The First Fifty Robotic Mitral Valve Repairs In The United Kingdom: Better Late Than Never, But Experience Is Important
John Massey1, Ken Palmer2, Omar Al-Rawi2, Tim Ridgway2, Alistair Marshall2, Paul Modi2.
1Northern General Hospital, Sheffiled, United Kingdom, 2Liverpool Heart and Chest, Liverpool, United Kingdom.
BACKGROUND: Compared to sternotomy, robotic mitral valve repair (rMVP) is associated with shorter hospital stay, less pain and faster return to normal activities, but this is expensive technology. The United Kingdom has been slow to adopt this, in part because the National Health Service (NHS) has finite resources. Before progressing to a totally endoscopic repair, prior experience with the video-assisted mitral approach was deemed necessary.
METHODS: Robotic mitral valve repair was adopted after the team had performed 400 video-assisted mitral surgeries, and was performed using the LEAR (Lateral Endoscopic Approach for Robotics) technique, except when the Intraclude was unavailable due to a product recall, when we used the Chitwood clamp. Antegrade cold Custodiol cardioplegia and systemic cooling to 28-30°C were used for myocardial protection in all cases. All patients had internal jugular venous cannulae (17-19Fr) placed. We analysed the results of the first 50 rMVPs performed between March 2018 to March 2022. All patients had severe MR due to posterior leaflet prolapse.
RESULTS: Median age was 60 years (IQR 52-67), 82% were male, 98% were elective, and logistic Euroscore was 2.5 (1.5-3.7). There was no mortality or strokes, and the repair rate was 100%. No patients were converted to sternotomy although we undocked the robot and completed the repair with shafted instruments in 4 cases. Valve repair was accomplished using up to 4 techniques: (1) loop neochordae, (2) individual pairs of neochordae, (3) cleft closure, and (4) flexible (Simulus, Dublin, Ireland) or semi-rigid (PhysioFlex, Edwards Lifesciences, CA) annuloplasty bands with either GoreTex running sutures or Corknot. Operative times, as expected, were initially longer (cardiopulmonary bypass 224 mins (208-233); cross-clamp 158 mins (140-168)) but reduced as our experience grew. No patients returned to theatre for bleeding. The ICU stay was 22 hours (19-43) and the post-op hospital stay was 4 days (4-5). There were no complications. All patients were discharged with 0-1+ MR and during annual follow-up of all patients, none developed more than 1+ MR.
CONCLUSIONS: With an appropriately experienced team, totally endoscopic robotic cardiac surgery can be safely introduced with excellent results into healthcare systems with finite resources.
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