Concomitant robotic mitral and tricuspid valve repair: technique and early experience

Robotic Totally Endoscopic Tricuspid Valve Surgery: Early Results and Midterm Outcomes

OBJECTIVE

Although robotic cardiac surgery is becoming more widely adopted for mitral valve procedures, robot-assisted tricuspid valve (TV) surgery is less common. We describe clinical and echocardiographic outcomes for 70 isolated and concomitant TV repair (TVr) cases.

METHODS

Patients who underwent robotic totally endoscopic TV surgery at our institution were retrospectively reviewed. The da Vinci Si or Xi robot (Intuitive Surgical, Sunnyvale, CA, USA) was used for all cases, employing an 8 to 10 mm working port and using cardiopulmonary bypass on a beating heart. Early and midterm outcomes were reviewed, along with echocardiogram results when available.

RESULTS

Between 2014 and 2024, 70 patients underwent TVr. Fourteen cases were isolated TV procedures and 56 were concomitant with mitral surgery. The mean patient age was 67 ± 14.4 years, 57% were female, and 11 patients (16%) had previous heart surgery. TVr with an annuloplasty band occurred in 97% of patients, 1 patient had a tissue valve replacement, and there were no conversions to sternotomy. Early mortality occurred in 1 patient (1.4%) with an observed to expected ratio of 0.4. Early postoperative echocardiography revealed none to mild residual tricuspid regurgitation (TR) in 65 patients (93%). Clinical follow-up was completed in 97% of patients. All-cause mortality occurred in 14 patients (20%), 11 of which were noncardiac, including cancer, gastrointestinal bleed, end-stage renal disease, SARS-CoV-2 infection, and drug overdose. Follow-up echocardiography results were available for 46 patients (66%) at a mean of 45 months, showing moderate or more recurrent TR in 6 patients (9%).

CONCLUSIONS

Robot-assisted totally endoscopic TV surgery, for both isolated and concomitant TV disease, is a safe and effective approach. The sternal-sparing nature allows for rapid recovery and positive midterm outcomes.

Concomitant Procedures in Robotic Mitral Valve Surgery

The robotic platform may provide advantages over sternotomy including improved visualization and greater dexterity. With emerging evidence increasingly supporting the importance of concomitantly addressing tricuspid regurgitation and atrial fibrillation, robotic surgeons should be encouraged to perform appropriate concomitant procedures where indicated.

Is concomitant tricuspid valve repair in patients undergoing robotic mitral valve repair safe and effective?

Objectives

Robotic-assisted mitral valve repair (MVr) is a well-established procedure for management of degenerative mitral valve disease. Limited data regarding concomitant robotic-assisted tricuspid valve repair (TVr) is available. This review investigates prevalence and outcomes of concomitant robotic-assisted mitral and tricuspid valve repair.

Methods

From 2014 to 2022, 839 patients underwent robotic-assisted MVr, including 76 patients with moderate or greater tricuspid regurgitation and/or tricuspid annular dilatation ≥40 mm. Among the 76 patients, 19 (25%) underwent isolated MVr and 57 (75%) had concomitant mitral and tricuspid valve repair. Outcome data between the 2 groups were analyzed.

Results

In the MVr/TVr group, tricuspid regurgitation grades were mild in 4 (7%) patients, moderate in 44 (77%) and severe in 9 (15.7%). Significant tricuspid annular dilatation ≥40 mm was present in all patients. In the isolated MVr group, 3 (15.7%) patients had mild tricuspid regurgitation and 16 (84.2%) had moderate tricuspid regurgitation with significant tricuspid annular dilatation present in only 6 patients. Cardiopulmonary bypass and crossclamp time were 130.6 and 91 minutes versus 85 and 55.4 minutes for robotic MVr/TVr group versus MVr group, respectively (P < .05). The intensive care unit and hospital length of stay were similar: 27.7 versus 27.7 hours and 4.4 versus 4.2 days for MVr/TVr versus MVr (P = .24), respectively. There were no perioperative deaths or heart block in either group. Survival and freedom from reoperation with median follow-up of 16 and 46 months for MVr/TVr and MVr groups, respectively were 100%.

Conclusions

Concomitant robotic-assisted tricuspid valve repair for functional regurgitation can be safely and effectively performed at the time of mitral valve repair with excellent short-term morbidity and mortality results.

