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.

Patient-reported outcome measures after mitral valve repair: a comparison between minimally invasive and sternotomy.

OBJECTIVES: To compare patient-reported outcome measures of minimally invasive (MI) to sternotomy (ST) mitral valve repair. METHODS: We included all patients undergoing isolated mitral valve surgery via either a right mini-thoracotomy (MI) or ST over a 36-month period. Patients were asked to complete a modified Composite Physical Function questionnaire. Intraoperative and postoperative outcomes, and patient-reported outcome measures were compared between 2 propensity-matched groups (n = 47/group), assessing 3 domains: 'Recovery Time', 'Postoperative Pain' (at day 2 and 1, 3, 6 and 12 weeks) and 'Treatment Satisfaction'. Composite scores for each domain were subsequently constructed and multivariable analysis was used to determine whether surgical approach was associated with domain scores. RESULTS: The response rate was 79%. There was no mortality in either group. In the matched groups, operative times were longer in the MI group (P < 0.001), but postoperative outcomes were similar. Composite scores for Recovery Time [ST 51.7 (31.8-62.1) vs MI 61.7 (43.1-73.9), P = 0.03] and Pain [ST 65.7 (40.1-83.1) vs MI 79.1 (65.5-89.5), P = 0.02] significantly favoured the MI group. Scores in the Treatment Satisfaction domain were high for both surgical approaches [ST 100 (82.5-100) vs MI 100 (95.0-100), P = 0.15]. The strongest independent predictor of both faster recovery parameter estimate 12.0 [95% confidence interval (CI) 5.7-18.3, P < 0.001] and less pain parameter estimate 7.6 (95% CI 0.7-14.5, P = 0.03) was MI surgery. CONCLUSIONS: MI surgery was associated with faster recovery and less pain; treatment satisfaction and safety profiles were similar.

Reinterventions and new aortic events after aortic surgery in Marfan syndrome.

OBJECTIVES: Pre-emptive strategies to manage the aortic complications of Marfan syndrome have resulted in improved life expectancy yet, secondary to the variation of phenotypic expression, anticipating the risk and nature of future aortic events is challenging. We examine rates of new aortic events and reinterventions in a Marfan cohort following initial aortic presentation. METHODS: Retrospective cohort study of Marfan patients with aortic pathology presenting to our institution 1998-2018. Patients were grouped according to index event: aortic dissection or root aneurysm. Patients with aortic dissection were classified according to Debakey criteria. Incidence of new aortic events and frequency of reintervention were analysed. RESULTS: One hundred and twenty-six aortic procedures were performed in 74 Marfan patients with a median follow-up of 7 years. Forty-seven patients had an index event of root aneurysm and 27 had aortic dissection. Following operative intervention in the aneurysm group, 7 patients developed Debakey III dissections raising the overall number of patients who developed dissection within this cohort to 34. Reinterventions were more frequent in the dissection group with full replacement of the native aorta in 5 patients. CONCLUSIONS: After operative intervention on the proximal aorta, a proportion will develop distal pathology. A greater focus on factors contributing to future events, such as mapping genotypes to clinical course, may lead the way for targeted operative techniques and surveillance.

Cost Analysis of Minimally Invasive Mitral Valve Surgery in the UK National Health Service.

BACKGROUND: In the UK National Health Service, finite resources make the adoption of minimally invasive (MI) mitral valve surgery challenging unless greater operative costs (vs sternotomy [ST]) are balanced by postoperative savings. This study examined whether the cost analysis now became unfavorable. METHODS: All patients (n = 380) undergoing isolated mitral valve surgery with or without a maze procedure over a 3-year period by either MI or ST approaches were included. Propensity matching (2 cohorts, 1:1 matched;, n = 75 per group) and multivariable regression were used to assess for the effect on cost. Cost data were prospectively collected from Service Line Reporting and reported in Sterling (£) as median (interquartile range [IQR]). RESULTS: Matched data revealed that total hospital costs were equivalent (MI vs ST, £16,672 [IQR, £15,044, £20,611] vs £15,875 [IQR, £12,281, £20,687]; P .33). Three of 15 costing pools were significantly different: operative costs were higher for the MI group (MI vs ST, £7458 [IQR, £6738, £8286] vs £5596 iIQR, £4204, £6992]; P < .001), whereas ward costs (boarding, nursing) (MI vs ST, £1464 [IQR, £1146, £1864] vs £1733 [IQR, £1403, £2445] P = .006) and pharmacy services (MI vs ST, £187 [IQR, £140, £239] vs £244 [IQR, £179, £375] P < .001) were lower for the MI group. Hospital stay was shorter in the MI group (MI vs ST, 6 days [IQR, 5, 8 days] vs 8 days [IQR, 6, 11 days]; P < .001). Multivariable regression produced similar findings. CONCLUSIONS: There was no difference in overall hospital cost between MI and ST mitral valve surgery: higher operative costs of MI surgery were offset by lower postoperative costs, with a 2-day shorter hospital stay.

