Two hundred robotic mitral valve repair procedures for degenerative mitral regurgitation: the Yale experience

Abstract

Background: Robotic surgery has gained popularity over the past two decades due to the benefits related to smaller surgical incisions, enhanced technical dexterity and better intraoperative visualization. We present the Yale experience of the first two hundred totally endoscopic, robotic-assisted mitral valve repair procedures for the treatment of degenerative mitral regurgitation.Methods: We performed a retrospective cohort study of patients undergoing totally endoscopic, roboticassisted isolated or concomitant mitral valve repair for degenerative mitral regurgitation at Yale-New Haven Hospital from October 2018 to April 2022. Mitral valve repair procedures for rheumatic or secondary functional mitral regurgitation and planned robotic-assisted mitral valve replacement cases were excluded.Results: Two hundred consecutive procedures were performed. The median age was 65 years (interquartile range, 58-73 years). Six patients (3.0%) had a history of mediastinal radiation, four patients (2.0%) had previous cardiac surgery, and one patient (0.5%) had cardiac dextroversion. Median cardiopulmonary bypass and aortic cross-clamp times were 122 and 79 minutes, respectively. Femoral vessel cannulation was performed percutaneously in 57 (28.5%) patients with no major access-site related complication. Aortic cross-clamping was performed with the endoaortic balloon occlusion device in 151 (75.5%) patients. No conversions to sternotomy occurred. Satisfactory repair was achieved in 100% of cases, with 184 (92.0%) and 16 (8.0%) of patients having trace/none or mild residual mitral regurgitation, respectively. Forty-two patients (21.0%) underwent concomitant Cox-maze procedure and 25 patients (12.5%) underwent concomitant tricuspid valve repair. Thirty-day mortality rate was 0.5%, with an observed-to-expected ratio of 0.53. Two patients (1.0%) underwent re-exploration for bleeding, one had early postoperative stroke (0.5%), five developed pneumothorax (2.5%) and two required dialysis for acute renal failure (1.0%). The median length of hospital stay was four days.Conclusions: Excellent short-term outcomes can be achieved in experienced centers for the treatment of degenerative mitral regurgitation with a totally endoscopic, robotic-assisted approach.

Minimal Access Tricuspid Valve Surgery

“…Robotic MATVS shares many similarities with the endoscopic techniques. Port configurations are similar: the working port which is typically placed in the third intercostal space (ICS) at the anterior axillary line, the left arm port which is placed in the second ICS (halfway between anterior axillary and midclavicular line), the right arm port in the fifth ICS below the anterior axillary line, and the atrial retractor which is placed in the fourth ICS, 2 cm medial to midclavicular line [ 25 ].…”

State of the art and new frontiers in robotic mitral valve surgery

“…We had the opportunity to previously report our surgical technique for various procedures that targeted the mitral valve [28][29][30][31][32] , with excellent short-term outcomes [33] . We approach all our robotic mitral cases by placing the patient in a supine position on the operating table, with a rolled towel (or a gel pad) positioned under the right scapula and the ipsilateral arm loosely tucked slightly below the chest.…”

“…In this frame, the routine positioning of the trocars can be slightly modified based on the patient's body habitus to further minimize conflicts and optimize surgical exposure. It is worth noting that we had the opportunity to perform robotic-assisted mitral valve repair on a patient with situs inversus and cardiac dextroversion, in which case we arranged the port configuration symmetrically on the left hemithorax [34] . We have also previously described our technique for unilateral percutaneous cannulation and endoaortic balloon management in robotic cases [31] , for approaching redo mitral valve procedures via totally endoscopic, robotic-assisted adhesiolysis and repair [30] , and for de-airing after robotic-assisted intracardiac procedures [35] .…”

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

“…4 A smaller number of robotic mitral surgeons, many of whom had previous clinical experience with endoaortic balloon occlusion, combined this method of aortic occlusion with robotic instrumentation in a port-only endoscopic approach. [5][6][7][8] The lateral endoscopic approach with robotics (LEAR) is an example We present a series of patients undergoing endoscopic mitral surgery with transthoracic clamp aortic occlusion. This technique may have advantages over endoaortic balloon occlusion in certain clinical situations.…”

“…Balloon occlusion of the ascending aorta enables this endoscopic robotic approach in a broad spectrum of patients, avoids a puncture hole in the ascending aorta, and facilitates mitral repair testing using the aortic root pressure and venting lumens integrated into the balloon catheter. [8][9][10] However, there are situations in which aortic balloon occlusion is technically challenging or not possible at all. For these situations, we evolved a transthoracic clamp technique that preserves the port-only approach, minimizes the risk of aortic clamp injury to adjacent structures, replicates the valve-testing capabilities of the endoaortic balloon catheter, and facilitates closure of the aortic cardioplegia site in a nonpressurized aorta.…”