Concomitant Tricuspid Valve Surgery Is Not Associated With Increased Operative Risk During Robotic Mitral Valve Surgery

OBJECTIVE

The aim of this study was to investigate the outcomes of robotic mitral valve surgery with and without concomitant tricuspid valve surgery.

METHODS

Patients who underwent robotic mitral surgery between March 2010 and September 2022 were included. Patients were grouped according to the presence of concomitant tricuspid interventions. The groups were compared for baseline factors, operative parameters, and early postoperative outcomes. Age- and gender-matched groups were also compared for outcomes.

RESULTS

The study included 285 robotic mitral surgery patients. There were 59 patients who underwent concomitant tricuspid interventions. In the concomitant tricuspid surgery group, cardiopulmonary bypass time (150.1 vs 128.4 min, P < 0.001) and cross-clamp time (99.2 vs 82.4 min, P < 0.001) were longer. Prolonged intubation was more frequent in the concomitant tricuspid intervention group (5.2% vs 0.5%, P = 0.029). The groups did not differ in terms of mortality, permanent pacemaker (PPM) requirement, or other morbidities. Perioperative outcomes were similar after matched group analysis.

CONCLUSIONS

Operative mortality and early adverse outcomes did not increase with the addition of tricuspid intervention in our cohort of robotic mitral surgery patients. The robotic approach for mitral disease and coexisting tricuspid disease may offer safe results without an increased risk of postoperative PPM requirement.

Short- and Midterm outcomes of modified robotic tricuspid annuloplasty for secondary tricuspid regurgitation

BACKGROUND

Despite the growing popularity of robotically assisted mitral repair, robotically assisted tricuspid repair has not been widely adopted. We assessed the safety and feasibility of robotic tricuspid annuloplasty with continuous sutures for tricuspid regurgitation (TR).

METHODS AND RESULTS

We studied consecutive 68 patients (median age, 74 years) with secondary TR who underwent tricuspid annuloplasty using continuous sutures with (n = 61) and without mitral valve repair (n = 7) from 2018 to 2021. Robotic tricuspid annuloplasty consists of continuous sutures with flexible prosthetic band to the tricuspid annulus using two V-Loc barbed sutures (Medtronic Inc., Minneapolis, MN). Concomitant maze procedure was performed in 45 (66%) patients. Robotic tricuspid annuloplasty with continuous sutures was successfully performed. There was no in-hospital or 30-day mortality; 65 patients (96%) did not experience major surgery-related complications. Preoperatively, the TR grade was mild in 20 (29%) patients and mildly higher in 48 (71%). Postoperatively, the TR severity significantly improved, with TR grade mildly higher in 9% at hospital discharge and 7% at 1-year follow-up (p < 0.001). The 1-year and 2-year freedom rates from heart failure were 98% and 95%, respectively.

CONCLUSIONS

Robotic tricuspid annuloplasty with continuous sutures is safe and feasible alone or concomitant with mitral valve repair. It offered sustained improvement in TR severity and might prevent heart failure readmission.

Totally Endoscopic Robot-Assisted Aortic Valve Replacement and Complex Mitral Valve Repair: The Lateral Approach

A 76-year-old male patient was referred to our institution with moderate-to-severe aortic and mitral insufficiency. The patient underwent totally endoscopic robot-assisted aortic valve replacement and mitral valve repair. In this article, we present our lateral approach to the robotic double valve surgery.

Combined transcatheter mitral and tricuspid edge-to-edge repair: expanding the horizons of interventional heart failure

PURPOSE OF REVIEW

The combination of mitral regurgitation and tricuspid regurgitation is common in patients with multiple valvular disease and patient management can be challenging. Surgical combined mitral and tricuspid valve surgery is a treatment option for patients meeting criteria but has demonstrated inconsistent long-term benefits.

RECENT FINDINGS

Transcatheter mitral and tricuspid edge-to-edge repair has demonstrated early promising results in patients with a prohibitive surgical risk, making it an interesting treatment option. The present review will discuss the physiopathology of this complex disease and contemporary data regarding treatment options for the treatment of combined mitral and tricuspid regurgitation.

