Minimally invasive and robotic approaches to mitral valve: Robotic is best

Abstract

Central MessageRobotic technology facilitates sophisticated mitral valve repair via small incisions with the quickest recovery and in a manner that is most acceptable to the patient.See Commentaries on pages 80 and 82. Robotic technology facilitates sophisticated mitral valve repair via small incisions with the quickest recovery and in a manner that is most acceptable to the patient. See Commentaries on pages 80 and 82. Asking the question “What is the best minimally invasive mitral valve operation?” is fraught with the same problems as asking, “What is the best … city, …car, …football team?” etc. It depends not only on what factors one considers important but also on how one weights each of those. While there are some parameters in mitral valve (MV) surgery that most would agree are fundamental and commonly measured, such as mortality and rate of repair, there are others that are more nebulous. Many factors important to patients, such as recovery time, return to normal activity, cosmesis, avoidance of long-term medication, and reintervention, are frequently not considered and are difficult to measure. The situation is further complicated by the need to accommodate not one viewpoint but multiple perspectives, such as the patient, the surgeon, and the health care system. In many circumstances, these needs are antithetical. For many reasons, the evidence to support superiority of one surgical approach over another is profoundly limited. We are not comparing one pill with another; rather, we are comparing complex management systems with individual clinicians at the core. Because of this, surgery does not lend itself to randomized controlled studies. The biases of patient selection, pathologic complexity, and outcome definition (and many others) make comparison between case series virtually impossible. However, at the most basic level, irrespective of approach, the “best” MV surgery needs to prove its efficacy and safety. So how does robotic mitral surgery measure up compared with the standard approach through median sternotomy? Over the last 20 years, several North American centers have achieved high-volume robotic mitral experience with good outcomes. In 2015, Murphy and colleagues1Murphy D.A. Moss E. Binongo J. Miller J.S. Macheers S.K. Sarin E.L. et al.The expanding role of endoscopic robotics in mitral valve surgery: 1,257 consecutive procedures.Ann Thorac Surg. 2015; 100 (discussion 81-2): 1675-1681Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar reported outcomes in 1257 consecutive cases of robotic MV surgery, of which 93% were MV repair. Mortality was 0.9% and stroke in 0.7%. Predischarge echocardiogram showed trace or mild mitral regurgitation (MR) in more than 98% of repaired valves and at a mean follow-up of 50 ± 26 months, 3.8% patients required reoperation. Gillinov and colleagues2Gillinov A.M. Mihaljevic T. Javadikasgari H. Suri R.M. Mick S.L. Navia J.L. et al.Early results of robotically assisted mitral valve surgery: analysis of the first 1000 cases.J Thorac Cardiovasc Surg. 2018; 155: 82-91.e2Abstract Full Text Full Text PDF PubMed Scopus (77) Google Scholar reported similar outcomes in their first 1000 robotic mitral procedures, with an in-hospital mortality of 0.1% and stroke rate of 1.4%, which declined from 2% in the first 500 patients in the series to 0.8% in the second 500 patients. More than 99% were planned MV repair, and 97.8% of these had mild or less MR on the predischarge echocardiogram. These results are comparable with results achieved through sternotomy, such as reported by Castillo and colleagues,3Castillo J.G. Anyanwu A.C. Fuster V. Adams D.H. A near 100% repair rate for mitral valve prolapse is achievable in a reference center: implications for future guidelines.J Thorac Cardiovasc Surg. 2012; 144: 308-312Abstract Full Text Full Text PDF PubMed Scopus (191) Google Scholar where more than 99% were valve repairs, with 0.8% mortality and 0.5% major stroke rate. Although there are