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Redo Mitral and Tricuspid Valve Surgery: Comparison of Robotic Endoscopic Approach to Redo Sternotomy and Right Thoracotomy
Emmanuel Moss1, Michael E. Halkos2, Jose N. Binongo2, Douglas A. Murphy2.
1Jewish General Hospital, McGill University, Montreal, QC, Canada, 2Emory University, Atlanta, GA, USA.

OBJECTIVE: To compare perioperative outcomes in patients with previous sternotomy undergoing mitral valve surgery via redo sternotomy, right thoracotomy, or lateral endoscopic approach using robotics (LEAR).
METHODS: From 2006-2013, 291 patients with a history of previous sternotomy surgery underwent reoperative isolated mitral +/- tricuspid valve surgery at a single US academic institution. Propensity scoring was used to compare in-hospital and 30-day outcomes between the LEAR technique and sternotomy or thoracotomy approaches.
RESULTS: Of 291 patients, 151 (51.9%) had a repeat sternotomy, 71(24.4%) had a right thoracotomy approach, and 69 (23.7%) had a LEAR approach. Composite outcome of death or stroke was 5.8% (n=4) with the LEAR technique, compared to 6.6% (p=0.9) and 11.3% (p=0.3) in the sternotomy and thoracotomy groups, respectively. Cardiopulmonary bypass (CPB) and aortic occlusion times in the LEAR group (139.8±53.3 and 87.8±37.0 min, respectively) were similar to the Sternotomy group (131.1±49.3 and 97.2±39.9 min, respectively), but were significantly shorter compared to the thoracotomy group (163.6±54.7 min, p=0.01 and 129.1±60.7 min, p<0.001, respectively). Following propensity adjustment, the LEAR technique was associated with a shorter hospital and ICU length of stay (p <0.01) compared to sternotomy, and fewer perioperative blood transfusions compared to both sternotomy and thoracotomy (37.7% vs 83.4% and 77.5%, p<0.01, respectively). Mitral valve repair rates were significantly higher with the LEAR technique (66.7%) compared to sternotomy (11.3%, p<0.001) and thoracotomy (5.6%, p<0.001).
CONCLUSIONS: Mitral valve repair or replacement after a previous sternotomy can be performed effectively using the LEAR technique with low morbidity and mortality, and is associated with fewer transfusion requirements and a higher repair rate compared to sternotomy and thoracotomy techniques.

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