Is obesity associated with poorer outcomes in patients undergoing minimally invasive mitral valve surgery?

OBJECTIVES: High body mass index (BMI) makes minimally invasive mitral valve surgery (MIMVS) more challenging with some surgeons considering this a contraindication. We sought to determine whether this is because the outcomes are genuinely worse than those of non-obese patients. METHODS: This is a retrospective cohort study of all patients undergoing MIMVS ± concomitant procedures over an 8-year period. Patients were stratified into 2 groups: BMI ≥ 30 kg/m2 and BMI ˂ 30 kg/m2, as per World Health Organization definitions. Baseline characteristics, operative and postoperative outcomes and 5-year survival were compared. RESULTS: We identified 296 patients (BMI ≥30, n = 41, median 35.3, range 30-43.6; BMI <30, n = 255, median 26.2, range 17.6-29.9). The groups were well matched with regard to baseline characteristics. There was only 1 in-hospital mortality, and this was in the BMI < 30 group. There was no difference in repair rate for degenerative disease (100% vs 96.3%, P > 0.99 respectively) or operative durations [cross-clamp: 122 min interquartile range (IQR) 100-141) vs 125 min (IQR 105-146), P = 0.72, respectively]. There were only 6 conversions to sternotomy, all in non-obese patients. There was no significant difference in any other perioperative or post-operative outcomes. Using the Kaplan-Meier analysis, there was no significant difference in 5-year survival between the 2 groups (95.8% vs 95.5%, P = 0.83, respectively). CONCLUSIONS: In patients having MIMVS, there is insufficient evidence to suggest that obesity affects either short- or mid-term outcomes. Obesity should therefore not be considered as a contraindication to this technique for experienced teams.

Causes of successful medico-legal claims following amputation.

INTRODUCTION: The causes of successful medico-legal claims following amputation were reviewed. METHODS: A retrospective analysis of claims handled by the National Health Service Litigation Authority, from 2005 to August 2010, was performed. Under the Freedom of Information Act, the National Health Service Litigation Authority provided limited details on closed claims, settled with damages, following a search of their database with the term "amputation." No demographic data were provided. RESULTS: During this period, 174 claims were settled by the National Health Service Litigation Authority, who paid out more than £36.3 million. The causes of the claims were the need for a lower limb amputation due to a delay in the diagnosis and or treatment of arterial ischaemia (56), an iatrogenic injury (15), the development of preventable pressure sores (15), the delay and or failure to diagnose a limb malignancy (6) and the delay in the management of an infected pseudo-aneurysm (1). Complications following orthopaedic surgery resulted in 25 successful claims as did the delayed diagnosis or mismanagement of 10 lower limb fractures. Additional claims followed the amputation of the wrong toe (1), a retained foreign body (2), an unnecessary amputation (4), inadequate consent (4), failure to provide thrombo-prophylaxis following amputation resulting in death (2) and a diathermy burn injury during an amputation (1). Delay in the diagnosis of and/or failure to manage an injury or infection resulted in 21 upper limb amputations. There was insufficient information provided in the remaining 11 claims to determine how the claim related to an amputation procedure. The largest single payout for damages (£1.9 million) resulted from the failure to diagnose and treat a femoral artery injury following a road traffic accident leading to an eventual below knee amputation. CONCLUSION: Delays in the diagnosis and or treatment of arterial ischaemia were the commonest reasons for a settled claim. Lessons can be learnt from potentially preventable cases that can be incorporated in medical education and training programs with the aim of reducing both amputation rates and litigation costs.