Robotic mitral surgery: recent advances and outcomes.

PURPOSE OF REVIEW: This review explores recent advancements in robotic cardiac surgery, specifically focusing on its application in diverse mitral valve surgeries. The aim is to provide an overview of current clinical practices and supporting evidence in this evolving field. RECENT FINDINGS: A literature review indicates a 30% surge in robotic mitral valve repair from 2015 to 2021, paralleled by a decline in sternotomy-based repair per the STS database. Robotic mitral valve repair consistently shows effective and safe outcomes, with comparable mortality but lower morbidity risks than sternotomy and thoracotomy. The robotic approach exhibits lower conversion to valve replacement, shorter ICU stays, and reduced 30-day readmissions. For experienced programs, robotic techniques prove versatile in various pathologies, including rheumatic heart valve disease, infective endocarditis, ischemic cardiomyopathy, and mitral annular calcification necessitating valve replacement. Literature supports their selective use in high-risk scenarios, including redo surgeries and elderly patients. SUMMARY: Recent evidence supports the growing use of robotic approaches in mitral valve surgery, highlighting their efficacy with comparable mortality rates but lower morbidity risks. Robotic techniques consistently yield positive outcomes across various pathologies and patient profiles, signaling a potential paradigm shift in mitral valve interventions.

Endoscopic Robotic Mitral Operating Room as a Microsystem for Safety and Sustainability.

OBJECTIVE: Safety and sustainability are key elements of a robotic mitral valve (MV) program at any stage of development. Challenges include the positioning of the surgeon at the robotic console, increasing patient complexity, and upstream administrative staffing difficulties. We instituted a systems approach to maximize patient safety and maintain robotic service viability. METHODS: A single dedicated robotic operating room (OR) was equipped as a microsystem with team training in the operative steps, ergonomics, digital tools, and an explicit culture of safety. Outcomes of all robotic mitral procedures including concomitant procedures in the microsystem OR by a single surgeon were retrospectively reviewed. RESULTS: From January 2014 through December 2023, 1,529 consecutive MV patients were operated with an endoscopic robotic approach. Ten patients (0.65%) were converted to conventional approaches. Overall, 1,300 MV repairs (85%) were performed with residual MV regurgitation of none to trace in 1,205 patients (92.7%), mild in 92 patients (7.1%), and moderate in 3 patients (0.23%). MV replacements were performed in 229 patients (15%) with no paravalvular leaks. Mortality was 0.08% in the repair group and 0.87% in the replacement group. No deaths have occurred in the last 38 months. Stroke occurred in 0.31% of repair patients and 1.3% of replacement patients. One patient developed transient renal failure. CONCLUSIONS: Organization of the robotic OR as a microsystem is associated with surgical efficacy and very low morbidity and mortality. A comparable microsystem approach using all or select components may promote safety and sustainability for robotic MV programs at all levels.

Developing Proficiency in Robotic Cardiac Surgery.

The purpose of this manuscript is to provide recommendations for cardiac surgeons interested in adopting a robotic platform into their programs. The recommendations are based on the experience of the authors and cover a diverse array of cardiac surgical procedures that are currently being performed with robotic assistance. The focus, as with any innovative surgical approach, is to ensure patient safety, maximize quality and efficacy, and to set realistic expectations about what is required to achieve proficiency in robotic cardiac surgery.

Transthoracic Aortic Clamp Technique for Port-Only Endoscopic Robotic Mitral Surgery.

OBJECTIVE: Many robotic mitral surgeons utilize right thoracotomy with transthoracic clamping of the aorta, while a smaller number employ a port-only endoscopic approach with endoaortic balloon occlusion of the aorta. We present our technique for a port-only endoscopic robotic approach with transthoracic clamping. METHODS: From July 2019 through December 2022, 133 patients underwent port-only endoscopic robotic mitral surgery with transthoracic clamp aortic occlusion and antegrade cardioplegia. Perfusion was through the femoral artery in 101 patients (76%) and axillary in 32 patients (24%). Clamp technique involved placing the clamp at the mid-ascending aorta, dynamic valve testing to 90 mm aortic root pressure, and closure of the cardioplegia cannula site prior to clamp removal. Indications for clamp utilization over balloon occlusion included both balloon supply issues and aortoiliac anatomy. RESULTS: Mitral repair was performed in 122 patients (92.7%) and mitral valve replacement in 11 patients (8.3%). Mean aortic occlusion time was 92 ± 21.4 min. Mean time from left atrial closure to clamp removal was 8.7 (7.2 to 12.8) min. There were no injuries to the aorta or surrounding structures, mortality, strokes, or renal failure. CONCLUSIONS: For robotic teams with endoaortic balloon capability, this technique may be useful in certain patients with aorto-iliac pathology or limited femoral artery access. Alternatively, robotic teams who employ transthoracic aortic clamping through a thoracotomy may find this technique useful to transition to a port-only endoscopic approach.

