Relative to sternotomy, thoracotomy for mitral repairs provides similar mortality, less morbidity, fewer infections, shorter stay, and significant cost savings during primary admission. The markedly lower readmission rates for thoracotomy will translate into additional institutional cost savings when a penalty on hospitals begins under the Affordable Care Act's Hospital Readmissions Reduction Program.

Background Recurrent mitral regurgitation after mitral valve (MV) repair for degenerative disease occurs at a rate of 2.6% per year and re-operation rate progressively reaches 20% at 19.5 years. We believe that MV repair durability is related to initial post-operative leaflet and annular geometry with subsequent leaflet remodeling due to stress. We tested the hypothesis that MV leaflet and annular stress is increased after MV repair. Methods Magnetic resonance imaging was performed before and intra-operative 3D trans-esophageal echocardiography was performed before and after repair of posterior leaflet (P2) prolapse in a single patient. The repair consisted of triangular resection and annuloplasty band placement. Images of the heart were manually co-registered. The left ventricle and MV were contoured, surfaced and a 3D finite element (FE) model was created. Elements of the P2 region were removed to model leaflet resection and virtual sutures were used to repair the leaflet defect and attach the annuloplasty ring. Results The principal findings of the current study are 1) FE simulation of MV repair is able to accurately predict changes in MV geometry including changes in annular dimensions and leaflet coaptation, 2) average posterior leaflet stress is increased, and 3) average anterior leaflet and annular stress are reduced after triangular resection and mitral annuloplasty. Conclusions We successfully conducted virtual mitral valve prolapse repair using FE modeling methods. Future studies will examine the effects of leaflet resection type as well as annuloplasty ring size and shape.

Outcomes analyses can be performed from hospital administrative collective databases. This real world analysis demonstrates comparable outcomes and less cost and ICU time with RAT for AVR.

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Objective 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. Methods 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. Results 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. Conclusions 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.

A preoperative image-guided perfusion strategy and aortic balloon clamping permit routine TERMR with excellent myocardial preservation and minimal complications.