Endoscopic Robotic Mitral Valve Repair Research Articles

Robotic mitral valve surgery.

Totally endoscopic robotic mitral valve repair is the least invasive surgical therapy for mitral valve disease. Robotic mitral valve surgery demonstrates faster recovery with shorter hospital stays, less morbidity, and equivalent mortality and mid-term durability compared to sternotomy. In this review, we will explore the advantages and disadvantages of robotic mitral valve surgery and consider important technical details of both operative set-up and mitral valve repair techniques. The number of robotic cardiac surgical procedures being performed globally is expected to continue to rise as experience grows with robotic techniques and increasing numbers of cardiac surgeons become proficient with this innovative technology. This will be facilitated by the introduction of newer robotic systems and increasing patient demand.

Subvalvular techniques enhanced with endoscopic robotic mitral valve repair

ObjectiveTotally endoscopic intracardiac robotic surgery is generally limited to uncomplicated mitral valve surgery. With experience, our team has developed a more aggressive approach to robotic cardiac surgery that allows for repair of a broad spectrum of mitral valve pathologies. We report complex subvalvular procedural advancements associated with this approach secondary to enhanced team experience and capabilities. MethodsAll robotic mitral procedures performed by a 2-surgeon team in a quaternary care medical center from July 2011 to May 2022 were reviewed. Natural language-processing techniques were used to analyze operative reports for subvalvular repair techniques. Complex subvalvular techniques included papillary muscle repositioning, division of secondary anterior leaflet chordae, septal myomectomy, division of aberrant left ventricular muscle band attachments, and left ventricular patch reconstruction. The surgical experience was divided into 2 periods: early robotic experience (pre-2018) versus late (2018 onwards). Baseline demographics, outcomes, and subvalvular techniques were analyzed and compared. ResultsA total of 1287 intracardiac robotic operations were performed by a 2-surgeon team. Thirty-day mortality was 0.6% (8/1287). Mitral valve repair was performed in 1024 patients. The mean age was 61 years (range, 18-90 years), and 15% were >75 years old; 29 patients (2.8%) had previously undergone cardiac surgery. There was a significant increase with experience in the application of advanced subvalvular techniques between the early versus late period (52.3% [268/512] vs 74.2% [380/512] (P < .001)). ConclusionsAn experienced 2-surgeon team can perform progressively more complex robotic subvalvular repair techniques. These subvalvular techniques are a surrogate for team proficiency and capabilities.

Robotic mitral valve surgery: a review and tips for safely negotiating the learning curve.

Totally endoscopic robotic mitral valve repair represents the least invasive surgical therapy for mitral valve disease. Comparative results for robotic mitral valve surgery against sternotomy are impressive, repeatedly demonstrating shorter hospital stay, faster return to normal activities, less morbidity and equivalent mortality and mid-term durability. We lack data comparing robotic approaches to totally endoscopic minimally invasive mitral valve surgery using 3D vision platforms. In this review, we explore the advantages and disadvantages of robotic mitral valve surgery and share technical tips that we have learned to help teams embarking on their robotic journey. We consider factors necessary for the successful implementation of a robotic programme including the importance of training a dedicated team, with the common goal to avoid any compromise in either patient safety or repair quality during the learning curve. As experience grows with robotic techniques and more cardiac surgeons become proficient with this innovative technology, the volume of robotic cardiac procedures around the world will increase helped by the introduction of new robotic systems and patient demand. Well informed patients will increasingly seek out the opportunity of robotic valve reconstruction in reference centres in the hands of a few highly experienced robotic surgeons.

Advanced experience allows robotic mitral valve repair in the presence of extensive mitral annular calcification

ObjectiveMitral annular calcification is underdiagnosed in patients with mitral regurgitation. After excision, it may require reconstruction of the atrioventricular groove and decreases the probability of valve repair. We reviewed the safety and efficacy of totally endoscopic robotic mitral valve repair in the presence of mitral annular calcification, with an emphasis on pathology and repair techniques. MethodsBetween May 2011 and August 2017, the same 2-surgeon team attempted totally endoscopic robotic mitral valve repair in 64 mitral annular calcification cases, accounting for 12.8% of our experience. Mitral annular calcification associated with a calcified posterior leaflet was not considered for totally endoscopic robotic mitral valve repair. When possible, the mitral annular calcification was excised en bloc using electrocautery, the posterior leaflet separated from the mitral annular calcification and spared, the atrioventricular groove was reconstructed, the posterior leaflet was reattached to the neoannulus, and the repair was completed with annuloplasty. ResultsThe median age of patients was 65 years, with 21 (32.8%) aged less than 60 years, and 34 (53.1%) were women. The etiology was Barlow's disease in 54 patients (84%). Repair was converted to replacement in 2 patients (3.1%). Cryoablation was performed in 8 patients (12.5%), hybrid percutaneous coronary intervention was performed in 5 patients (7.8%), and tricuspid annuloplasty was performed in 2 patients (3.1%). Median aortic occlusion was 122 minutes, excluding cases with concomitant tricuspid repair. Thirty-three patients (52%) were extubated in the operating room. The median length of stay was 4 days. Residual mitral regurgitation on discharge transthoracic echocardiogram was none to mild in all patients. None of the patients had a perioperative stroke or needed a pacemaker. Thirty-day mortality was 2 (3.1%). ConclusionsMitral annular calcification is present in a significant percentage of patients with mitral regurgitation, especially in Barlow's disease, including younger patients. By using a variety of repair techniques, totally endoscopic robotic mitral valve repair can be performed safely and effectively in most mitral annular calcification cases with a noncalcified posterior leaflet.

