: Robotic surgery; aortic valve disease; minimally invasive surgery.

Figure 1

Intraoperative pictures of the robotic set up and the exposure of the aortic valve. (A) shows how the trocars are placed in the chest. (B) shows direct administration of ostial crystalloid cardioplegia with a regular balloon. (C,D) displays the excellent exposure of the aortic valve, either bicuspid or tricuspid.

Figure 2

Intraoperative pictures of the aortic valve replacement and aorta closure. (A) shows the placement of the non-coronary sinus stitches, with the pledgets in the ventricular aspect of the annulus for supra-annular implant. (B) shows the final positioning of the prosthesis in the native annulus and a direct inspection of the left ventricular outflow tract. In (C) we can see how the aortotomy is closed with a double polypropylene suture.