Is minimally invasive thoracoscopic surgery the new benchmark for treating mitral valve disease?

Robotic mitral valve replacement: a short-term single institution experience

Purpose

This study evaluates the safety, efficacy, reproducibility and short-term clinical outcomes of robotic mitral valve replacement (MVR).

Methods

Between September 2022 and May 2024, 64 robotic cardiac and thoracic surgeries were performed in our institute. Twelve consecutive patients who underwent MVR using da Vinci Xi robotic system were retrospectively analysed. It was performed by right side approach using four instrument ports and one 4-cm working port, under peripheral cardiopulmonary bypass (CPB) with transoesophageal echocardiography (TEE) surveillance.

Results

The mean age of patients was 39 ± 9 years (median = 42 years), male-to-female ratio of 1:2, left ventricular ejection fraction (LVEF) = 60 ± 5%. The mean CPB and aortic cross clamp (ACX) time was 273 ± 119 min (174-568 min) and 160 ± 91 min (85-395 min) respectively. All patients received mechanical valve. The ventilation time and length of intensive care unit (ICU) stay was 21 ± 8 h and 3 ± 2 days respectively. The median drain output was 258 ml (Interquartile Range (IQR) = 240-353ml). Two patients (16.67%) were re-explored the same day in view of excessive drain output. Two patients required postoperative opioid analgesics (16.67%). One (8.33%) patient had groin wound infection. There was no mortality. Patients were ambulated from postoperative day 3.91 ± 1.80 days. Duration of hospital stay post-surgery was 9 ± 3 days, and patients were discharged after therapeutic International Normalised Ratio (INR) of 3 was achieved. Postoperative pain score of study group was 3 ± 1 (mild). Patients were satisfied with aesthetically pleasing scar and returned to routine activity within 4 ± 1 weeks. The mean follow-up time was 10.17 ± 5.11 months.

Conclusion

Robotic MVR surgery is safe and has excellent short-term outcomes. Patients experienced less pain and faster recovery.

Contemporary Review of Minimally Invasive Mitral Valve Surgery: Current Considerations and Innovations

Minimally invasive mitral valve surgery (MIMVS) has become a well-established alternative to traditional median sternotomy at high-volume surgical centers. Advancements in surgical instruments have led to further refinement of MIMVS. However, MIMVS remains limited to select patients in select settings. In this review, we provide a brief overview of the evolution of MIMVS, as well as a technical description of the most relevant aspects of minimally invasive mitral valve surgery.

Totally thoracoscopic surgical resection of left ventricular benign tumor

OBJECTIVE

The study objective was to explore the feasibility and safety of totally endoscopic resection of a left ventricular tumor through small chest incisions without robotic assistance.

METHODS

Four patients with a left ventricular tumor (1 papillary fibroelastoma, 1 lipoma, and 2 myxomas) underwent surgery with peripheral cardiopulmonary bypass. The mean age of patients was 58 ± 15 years. There were 3 female patients and 1 male patient. Through 3-port incisions in the right chest, pericardiotomy, bicaval cannulation, cardiac arrest, and atriotomy, left ventricular tumor resection was performed under thoracoscopy.

RESULTS

All patients had successful resections. The cardiopulmonary bypass and aortic crossclamp times were 110 ± 14 minutes and 58 ± 19 minutes, respectively. The length of stay in the intensive care unit was 38 ± 27 hours. There were no mortalities or complications in this cohort. Patients were discharged 7 days after the operation. Transthoracic echocardiography showed that the cardiac tumor was completely removed without any residue 3 months after surgery.

CONCLUSIONS

Totally endoscopic left ventricular tumor resection without a robotically assisted surgical system is feasible and reproducible. This technique could minimize surgical trauma and achieves complete tumor resection.

Feasibility, safety, and short-term outcome of totally thoracoscopic mitral valve procedure

Background

The totally thoracoscopic procedure for mitral valve (MV) disease is a minimally invasive method. We investigated the procedure’s feasibility, safety and effectiveness when it was performed by an experienced operator.

Methods

We retrospectively analysed 53 consecutive patients with MV disease treated between December 2014 and April 2017 by minimally invasive procedures. The procedures were performed on femoral artery-vein bypass through three 2–4 cm incisions, with one additional penetrating point on the right chest wall under totally thoracoscopic visual guidance and surveillance of transoesophageal echocardiography.

Results

Two patients who underwent intraoperative conversion to sternotomy were excluded due to indivisible pleural cavity adhesion. Of the others (38 female patients, average age, 49 ± 14 years, left ventricular ejection fraction, 59 ± 7%), 34 received MV replacement for rheumatic mitral lesions, which was redone for one patient after the discovery of serious paravalvular leakage, 17 received MV repair for mitral regurgitation (with 4 secondary to atrial septum defect, 2 diagnosed with left atrial myxoma, and 2 redone for mitral valve replacement due to repair failure), 28 received additional tricuspid valvuloplasty, and one patient received a Warden procedure. The cardiopulmonary bypass and aortic cross clamp times were 144 ± 39 min and 80 ± 22 min, respectively. Postoperational chest tube drainage in the first 48 h was 346 ± 316 ml. The ventilation time and intensive care unit stay length were 11 ± 11 h and 23 ± 2 h, respectively. One patient died of disseminated intravascular coagulation and prosthesis thrombosis with fear of anticoagulation-related bleeding.

Conclusions

The totally thoracoscopic procedure on mitral valves by an experienced surgeon is technically feasible, safe, effective and worthy of widespread adoption in clinical practice.