First Major Clinical Outcomes of Totally Endoscopic Robotic Mitral Valve Repair in Japan - A Single-Center Experience.

In 2018, Japan became the first country to have robotic cardiac surgery covered under the national health insurance. The number of patients undergoing robotic mitral valve (MV) repair has been estimated to increase remarkably, but no reports in Japan have yet described the outcomes of robotic MV repair. This study aimed to analyze the early clinical outcomes of patients undergoing totally endoscopic robotic MV repair (TERMVR) as a landmark national study for this procedure.Methods and Results:A total of 213 patients (152 men; mean age, 55±11 years) underwent TERMVR during May 2014 to December 2018. Preoperative demographics, operative profiles, and postoperative outcomes, including follow-up echocardiography, were analyzed. Successful TERMVR was achieved in all patients. Operation, cardiopulmonary bypass, and aortic cross-clamp times were 192±49.8, 127±23.8, and 70.1±16.2 min, respectively. Intraoperative transfusion was performed in 20 patients (10%). There were no in-hospital deaths. All patients were alive during the median follow-up period of 255 days (interquartile range, 32.5-208 days). Freedom from recurrence of MR >grade 2+ was 97.3%, 95.0%, and 90.7% at 6, 12, and 24 months, respectively. TERMVR is an effective and safe procedure with acceptable early postoperative outcomes.

Does paravertebral blockade facilitate immediate extubation after totally endoscopic robotic mitral valve repair surgery?

Immediate extubation of select patients in the operating room after cardiac surgery has been shown to be safe and may result in improved hemodynamics and decreased cost perioperatively. The aim of this study was to evaluate whether the addition of paravertebral blockade (PVB) to general anesthesia facilitates extubation in the operating room in patients undergoing totally endoscopic robotic mitral valve repair (TERMR). A review of 65 consecutive patients who underwent TERMR between January 2012 and June 2013 at a single institution was conducted. Patients were divided into two groups, one group that received PVB and general anesthesia and a second group that received general anesthesia alone. The data analyzed included quantities of anesthetic administered during surgery and the location of extubation after surgery. A total of 34 patients received PVB and general anesthesia, whereas 31 received general anesthesia alone. The two groups had similar demographic and surgical data. Patients in the PVB and general anesthesia group were more likely to be extubated in the operating room (67.6%, n = 23 vs 41.9%, n = 13, P = 0.048) and required less intraoperative fentanyl (3.41 μg/kg vs 4.90 μg/kg, P = 0.006). There were no adverse perioperative events in either group related to PVB or extubation. The addition of PVB to general anesthesia for perioperative pain control facilitated extubation in the operating room in patients undergoing TERMR. Paravertebral blockade allowed for lower intraoperative fentanyl dosing, which may account for the increased incidence of immediate extubation. A detailed prospective study is warranted.

Does Paravertebral Blockade Facilitate Immediate Extubation after Totally Endoscopic Robotic Mitral Valve Repair Surgery?

Does Paravertebral Blockade Facilitate Immediate Extubation after Totally Endoscopic Robotic Mitral Valve Repair Surgery?

Fluorescence-guided placement of an endoaortic balloon occlusion device for totally endoscopic robotic mitral valve repair

Fluorescence-guided placement of an endoaortic balloon occlusion device for totally endoscopic robotic mitral valve repair

Outcomes of peripheral perfusion with balloon aortic clamping for totally endoscopic robotic mitral valve repair