Age period cohort analysis of rheumatic heart disease in high-income countries.

INTRODUCTION: Rheumatic heart disease is considered well-controlled in high-income countries; however, its actual trends in mortality remain unclarified. We analyzed trends in mortality from rheumatic heart disease in association with age, period, and birth cohort. METHODS: We analyzed the WHO mortality database to determine trends in mortality from rheumatic heart disease in the UK, Germany, France, Italy, Japan, Australia, USA, and Canada from 2000 to 2020. We used age-cohort-period modeling to estimate cohort and period effects. Net drift (overall annual percentage change), local drift (annual percentage change in each age group) and heterogeneity were calculated. RESULTS: In the most recent year, crude mortality rates and age-standardized mortality rates ranged from 1.10 in the USA to 6.17 in Germany, and 0.32 (95% CI 0.31-0.34) in Japan and 1.70 (95% CI 1.65-1.75) in Germany, respectively. During the observation period, while Germany had a constant trend in overall annual percentage change, all the other countries had significant decreasing trends (p < 0.0001, respectively). Annual percent change was not homogeneous across each group in all 8 countries (pheterogeneity < 0.0001), with 2 peaks in the younger and older age categories. In Germany, Italy, Australia, and Canada, we found increasing mortality rates among older patients. Improving period and cohort risks for rheumatic heart disease mortality were generally observed, excluding Germany where the period effect was worsening and the cohort effect was constant. CONCLUSIONS: Mortality trends from rheumatic heart disease were decreasing in the study high-income countries except for Germany where higher mortality and two peaks in annual percentage change in younger and older age groups warrant further investigation.

Endoscopic Robotic Mitral Valve Surgery in Patients With Previous Sternotomy Cardiac Surgery.

Objective: Mitral surgery is higher risk in patients with a previous median sternotomy. We describe an endoscopic robotic approach in this higher-risk cohort by an experienced robotic team. Methods: From January 2006 through June 2021, 152 consecutive patients with previous sternotomy cardiac surgery underwent mitral surgery using endoscopic robotics. Peripheral perfusion with endoaortic balloon occlusion was used in 148 patients (97.4%) and ventricular fibrillation in 4 patients (2.6%). Results: Mitral repair was performed in 73 patients (48%) including primary repair in 57 patients and re-repair in 16 patients, mitral replacement in 78 patients (51.3%) including primary replacement in 26 patients, conversion of a previous repair to replacement in 28 patients, and re-replacement in 24 patients. A paravalvular leak was primarily repaired in 1 patient (0.7%). Concomitant procedures included tricuspid repair in 28 patients (18.4%) and cryoablation in 8 patients (5.3%). Postoperative echocardiography in the mitral repair patients demonstrated none to mild regurgitation in 72 patients (98.6%). One repair patient (1.4%) had severe regurgitation and required robotic mitral replacement 5 days postoperatively. There were no paravalvular leaks in the mitral replacement patients. Operative mortality occurred in 3 patients (1.97%). Stroke occurred in 1 patient (0.7%), prolonged ventilation in 18 patients (11.8%), renal failure in 2 patients (1.4%), and re-exploration for bleeding in 10 patients (6.6%). Mean length of stay for the entire cohort was 5 ± 5.4 days. Conclusions: Robotic mitral valve surgery can be extended to patients with previous sternotomy with satisfactory efficacy and low operative mortality and morbidity.

Endoscopic Robotic Retrieval of a Migrated Subclavian Vein Stent from the Right Ventricle.

