This editorial discusses recent advances in minimally invasive mitral valve repair techniques, including robotic-assisted surgery. It summarizes a study from Mayo Clinic that found robotic mitral valve repair to have no mortality and short hospital stays. While robotic surgery outcomes are promising, the editorial notes competing techniques like percutaneous mitral valve repair and right minithoracotomy are also effective options. Further research is still needed to determine the optimal minimally invasive mitral valve repair method and whether one technique is clearly superior.

1. Editorial
Mayo Clin Proc. • September 2011;86(9):834-835 • doi:10.4065/mcp.2011.0477 • www.mayoclinicproceedings.com834
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedingsa .
Editorial
Address correspondence to Alfredo Trento, MD, Director, Division of Cardiotho-
racic Surgery, Cedars-Sinai Heart Institute, 8700 Beverly Blvd, Ste 6215, Los
Angeles, CA 90048 (trento@cshs.org).
© 2011 Mayo Foundation for Medical Education and Research
Mayo Clinic
Proceedings
September 2011
Volume 86
Number 9
Clinical Outcomes Associated With Robotic Repair of the Mitral Valve
See also
page 838
In the current issue of Mayo Clinic Proceedings, Suri et al1
of Mayo Clinic in Rochester, MN, retrospectively report
on their first 100 mitral valve repairs using robotic surgical
techniques. This report is another important contribution to
the field of less-invasive mitral valve surgery and adds to the
understanding of different technologic platforms available
for this procedure. The outcomes presented are impressive.
There was no patient mortality. The last 25 patients were
extubated in the operating room. Median hospital stay was
3 days. Only 15% of patients had any blood products. At 1
month after surgery, 82 patients had no mitral regurgitation
(MR) or trivial MR, and 18 had mild MR. These outcomes
are a testament to the expertise and commitment of the
Mayo Clinic team of clinicians. Prior publications2-9
have
shown similar results, indicating that the technique of ro-
botic mitral valve repair is reproducible.
Robot-assisted mitral valve surgery is but one effort
to improve mitral valve function while reducing periop-
erative morbidity and mortality compared with traditional
open chest, open heart surgery. Competing with robotic-
assisted mitral valve repair is the cutting edge technology
of the mitral clip percutaneous procedure.10
The mitral
clip is inserted through a delivery catheter from the right
femoral vein and, via a transeptal approach, is positioned
into the mitral valve under echocardiographic and fluoro-
scopic control. The clip grasps the free edge of the anterior
and posterior leaflet at the site of regurgitation, creating a
double-orifice mitral valve and decreasing significantly
the amount of regurgitation. The percutaneous clip will
most likely be combined with a percutaneous mitral an-
nular band system that may be introduced into the clinical
arena in the near future.
These developments need to be put in perspective with
what is happening in Europe, where percutaneous valve
therapies have a much larger penetration than in the United
States and where robotic technology in cardiac surgery is
far behind that of the United States as far as acceptance by
surgeons.
In Europe, alternative, less-invasive procedures include
mitral valve repair under direct vision through a right
minithoracotomy11-14
and the total endoscopic approach
through a 3- to 4-cm incision as performed
by Casselman et al.15,16
These approaches
have also been performed in the United
States, particularly by New York University
surgeons.16,17
These techniques compete with the robotic
approach, and currently, there is no indication that the
robotic technique is any better or worse than the others or
that it is any more reproducible. Further study is required to
determine which surgical approach is eventually superior
and whether superiority of one technique over another is
limited to specific subsets of patients.
Having personally seen surgical pioneers Dr Hugo
Vanermen of Aalst, Belgium, and Dr Friedrich Mohr of
Leipzig, Germany, perform a mitral valve repair via the
total endoscopic approach or under direct visualization
through a right minithoracotomy incision, respectively, I
must say that both techniques appear to be equivalent and
probably equally acceptable to patients.
A consensus statement of the International Society of
Minimally Invasive Cardiac Surgery (ISMICS) 201018
on
minimally invasive vs open mitral valve surgery concluded,
on the basis of review of retrospective studies, that, in pa-
tients with mitral valve disease, minimally invasive surgery
either robotically or through a right minithoracotomy may
be an alternative to conventional mitral valve surgery, given
the similar short- and long-term mortality and also the
reduced sternum complications, transfusion requirements,
and hospital stay. However, the risk of stroke was higher
with minimally invasive surgery than with conventional
approaches (2.1% vs 1.2%) as was the risk of aortic dis-
section, phrenic nerve palsy, and groin complications; ad-
ditionally, cross clamp times and cardiopulmonary bypass
time were increased. These data and conclusions were

2. editorial
Mayo Clin Proc. • September 2011;86(9):834-835 • doi:10.4065/mcp.2011.0477 • www.mayoclinicproceedings.com 835
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedingsa .
obviously based on observation studies and not on random-
ized trials.
Our experience with the DaVinci robotic system (ie,
the system also used by Suri et al) in the performance
of minimally invasive mitral valve surgery continues to
be positive and satisfying, encompassing more than 200
patients with 1 death and 2 permanent strokes. Yes, there
is room for improvement in the robotic arena. There is still
only one company in the world that makes the robotic sys-
tem (Intuitive Surgical, Inc, Sunnyvale, CA) and thus no
competition in the field. The price for the robotic system is
arbitrarily too high and limits the number of units that any
institution can have available. Improvements need to be
made in the instrumentation. For example, a third robotic
mitral retractor is needed to retract the posteromedial atrial
fold and expose the posterior medial portion of the valve
much more effectively than what is currently available. All
these issues will ultimately be resolved, and I believe that
the robotic approach will continue to provide an alterna-
tive to other minimally invasive techniques for mitral valve
surgery.
Robotic-assisted mitral valve surgery may eventually
become the standard of care in the United States. More work
needs to be done to improve surgical outcomes and to re-
duce postoperative complications. Given that most of these
patients with degenerative mitral valve disease are young,
the eventual complication rate from this procedure should
approach zero. I applaud Suri et al for their impressive
results and for getting close to this goal of a zero complica-
tions rate.
Alfredo Trento, MD
Director, Division of Cardiothoracic Surgery
Cedars-Sinai Heart Institute
Los Angeles, CA
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