SUMMARY

Combined transcatheter mitral and tricuspid edge-to-edge repair is a novel treatment option for patients with multiple valvular disease. Further studies are needed to determine optimal patient selection and timing of intervention and demonstrate survival benefit and improvement in clinical outcomes. Advances in technology, with dedicated devices and enhanced imaging techniques may also improve patient outcomes.

Is tri-port totally thoracoscopic surgery for mitral valve replacement a feasible approach?

Background

Minimally invasive cardiac surgery is an attractive approach for both surgeons and patients. This study aims to describe the experience of mitral valve replacement (MVR) with Ma's tri-port totally thoracoscopic cardiac surgery technique (MTCST) and to prove the feasibility and safety of this technique.

Methods

A total of 490 consecutive patients undergoing MVR were divided into MTCST group (MT group, n=267) and conventional median sternotomy group (MS group, n=223). The perioperative characteristics and the follow-up information were recorded and analyzed between the two groups.

Results

The in-hospital mortality and re-operation rate were not significant between the two groups. Compared with the MS group, cardiopulmonary bypass time and aortic cross-clamp time were both longer in the MT group while total operative time was similar to the MS group. Patients in the MT group had less pain and required a decreased analgesic administration than that in the MS group. Intraoperative blood loss, perioperative blood transfusion and the postoperative drainage were all significantly reduced in the MT group as compared to the MS group. Mechanical ventilation time, ICU duration, hospitalization time and hospitalization cost were decreased in the MT group. Patients undergoing MVR with MTCST had a higher Medical Treatment Satisfactory Score than those with conventional sternotomy.

Conclusions

MTCST for mitral valve disease was technically safe and feasible. The results showed that MTCST was a suitable minimally invasive alternative to the conventional sternotomy approach and was a desirable approach for patients with mitral valve disease.

The feasibility of robotic-assisted concomitant procedures during mitral valve operations

BACKGROUND

In this study, we present our clinical experience and midterm results with the robotic-assisted concomitant procedures during mitral valve operations.

METHODS

Between March 2010 and February 2018, a total of 34 patients (8 males, 26 females; mean age 58.3 years; range, 34 to 78 years) who underwent robotic-assisted concomitant procedures during mitral valve surgery were retrospectively analyzed. Demographic characteristics of the patients, comorbidities, medical, and surgical histories, operative and laboratory results, electrocardiographic findings, postoperative intensive care unit and ward outcomes, and cardiac follow-up data were recorded. Atrial fibrillation-related medication use, stroke, or other thromboembolic events, and electrocardiographic reports in patients who underwent cryoablation were reviewed at three and 12 months after the operation.

RESULTS

A total of 76 robotic-assisted concomitant procedures were performed during mitral valve repair (n=11) or replacement (n=23) in 34 patients. These procedures were cryoablation (n=29), tricuspid valve repair (n=6), tricuspid valve replacement (n=2), left atrial appendage ligation (n=32), atrial septal defect and patent foramen ovale closure (n=5), and left atrial thrombectomy (n=2). The mean preoperative EuroSCORE values were 5.1±2.5. The mean duration of cardiopulmonary bypass and cross-clamp was 156±69.4 min and 101±42 min, respectively. Normal sinus rhythm was restored in 85% of the patients (24/28) after cryoablation and two patients (5.8%) had permanent pacemaker within a year during follow-up. There was one (2.9%) mortality in the early postoperative period due to hemorrhage related to the posterior left ventricular wall rupture. No blood product was used in 82.4% of the patients. One patient had a transient cerebral event and symptoms regressed completely within two months.

CONCLUSION

Technological improvements and growing experience can decrease the suspects related to prolonged operational duration during robotic-assisted cardiac surgery. Concomitant procedures in addition to mitral valve operations can be performed with low complication rates in centers with experience of robotic surgery.

External aortic clamping versus endoaortic balloon occlusion in minimally invasive cardiac surgery: a systematic review and meta-analysis

OBJECTIVES

Minimally invasive cardiac valve surgery is safe, effective and increasingly popular. It is performed worldwide with the use of either external aortic clamping or endoaortic balloon occlusion.