Although the technique of totally endoscopic robotic mitral valve repair (TERMR) has been well described, few reports have examined the results of peripheral perfusion with balloon clamping. We analyzed the outcomes of TERMR performed using this strategy. A total of 108 consecutive patients underwent TERMR by a 2-surgeon team. The preoperative evaluation included chest computed tomography and abdominal and pelvis computed tomography. Additional procedures included appendage exclusion in 96, patent foramen ovale closure in 29, cryoablation in 16, tricuspid valve repair in 2, and septal myectomy in 2. The mean patient age was 59 years (range, 21-86). Central venous drainage was obtained with a long cannula. Arterial return was achieved with femoral cannulation, when possible. An endoballoon catheter was placed through the femoral artery. Transesophageal echocardiography was used to position all catheters. Femoral artery perfusion was possible in 103 of 108 patients (95.3%). The subclavian artery was used in 5 patients (4.6%) with contraindications to retrograde perfusion. An endoballoon clamp was placed by way of the femoral artery. In 105 of 108 patients (97.2%), endoaortic occlusion was successfully used; the mean crossclamp time was 87.4 minutes. The coronary sinus cardioplegia catheter was placed successfully in 81 of the 108 patients (75%). Postoperatively, no or mild inotropic support was needed in 94 (87%) and moderate support in 14 (13.0%). Of the 108 patients, 55 (50.9%) were extubated in the operating room. No hospital mortality, aortic injury, vascular complications, or wound infections occurred. Complications included 2 strokes (no residual deficit) (1.8%) and atrial fibrillation in 18 (16.7%). The median hospital stay was 4 days. Eighty patients (74.1%) were discharged by postoperative day 5. A preoperative image-guided perfusion strategy and aortic balloon clamping permit routine TERMR with excellent myocardial preservation and minimal complications.

Can the Learning Curve of Totally Endoscopic Robotic Mitral Valve Repair be Short-Circuited?

A concern with the initiation of totally endoscopic robotic mitral valve repair (TERMR) programs has been the risk for the learning curve. To minimize this risk, we initiated a TERMR program with a defined team and structured learning approach before clinical implementation. A dedicated team (two surgeons, one cardiac anesthesiologist, one perfusionist, and two nurses) was trained with clinical scenarios, simulations, wet laboratories, and "expert" observation for 3 months. This team then performed a series of TERMRs of varying complexity. Thirty-two isolated TERMRs were performed during the first programmatic year. All operations included mitral valve repair, left atrial appendage exclusion, and annuloplasty device implantation. Additional procedures included leaflet resection, neochordae insertion, atrial ablation, and papillary muscle shortening. Longer clamp times were associated with number of neochordae (P < 0.01), papillary muscle procedures (P < 0.01), and leaflet resection (P = 0.06). Sequential case number had no impact on cross-clamp time (P = 0.3). Analysis of nonclamp time demonstrated a 71.3% learning percentage (P < 0.01; ie, 28.7% reduction in nonclamp time with each doubling of case number). There were no hospital deaths or incidences of stroke, myocardial infarction, unplanned reoperation, respiratory failure, or renal failure. Median length of stay was 4 days. All patients were discharged home. Totally endoscopic robotic mitral valve repair can be safely performed after a pretraining regimen with emphasis on experts' current practice and team training. After a pretraining regimen, cross-clamp times were not subject to learning curve phenomena but were dependent on procedural complexity. Nonclamp times were associated with a short learning curve.

Can the Learning Curve of Totally Endoscopic Robotic Mitral Valve Repair be Short-Circuited?

Can the Learning Curve of Totally Endoscopic Robotic Mitral Valve Repair be Short-Circuited?

Multicenter Mitral Valve Study: A Lateral Approach Using the da Vinci Surgical System

: The purpose of this study was to demonstrate the feasibility of simple to complex endoscopic robotic mitral valve repair, using a lateral approach. : Data were retrospectively collected on 201 patients undergoing a lateral "ports only" endoscopic robotic mitral valve repair at three institutions. Techniques of aortic occlusion included the endoaortic balloon or a transthoracic clamp. The efficacy of the repair was measured intraoperatively by transesophageal echocardiogram. : Two hundred one patients with a mean age of 55.2 ± 14.2 were intended to undergo elective robotic mitral valve surgery. One hundred eighty-six (92.5%) were scheduled for a repair procedure and 15 (7.5%) were scheduled for replacement. The repair was accomplished in 179 of 186 (96.2%) of patients. Eight patients (4.3%) required a conversion to sternotomy incision. Seven converted patients received a mitral valve repair and one received a replacement mitral valve. Mitral valve pathology included 10% isolated anterior leaflet involvement, 43% isolated posterior leaflet involvement, and 6% bileaflet pathology, and the remaining patients had dilated annulus, chordal rupture, or elongation. One hundred seventy-nine patients (96.2%) had regurgitation grade of 0 to 1 after repair. Two patients (1%) died. Other adverse events included reoperation for valve-related complications, 2 of 201 (1%); reoperation for cardiac-related complications, 3 of 201 (1.5%); and new onset of atrial fibrillation, 35 of 201 (17.4%). : A lateral endoscopic robotic approach to mitral valve repair is safe, feasible, and can be performed consistently with acceptable postoperative results. Further follow-up is required to determine the long-term efficacy of this approach to robotic mitral valve repair.