A 54-year-old woman with end-stage renal disease on hemodialysis with access through a right arm arteriovenous fistula presented with right arm swelling. Venography demonstrated right subclavian vein stenosis. A balloon angioplasty of the stenotic vein was unsuccessful, and she subsequently underwent stent placement with balloon angioplasty. Ten days following the procedure, she developed acute shortness of breath. Transthoracic echocardiogram demonstrated the migration of the venous stent into the right ventricle. Using an endoscopic robotic approach, the stent was successfully extracted from the beating heart.

Choosing the Ideal Candidate for a Robotic Valve Intervention.

Robotic cardiac surgery addressing the mitral and tricuspid valves is a highly developed field offering multiple potential advantages regarding postoperative complications, valve repair rates, hospital length of stay, and rapid functional recovery compared with the conventional sternotomy approach for select patients. The unparalleled stereoscopic view within the heart and precision of robotic arms make robotic surgery a highly attractive minimally invasive approach, facilitating repair of even the most complex valvular pathology. Careful candidate selection and surgical planning are paramount to optimising the outcomes of those who undergo robotic valve surgery. As a team's experience grows, the technique can be applied to a wider range of patients that may derive even greater benefit, such as those with significant comorbid conditions, ventricular dysfunction, and previous sternotomy. The goal of this review is to provide clinicians with a practical overview of the factors influencing a patient's candidacy for robotic valve surgery. We discuss key issues such as preoperative diagnostic assessment, concerns regarding demographics and surgical pathology, and additional considerations relating to surgical exposure, cardiopulmonary bypass, and myocardial protection. Diligent patient assessment and a strong team-based approach are paramount to developing and maintaining a successful robotic valve surgery program, with the most seasoned teams being able to safely offer the technique to the vast majority of patients referred for mitral or tricuspid valve repair or replacement.

Repeat Robotic Endoscopic Mitral Valve Operation: A Safe and Effective Strategy.

BACKGROUND: Mitral valve reoperation is necessary in a finite percentage of patients. With growth in robotic mitral valve operations, reoperative strategies need to be developed. A review of institutional mitral valve reoperations after a previous robotic approach was undertaken. METHODS: From January 2006 through April 2017, 1,853 patients underwent an initial robotic mitral valve operation by a dedicated robotic team. During this interval, 54 of these patients (2.9%) required mitral reoperation at our institution. The prospectively collected operative, echocardiographic, videoscopic, and outcome data for these patients were retrospectively reviewed to assess the feasibility, efficacy, and safety of a repeat robotic mitral valve operation. RESULTS: Reoperative mitral operation after a previous robotic procedure was completed robotically in 50 patients (92.6%). Robotic mitral re-repair was achieved in 36 of the 50 patients (72%), including 33 of the 39 patients (85%) with degenerative disease. Conversion of a previous repair to a replacement was performed in 12 patients (24%) and re-replacement in 2 patients (4%). No patients were converted from a robotic approach to a thoracotomy or sternotomy approach. There were no deaths or strokes in this series. Major morbidity occurred in 1 patient (2%) in the repeat robotic group. Sternotomy for reoperation was required in 4 patients (7%) due to right chest access or peripheral perfusion limitations. CONCLUSIONS: Repeat robotic mitral operation after a previous robotic approach is feasible and appears to be an effective and safe strategy in a high percentage of patients when performed by an experienced robotic team.

Prevention of Unilateral Pulmonary Edema Complicating Robotic Mitral Valve Operations.

