Commentary
In this issue of the Journal of Cardiac Surgery, Zheng et al.
demonstrate that robotic mitral valve repair provided comparable short-
and mid-term survival and freedom from mitral valve reoperation when
compared to mini-thoracotomy approach in a propensity matched cohort
[1]. Minimally invasive mitral valve surgery (MIMVS) with a
mini-thoracotomy approach was first described in 1998 [2], followed
by the first robotic assisted MIMVS performed by the same group [3].
In the United States, after the da Vinci surgical system was approved in
2002 following FDA trials lead by Chitwood, Nifong and colleagues [4,
5], the number of both mini-thoracotomy and robotic assisted MIMVS has
dramatically increased over the last 20 years [6]. This trend has
been encouraged by favorable short-term outcomes of both MIMVS
approaches reported in several meta-analysis and retrospective studies
in high-volume centers. Almost all the studies comparing sternotomy
versus mini-thoracotomy [7-11], or sternotomy versus robotic
assisted MIMVS [12-18], demonstrated similar findings in that both
MIMVS approaches provided better short-term outcomes including shorter
hospital stay, less need for blood transfusions, lower incidence of
postoperative atrial fibrillation, and earlier return to normal activity
despite the longer procedure time compared to sternotomy. Mid-term
outcomes of mini-thoracotomy [8] and robotic assisted MIMVS [13]
were also equivalent to a sternotomy approach. Although, the safety and
feasibility of the two MIMVS approaches have been verified, as the
authors mentioned, there has been a paucity of data directly comparing
mini thoracotomy versus a robotic assisted approach in the literature.
One study investigating these two MIMVS approaches was a propensity
matched analysis conducted by Mihaljevic et al. who found that robotic
assisted MIMVS resulted in longer procedure times, but lower rates of
atrial fibrillation resulting in shorter length of hospital stay
compared to mini-thoracotomy MIMVS [19]. Hawking et al. compared 295
propensity matched patients who underwent MIMVS with either
mini-thoracotomy or robotic assisted approach and concluded that robotic
assisted MIMVS had higher rate of atrial fibrillation, more need for
blood transfusions and longer length of hospital stay [20].
Regarding long-term outcome comparisons, a propensity matched study by
Barac et al. demonstrated 5-year mortality of 3 % and incidence of
mitral valve reoperation of 3 %, which did not differ between robotic
assisted MIMVS and mini-thoracotomy MIMVS [21]. Although further
studies including randomized controlled trials would be warranted on
this topic, most surgeons and institutions focus on one or the other of
these techniques making it difficult to achieve meaningful
randomization. In addition, the current evidence points to the fact that
both mini-thoracotomy and robotic assisted MIMVS provide similar short-
and long-term outcomes in terms of morbidity and mortality.
Even with equivalent clinical outcomes seen in the two MIMVS approaches,
we think that the most crucial advantage of using robotic technology is
the excellent visualization afforded by the high-definition
three-dimensional camera in current robotic systems. In addition to
that, wristed instruments and the dynamic manipulability of a left
atrial retractor facilitate excellent exposure of mitral valve and the
meticulous execution of complex repair techniques (e.g., neo-chord
implantation, leaflet resection, and patch reconstruction) all while
using a port only approach. With the aid of these technologies, several
centers have recently reported excellent clinical outcomes of robotic
assisted MIMVS. The largest series of robotic assisted MIMVS to date was
published by Murphy et al in 2015, who reviewed outcomes of 1257
patients with short-term mortality of 0.9% and incidence of mitral
valve reoperation of 3.8 % at a mean follow-up of 50 months [22].
The Cleveland Clinic group reported outcomes of 1000 robotic assisted
MIMVS cases and showed excellent short-term mortality of 0.1 %
[23]. Other centers also reported similar short-term results of
their series of hundreds of patients undergoing robotic MIMVS [24,
25]. Chitwood et al. reported
long-term outcomes of robotic assisted MIMVS with a 5-year mortality of
3.4 % and incidence of mitral valve reoperation of 6.2 % [26].
Mayo Clinic reviewed 487 robotic assisted MIMVS cases and found that the
5-year mortality was 0.5 % and the incidence of reoperation was 2.3 %
[27]. The same institution published 10-year outcomes of 843
patients with a mortality of 7 % and incidence of mitral valve
reoperation of 7.4 % in 2021 [28]. These long-term outcomes were
comparable to the sternotomy data published in previous reports [29,
30]. Some centers have assessed the feasibility of robotic assisted
MIMVS in a wide range of mitral pathologies with more complex repair
techniques (e.g., bileaflet repair, mitral annular calcification
excision) [31-33]. Fujita et al. reported that patients who
underwent robotic assisted MIMVS had a higher complexity score requiring
more complex repairs than patients undergoing mini-thoracotomy MIMVS
[32]. Neo-chord implantation was attempted more in robotic assisted
MIMVS though procedure times did not differ between the two groups.
Regarding complexity, Rowe et al. conducted robotic MIMVS for Barlow
type mitral disease with 5-year freedom from greater than moderate
mitral regurgitation of 92 %, which was similar to non-Barlow disease
[33].
In our own practice the senior author has been performing sternal
sparing mitral valve surgery since 2003 which began as a
mini-thoracotomy approach and gradually transitioned to an all-robotic
approach around 2010. The impetus to moving to a robotic approach was to
minimize the size of the ports and transition to a truly endoscopic
procedure, while adding the benefits of dexterity and improved
visualization. In our current practice we perform endoscopic robotic
MIMVS as a standard treatment for both simple and complex mitral valve
disease. Based on our experience, the key to safely perform robotic
MIMVS for a wide range of patients with various types of mitral
pathology is to have a dedicated robotic team for whom the robot is a
routine addition in the operating room. Another key factor is a thorough
understanding of peripheral perfusion techniques and myocardial
protection options. In particular, having several cardiac arrest options
is important. We routinely utilize 3 modalities which are transthoracic
aortic clamp, endoaortic balloon occlusion and ventricular fibrillatory
arrest based on patient and technical factors. In general, transthoracic
aortic clamp is the most used in mini-thoracotomy MIMVS and is the
easiest to master. The endoballoon however may be more attractive in
re-operative procedures and to avoid the need for a separate aortic
antegrade catheter puncture site. On the other hand, if the patient has
a competent aortic valve and a patent IMA graft, moderate hypothermic
ventricular fibrillatory arrest can be an option in less complex
repairs.
These considerations are obviously important in non-robotic approaches
to MIMVS as well.
Finally, cost considerations have forced many programs interested in
MIMVS to adopt a non-robotic platform. Recent advances in non-robotic 3D
visualization have helped enhance this approach. As can be seen by this
study from Zheng et al and from prior publications in the literature,
excellent outcomes can and should be expected in MIMVS whether or not a
robotic platform is used.
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