Robotic mitral valve replacement

The role of robotic technology in minimally invasive surgery for mitral valve disease

INTRODUCTION

Robotic mitral valve surgery has developed for more than 20 years. The main purpose of robotic assistance is to use multiwristed instruments for surgical endothoracic maneuvers on the mitral valve without opening the chest. The surgeon controls the instruments remotely from a console but is virtually immersed into the operative field.

AREAS COVERED

This review outlines indications and contraindication for the procedure. Intra- and postoperative results as available in the literature are reported. Further areas focus on the technological development, advances in surgical techniques, training methods, and learning curves. Finally we give an outlook on the potential future of this operation.

EXPERT OPINION

Robotic assistance allows for the surgically least invasive form of mitral valve operations. All variations of robotic mitral valve repair and replacement are feasible and indications have recently been broadened. Improved dexterity of instrumentation, 3D and HD vision, introduction of a robotic left atrial retractor, and adjunct technology enable most complex forms of minimally invasive mitral valve interventions through ports on the patient's right chest wall. Application of robotics results in significantly reduced surgical trauma while maintaining safety and outcome standards in mitral valve surgery.

Robotic mitral valve operations can be safely performed in obese patients

INTRODUCTION

Robotic cardiac surgery offers mitigated risks for obese patients requiring mitral valve surgery. We aimed to study the safety of robotic mitral surgery in the obese patient population by analyzing the outcomes of mitral surgery patients in our center for robotic cardiac surgery.

METHOD

This study retrospectively included 123 consecutive patients who underwent robotic mitral valve operations in a single center for robotic cardiac surgery. Patients with body mass index (BMI) ≥ 30 were compared against patients with BMI < 30 for demographic and operative parameters as well as postoperative outcomes.

RESULTS

Mean BMI was 33.9 ± 2.8 in the obesity group (n = 87) and 25.4 ± 2.7 in the no-obesity group (n = 36). Female gender (80.6% vs. 52.9%, p = .004), diabetes (25.0% vs. 10.3%, p = .036), and hypertension (48.6% vs. 26.4%, p = .018) were more common in patients with obesity. The obesity group was operated with similar cardiopulmonary bypass and total operative times with the no-obesity group. Postoperative drainage and blood transfusion requirements were similar between the groups. Mechanical ventilation times (6.1 ± 2.2 vs. 8.0 ± 4.4 h, p = .003) and intensive care unit stay (20.4 ± 1.6 vs. 29.4 ± 3.7, p = .027) were shorter in the obesity group. Other postoperative outcomes of infection, atrial fibrillation, hospital stay duration, and readmission rates were similar between the groups.

CONCLUSION

Robotic mitral surgery is safe to perform in obese patients. Obesity should not be a contraindication for robotic mitral surgery as obese patients have outcomes similar to nonobese patients despite increased challenges and risk-factors.

An analysis of the learning curve for robotic-assisted mitral valve repair

BACKGROUND

Many cardiac surgeons receive training for sternotomy-based cardiac surgical operations in residency programs and only a few education programs offer training specifically in minimally invasive cardiac surgery. In this report, we aimed to search and analyze the learning curve for robotic-assisted mitral valve (MV) repair in cardiac surgeons.

METHOD

Between January 2010 and July 2019, 60 robotic-assisted isolated MV repair surgeries were performed with DaVinci Robotic Systems in our center. Different kinds of surgical techniques were used. The assessment of the learning curve was based on cardiopulmonary bypass (CPB) and transthoracic aortic clamp (CC) times.

