Robotic Mitral Valve Repair for All Prolapse Subsets Using Techniques Identical to Open Valvuloplasty: Establishing the Benchmark Against Which Percutaneous Interventions Should Be Judged

Study Questions:

How do outcomes of robotic mitral valve repair compare with repair outcomes associated with open sternotomy?

Methods:

Among 745 consecutive patients at a single center undergoing open or robotic mitral repair for degenerative disease, 95 propensity-matched pairs were identified. Leaflet prolapse categories were similar between groups. Complete mitral valve repair was performed using identical techniques.

Results:

Median cross-clamp and bypass times were longer in the robotic group, but decreased significantly over time (p < 0.001). Among patients in the robotic group, there were no conversions to open sternotomy, repair rate and early survival were 100%, and dismissal mitral regurgitation grade was similar (p = 1.00). All patients in the robotic group had mild or less mitral regurgitation 1 month after repair. There were no differences in adverse events (5% open vs. 4% robotic, p = 1.00). Patients in the robotic group had shorter postoperative ventilation time, intensive care unit stay, and hospital stay.

Conclusions:

The authors concluded that robotic mitral valve repair allows complete anatomic correction of all categories of leaflet prolapse using techniques identical to open approaches. Robotic repair effectively corrects mitral regurgitation, offers excellent freedom from adverse events, and facilitates rapid weaning from ventilation, translating into earlier hospital dismissal. Safety and efficacy after both open and robotic mitral valve repair are higher than recently reported in the EVEREST II trial, and establish a benchmark against which nonsurgical therapies should be evaluated.

Perspective:

Recently published results of the EVEREST II trial (Feldman, et al. N Engl J Med 2011;364:1395-406) comparing a percutaneously delivered mitral valve clip with surgical mitral valve repair revealed similar outcomes between the two techniques. However, surgical results were by most standards unacceptable, including ~20% incidence of 3+ to 4+ mitral regurgitation 12 months after surgical mitral repair. These authors demonstrate that, in their hands, surgical mitral valve repair––whether robotic or performed via open sternotomy––has substantially better outcomes than what was shown in the EVEREST II trial. Implications include: 1) that a flawed comparison group could make a new therapy appear equivalent to existing therapies, and 2) that any interventional outcome (including robotic mitral valve repair) should consider the experience and expertise of the site and the operators.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and VHD, Interventions and Structural Heart Disease, Mitral Regurgitation

Keywords: Incidence, Sternotomy, Surgical Instruments, Robotics, Mitral Valve Prolapse, Mitral Valve Insufficiency, Cardiology, Cardiac Surgical Procedures, Angioplasty


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