METHODS

We conducted a literature search using MEDLINE, EMBASE, Scopus and Web of Science. Primary outcomes included aortic dissection, conversion to sternotomy, mortality, stroke and cross-clamp time. Secondary outcomes included atrial fibrillation, acute kidney injury, reoperation for bleeding, cardiopulmonary bypass times, myocardial infarction, use of intra-aortic balloon pump and length of hospital stay. The random effects model was used to calculate the outcomes of both binary and continuous data.

RESULTS

Thirty retrospective studies were included in the meta-analysis. The incidence of aortic dissection (pooled odds ratio = 3.88, 95% confidence interval = 1.06-14.18; P =0.04) and conversion to sternotomy (pooled odds ratio = 3.07, 95% confidence interval = 1.33-7.10; P = 0.009) was higher in the endoaortic balloon occlusion group than in the external aortic clamping group, in whom a direct comparison was possible. The remaining observational studies did not show any significant differences in either group. There was no significant difference in 30-day mortality (P = 0.37), stroke (P = 0.26), cross-clamp time (P = 0.20), atrial fibrillation (P = 0.18), acute kidney injury (P = 0.49), reoperation for bleeding (P = 0.24), cardiopulmonary bypass time (P = 0.06), myocardial infarction (P = 0.74), use of intra-aortic balloon pump (P = 0.11) or length of hospital stay (P = 0.47).

CONCLUSIONS

External aortic clamping may be safer than endoaortic balloon occlusion with respect to aortic dissection and conversion to sternotomy. However, mortality, length of stay, stroke, cross-clamp time and other cardiovascular complication rates were similar between the 2 techniques.

Totally Endoscopic Robotic Management of Failed Percutaneous Atrial Septal Defect Closure With Tricuspid Valve Injury

Totally endoscopic robotic surgery is a safe approach to atrial septal defect closure in adults. Robotic approach can be an alternative to traditional incisions in the management of concomitant tricuspid valve regurgitation with ruptured chordae tendineae. Herein, we describe a woman who presented with atrial septal defect and tricuspid insufficiency after an unsuccessful percutaneous intervention with device removal from the right ventricle. Concomitant closure of septal defect and tricuspid valve repair with artificial chords was successfully performed using robot assistance.

Minimally Invasive Redo Mitral Valve Replacement using a Robotic-Assisted Approach

Minimally invasive, robotic-assisted cardiac surgery has been shown to decrease transfusion rates, decrease wound infection rates, shorten hospital length of stay, and allow for a faster return to full activity compared with traditional sternotomy approaches. However, its application has chiefly been limited to primary, isolated procedures such as primary mitral valve repair or replacement. We describe the first reported use of a robotic surgery platform to perform reoperative mitral valve replacement using a minimally invasive, totally endoscopic, port-access approach.

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.

Clinical outcomes of robotic mitral valve repair: a single-center experience in Korea

BACKGROUND

Since the inception of robotic mitral valve repair (MV) in 2007 at our institution, it has become an acceptable surgical option with proven efficacy and safety. The objective of this study is to analyze the early and long-term clinical outcomes of patients undergoing robotic MV repair.

METHODS

A total of 310 patients (aged 48.4±13.7 years, 201 males) undergoing robotic MV repair using the da Vinci system (Intuitive Surgical, Inc., Sunnyvale, CA) between August 2007 and December 2015 in our institution were evaluated. The preoperative demographics, operative profiles and postoperative outcomes including follow-up echocardiographic results were analyzed.

RESULTS

Successful MV repair was achieved in 98.4% (n=305) of patients, with no significant residual mitral regurgitation (MR) postoperatively. There were no early postoperative deaths. Early postoperative complications included: stroke (n=3, 1.0%), new onset dialysis (n=1, 0.3%) and reoperation (n=3, 1.0%). During a median follow-up of 55.7 months (inter-quartile range 30.3 to 81.3 months), six (1.9%) patients died, while four patients underwent late reoperation for mitral regurgitation (n=2) or infective endocarditis (n=2). Major event-free survival at five years was 87.6%. Late echocardiographic profiles (>6 months) were obtained in 295 (95.2%) patients. During follow-up, 32 (10.8%) patients developed significant mitral regurgitation (MR > grade 2), while freedom from significant MR at five years was 86.5%.

CONCLUSIONS

Robotic MV repair is a safe procedure with acceptable postoperative results, including low early postoperative morbidity and mortality and acceptable long-term repair durability.