RESULT

There were 23 (38.3%) men and 37 (61.7%) women with a mean age of 48.3 years. The lesions of the MV were posterior leaflet prolapsus (n = 42, 70.0%), anterior leaflet prolapsus (n = 8, 13.3%), Barlow disease (n = 3, 5%), and annular dilatation (n = 7, 11.6%). The patients underwent notochordal implantation (n = 27, 45%), quadrangular or triangular resection (n = 23, 38.3%), isolated ring annuloplasty (n = 7, 11.7%), resection, and leaflet reduction (n = 2, 3.3%) or edge to edge repair (n = 1, 1.7%). The maturation of the learning curve appeared to be about 30 cases. The statistical analysis showed that the mean CPB and CC times for the first 30 cases were greater compared with the 30 after learning curve (155.3 vs. 118.9 min [p = .00], 102.3 vs. 80 min [p = .00], respectively). There was no case of conversion to open surgery. No perioperative mortality was observed.

CONCLUSION

The maturation of the learning curve for robotic-assisted MV repair appeared to be about 30 cases in our group of patients. This study had encouraging results for surgeons who desire to start a robotic mitral surgery program.

Surgical effect and long-term clinical outcomes of robotic mitral valve replacement: 10-year follow-up study

BACKGROUND

To assess the safety and effectiveness, clinical experience with totally robotic mitral valve replacement (TE-MVR) for treating valvular heart disease was summarized and analyzed, and patients' recovery conditions were followed-up.

METHODS

The clinical data of 47 patients who received TE-MVR in our hospital between October 2008 and December 2015 were retrospectively analyzed. Among the patients, there are 26 men and 21 women. The mean age was 47.53±10.80 years. We followed up the transesophageal echocardiography (TTE) data of post-discharge patients and analyzed the operation results to determine the surgical effects of TE-MVR. The surgeries were mainly performed with the da Vinci Si robotic surgical system.

RESULTS

Thirty-five mechanical valves and twelve bioprosthetic valves were implanted. The cardiopulmonary bypass and aortic cross-clamping times were 122.02±25.45 min and 85.68±20.70 min, respectively. There was no operative mortality. The perioperative complication could only be found in one case, which was pleural effusion. All the TTE results were satisfying before discharge. No paravalvular leakage or prosthetic valve dysfunction was detected. All 47 patients were discharged successfully. During the long-term follow-up (28-110 months), 42 patients were followed-up (89.4%). Most of their heart function was NYHA class I and II. The postoperative TTE showed that the left atrial diameter and left ventricle diameter were decreased (P<0.01).

CONCLUSIONS

TE-MVR is reliable and effective, and the postoperative follow-up results revealed good heart function. Patients will obtain benefits from TE-MVR, such as small trauma and rapid recovery. Thus, it is a good minimally-invasive surgery of choice.

Application of cryoablation for the treatment of atrial fibrillation in patients undergoing cardiac surgery: Our mid-term results

Background

In this study, we aimed to present mid-term results of concomitant argon-based cryoablation in patients undergoing cardiac surgery.

Methods

Between August 2014 and May 2016, 33 patients (17 males, 16 females; mean age 63.9 years; range 45 to 82 years) underwent the Maze procedure using cryoablation for the treatment of atrial fibrillation during a concomitant open cardiac operation. Robot-assisted procedures were used in 12 patients. Biatrial or isolated left atrial ablation was performed according to the underlying pathology. The rhythm assessment with 12-lead electrocardiography and 24-hour Holter, and recordings of atrial fibrillation-related medications, stroke or other thromboembolic events were evaluated by the cardiologist at 3 and 12 months postoperatively.

Results

Thirty patients (90.9%) were in sinus rhythm and three (9.1%) were in atrial fibrillation at the time of discharge. Cryoablation failed in three patients (n=2, 8.3% in isolated left atrial and n=1, 11.1% in biatrial group) following the operation in the mid-term. Among the patients, there was no in-hospital mortality and no major postoperative complications such as stroke, sepsis, renal failure requiring dialysis, and prolonged respiratory failure.

Conclusion

Concomitant surgical cryoablation is an effective method for the treatment of atrial fibrillation, when performed concomitantly with other cardiac surgical procedures and results in very low atrial fibrillation recurrence, even in robotic surgery.