Adult: Mitral Valve: Evolving Technology
A conservative screening algorithm to determine candidacy for robotic mitral valve surgery

https://doi.org/10.1016/j.jtcvs.2020.12.036Get rights and content

Abstract

Objective

Patient selection for robotically assisted mitral valve repair remains controversial. We assessed outcomes of a conservative screening algorithm developed to select patients with degenerative mitral valve disease for robotic surgery.

Methods

From January 2014 to January 2019, a screening algorithm that included transthoracic echocardiography and computed tomography scanning was rigorously applied by 3 surgeons to assess candidacy of 1000 consecutive patients with isolated degenerative mitral valve disease (age 58 ± 11 years, 67% male) for robotic surgery. Screening results and hospital outcomes of those selected for robotic versus sternotomy approaches were compared.

Results

With application of the screening algorithm, 605 patients were selected for robotic surgery. Common reasons for sternotomy (n = 395) were aortoiliac atherosclerosis (n = 74/292, 25%), femoral artery diameter <7 mm (n = 60/292, 20%), mitral annular calcification (n = 83/390, 21%), aortic regurgitation (n = 100/391, 26%), and reduced left ventricular function (n = 126/391, 32%). Mitral valve repair was accomplished in 996. Compared with sternotomy, patients undergoing robotic surgery had less new-onset atrial fibrillation (n = 144/582, 25% vs n = 125/373, 34%; P = .002), fewer red blood cell transfusions (n = 61/601, 10% vs 69/395, 17%; P < .001), and shorter hospital stay (5.2 ± 2.9 days vs 5.9 ± 2.1 days; P < .001). No hospital deaths occurred, and occurrence of postoperative stroke in the robotic (n = 3/605, 0.50%) and sternotomy (n = 4/395, 1.0%; P = .3) groups was similar.

Conclusions

This conservative screening algorithm qualified 60% of patients with isolated degenerative mitral valve disease for robotic surgery. Outcomes were comparable with those obtained with sternotomy, validating this as an approach to select patients for robotic mitral valve surgery.

Graphical abstract

A conservative screening algorithm for selection of candidates for robotic mitral valve surgery. Preoperative echocardiography and computed tomographic scanning are used to identify patients with isolated degenerative mitral valve disease who are candidates for a robotic approach. Numbers indicate the numbers of patients with preoperative findings that led to exclusion from the robotic approach.

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Section snippets

Patients and Methods

From January 2014 to January 2019, 1000 consecutive patients with isolated degenerative mitral valve disease underwent mitral valve surgery by 1 of 3 surgeons with expertise in both robotic and sternotomy-based approaches. These surgeons did not perform mitral valve repair via right thoracotomy without robotic assistance. During this time frame, the 3 surgeons adopted a uniform approach to mitral valve repair, and they all agreed to rigorous application of the preoperative screening algorithm

Screening and Eligibility for Robotic Surgery

The screening algorithm was applied to 1000 consecutive patients scheduled for surgical treatment of isolated degenerative mitral regurgitation; 605 (60%) met the criteria for robotic surgery, and the remaining 395 (40%) underwent a sternotomy. Echocardiographic findings leading to a sternal approach included greater-than-mild aortic regurgitation in 26%, moderate or severe MAC in 21%, left ventricular dysfunction in 32%, and severe pulmonary hypertension in 2.3% (Table 1 and Figure 2).

Principal Findings

After application of our conservative screening algorithm, 60% of patients with isolated degenerative mitral valve disease met echocardiographic and CT criteria for robotic surgery. The most common reasons precluding a robotic approach were aortoiliac atherosclerosis, small femoral arteries, greater-than-mild aortic regurgitation, moderate or more MAC, and left ventricular dysfunction. Patients who underwent robotic surgery were younger and had fewer preoperative comorbidities than those

Conclusions

With this conservative screening algorithm, 60% of patients with isolated degenerative mitral valve disease qualified for robotic surgery. Postoperative outcomes were excellent and comparable for robotic and sternotomy-based approaches, validating the application of this screening algorithm to select candidates for robotic mitral valve surgery. This screening algorithm illustrates one approach to choosing patients for robotic mitral valve surgery, but it should not be used to limit the

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      A summary of Chitwood's et al. patient selection criteria is presented in Table 2a. A while later, Chemtob et al. published an article describing how the use of the echocardiography and the CT angiography can preclude high risk patients from undergoing R-MVR [28]. Chemtob et al. suggested some stringent patient selection criteria according to which any patient with severe mitral valve calcification, concomitant aortic valve disease, left ventricular disfunction, pulmonary hypertension, aortic atherosclerosis, pectus excavatum and femoral artery diameter less than 7 mm shall be recommended to undergo non-robotic MVR (Table 2b) [28].

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    This study was funded in part by the Judith Dion Pyle Chair in Heart Valve Research, held by Dr Gillinov.

    The Cardiac Robotic Surgery Working Group members are listed at end of article.

    Dr Mick is now at New York Presbyterian Hospital Weill Cornell Medicine, New York, NY.

    View full text