BACKGROUND: Unilateral pulmonary edema (UPE) has been reported after mitral operations performed through the right side of the chest. The clinical presentation is compatible with an ischemia-reperfusion injury. This report describes modifications to robotic mitral valve operations that were designed to reduce UPE. METHODS: We reviewed 15 patients with UPE after robotic mitral valve operations from 2006 through 2012. Technique modifications to reduce right lung ischemia were used from 2013 through June 2015. Modifications included alterations in patient position, ventilation, and perfusion factors. The incidence of UPE before and after modifications was determined, as was perfusion factors and outcomes in a higher-risk patient subgroup with pulmonary hypertension and prolonged bypass procedures. RESULTS: The incidence of UPE was 1.4% (n = 15) in 1,059 consecutive robotic mitral valve procedures using the standard technique and 0.0% in 435 consecutive procedures using the modified technique (p < 0.02). All patients with UPE had pulmonary hypertension and bypass times of greater than 120 minutes. Patients in the higher-risk subgroup had significantly lower systemic temperature (31°C [range, 30°-32°C] versus 34°C [range, 33°-34°C]; p < 0.01) and higher mean perfusion pressure (67mm Hg [range 62-72 mm Hg] versus 54 mm Hg [range, 52-57 mm Hg]; p < 0.01) on bypass using the modified technique. The incidence of UPE in higher-risk patients was significantly reduced using the modified technique (0% versus 5.6%; p < 0.01) without any increase in overall morbidity or mortality. CONCLUSIONS: The incidence of UPE in patients undergoing robotic mitral valve operations has been significantly reduced using a modified technique, without increasing the perioperative complication rate. Further work is necessary to validate this protocol and understand the pathophysiology of postoperative UPE.

Minimally Invasive Mitral Valve Surgery I: Patient Selection, Evaluation, and Planning.

Widespread adoption of minimally invasive mitral valve repair and replacement may be fostered by practice consensus and standardization. This expert opinion, first of a 3-part series, outlines current best practices in patient evaluation and selection for minimally invasive mitral valve procedures, and discusses preoperative planning for cannulation and myocardial protection.

Minimally Invasive Mitral Valve Surgery II: Surgical Technique and Postoperative Management.

Techniques for minimally invasive mitral valve repair and replacement continue to evolve. This expert opinion, the second of a 3-part series, outlines current best practices for nonrobotic, minimally invasive mitral valve procedures, and for postoperative care after minimally invasive mitral valve surgery.

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.

Comparison of Endoscopic Robotic Versus Sternotomy Approach for the Resection of Left Atrial Tumors.

OBJECTIVE: Primary cardiac tumors most commonly occur in the left atrium. The aim of this study was to compare outcomes among patients undergoing isolated left atrial tumor resection via sternotomy or robotic approach. METHODS: From 2003 to 2013, 69 patients underwent isolated left atrial tumor resection at 3 affiliated hospitals with either a sternotomy (n = 39) or robotic approach (n = 30). A retrospective review of prospectively collected data was performed, and outcomes were compared between the sternotomy and robotic groups. Univariate and multivariate analyses controlling for pertinent preoperative characteristics were performed. RESULTS: Patients' characteristics in the 2 groups were similar, with the exception of a history of chronic obstructive pulmonary disease (sternotomy, 12.8% vs robotic, 0%; P < 0.04) and elective surgical status (sternotomy, 64.1% vs robotic, 93.3%; P < 0.02). On univariate analysis, robotic-assisted surgery was associated with significantly shorter postoperative mechanical ventilation, intensive care unit (ICU) length of stay (LOS), hospital LOS, and a lower rate of perioperative blood transfusion. After controlling for patient comorbidity in a multiple logistic regression model, there remained a trend toward decreased blood transfusions (adjusted odds ratio, 0.33; CI, 0.09-1.20; P = 0.09), shorter ICU (16.3 fewer hours; P = 0.11), and hospital LOS (1.1 fewer days; P = 0.17) in the robotic group. There was one postoperative stroke in the sternotomy group and none in the robotic group (P = 0.21). CONCLUSIONS: Robotic-assisted left atrial tumor resection is feasible and may be associated with a lower incidence of perioperative blood transfusion as well as shorter ventilation time, and shorter ICU and hospital LOS.

Successful Robotic Excision and Early Chemotherapy for Primary Cardiac Lymphoma.

We present a 67-year-old patient who underwent robotic excision of a mobile left ventricular mass found incidentally on echocardiography. Intraoperative findings revealed a pedunculated mass infiltrating the interventricular septum, and the results of pathologic examination of the frozen section were consistent with malignancy. The final pathologic examination showed a diffuse large B-cell lymphoma, and early chemotherapy was initiated. Follow-up cardiac positron emission tomography/computed tomography showed completely normal myocardium without evidence of malignancy. The lateral endoscopic robotic approach across the mitral valve permitted optimal tumor visualization and early chemotherapy initiation without concern for cardiac rupture or related adverse events.