Robotic Totally Endoscopic Mitral Valve Surgery in the Setting of a Comprehensive Robotic Cardiac Program: Early and Mid-term Outcomes in 500 Consecutive Patients

H. Kitahara¹, S. Nisivaco², R. Bhasin³, I. Hamzat¹, K. Grady¹, H. H. Balkhy^4
1The university of Chicago, Chicago, Illinois ²University of Chicago Medicine, Chicago, Illinois ³University of Chicago, Chicago, Illinois ⁴The University of Chicago Medicine, Chicago, Illinois

Purpose: Robotic cardiac surgery is experiencing an increase in adoption with 15% of mitral valve (MV) repairs being performed robotically in the US. We initiated a comprehensive multi-spectrum robotic cardiac surgery program in 2013 with emphasis on the totally-endoscopic approach. We reviewed outcomes of patients undergoing MV surgery within this context.

Methods: A retrospective review of 1570 robotic endoscopic cardiac surgical procedures performed at our institution between September 2013 and July 2023 was conducted. Of these, 502 consecutive patients underwent robotic totally-endoscopic MV operations and were analyzed. All mitral pathologies were included whether they required repair (via 8-mm port) or replacement (via 20-mm port). Early and mid-term outcomes of the MV patients were reviewed.

Results: The median age was 65-years and 40% were male. Ninety-four percent of patients had mitral regurgitation (MR) and 6% had rheumatic stenosis. Of the MR patients, 62% had isolated posterior leaflet prolapse. Mean STS predicted mortality risk was 2% [range 0.15-19.4] and 44 patients had previous cardiac surgery. MV repair occurred in 98% of patients with degenerative MR. Concomitant procedures included: Cox-maze procedure in 109 patients (22%); tricuspid valve repair in 43 (9%); septal myectomy in 10, totally endoscopic coronary bypass in 5 and robotic aortic valve replacement in 2 patients. Endo-aortic balloon occlusion was used in 70%, fibrillatory arrest in 21% and external clamping in 9% of patients. Intra-operative echo revealed trace/no residual MR in 96% and mild residual MR in 4%. MV replacement occurred in 59 patients, of which 83% were non-degenerative (60% rheumatic, 40% other including endocarditis, functional, and failed previous MV procedure). Observed-to-expected thirty-day mortality was 0.5. The mean length of hospital stay was 2.8+1.4 days. Clinical follow-up was complete in 99% of patients at mean 39-months, and re-operation for recurrent MR was 2.4%. Follow-up echo at mean 42-months showed 8% of patients with degenerative MR had moderate or more recurrent MR.

Conclusion: Robotic endoscopic MV surgery, including MV replacement as well as concomitant procedures, is feasible within the context of a comprehensive multi-spectrum robotic cardiac surgery program with good outcomes.

Identify the source of the funding for this research project: none