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Eur J Cardiothorac Surg 2006;29:362-366
© 2006 Elsevier Science NL

Mitral valve repair robotic versus sternotomy

Thierry Folliguet * , Fabrice Vanhuyse, Xanis Constantino, Matteo Realli, François Laborde

Division of Cardiac Surgery, Department of Cardiovascular Surgery, Institut Mutualiste Montsouris, 42 Boulevard Jourdan, 75014 Paris, France

Received 29 September 2005; received in revised form 24 November 2005; accepted 2 December 2005.

* Corresponding author. Tel.: +33 1 56 61 65 10; fax: +33 1 56 61 65 23. (Email: thierry.folliguet{at}imm.fr).


   Abstract
Top
 Abstract
1. Introduction
 2. Material and methods
 3. Results
 4. Discussion
 Appendix A
 References
 
Objective: Robotically assisted mitral valve repair were compared with sternotomy mitral valve repair. Prospectively we evaluated safety and efficacy in performing simple mitral repairs. Methods: Between February 2004 and September 2005, 25 patients with posterior leaflet insufficiency underwent mitral valve repair using the da Vinci system. They were matched retrospectively with 25 patients who underwent the same repair via a median sternotomy. The minimal invasive repairs were performed with peripheral cardiopulmonary bypass, transthoracic aortic cross-clamp, and antegrade cardioplegia. Repair was performed with two ports and a 4-cm intercostals lateral incision in the right chest for access. All patients had posterior leaflet resection and placement of a ring annuloplasty. Results: All patients had successful valve repairs. There were no deaths. There was one conversion to an extended thoracotomy in the minimal invasive group due to a bleeder on the left atrial appendage. Overall mean study times showed a longer aortic cross-clamp (range, 96.1 min vs 69.6 min) and cardiopulmonary bypass (range, 122.1 min vs 85.7 min) for the minimal invasive group. Length of stay was less for the minimal group (7 days vs 9 days). At postoperative echocardiography two patients in both group developed 2+ mitral regurgitations. All other patients had a competent mitral valve repair with no insufficiency. Conclusions: Simple mitral valve repair can be successfully performed with the da Vinci robotic system. This approach is as safe as a sternotomy and long-term follow-up is needed to determine the durability of the mini invasive repair.

Key Words: Robotic • Video-thoracoscopy • Mitral valve plasty


   1. Introduction
Top
 Abstract
 1. Introduction
2. Material and methods
 3. Results
 4. Discussion
 Appendix A
 References
 
Minimally invasive endoscopic operative techniques are slowly being applied in cardiac surgery. Many surgical teams have shown that mitral and aortic valve surgery could be performed with a small incision by modifying the standard sternotomy [1–7]. Vanermen and co-workers [8] has pioneered the endoscopic mitral valve approach using an endo-CPB system and 2D vision. This approach in their hands allows complex mitral valve repairs, mitral valve replacement, excision of atrial myxomas, and ASD repair. However, some reluctance with this technique persists from the cardiac surgeon community, since it requires endoscopic surgical skills and manipulation of the endo-clamp which is not frequently used by all cardiac surgeons.

Recently, a new generation of surgical telemanipulation systems has allowed surgeons to perform robotically assisted coronary artery bypass grafts [9], interruption of patent ductus arteriosus [10], closure of atrial septal defect [11], mitral valve repair [12–15], epicardial ablations for treatment of atrial fibrillation [16], and aortic valve replacement [17]. However, there is still concern from the medical community with the minimal approach due to an increased risk from prolonged aortic cross-clamp and extra circulation time.

The purpose of this study was to compare our group of patients with mitral valve repair performed through a minimal incision with robotic assistance to a group of patients who underwent the same repair through a median sternotomy.


   2. Material and methods
Top
 Abstract
 1. Introduction
 2. Material and methods
3. Results
 4. Discussion
 Appendix A
 References
 
2.1 Patients
Between February 2004 and September 2005, 25 patients with posterior leaflet insufficiency underwent mitral valve repair using the da Vinci system (Intuitive Surgical, Inc., Sunnyvale, CA, USA). Selection of the patients for minimal invasive repair included posterior leaflet insufficiency involving only the P2 segment with no annulus calcifications, no coronary lesions, no aortic or tricuspid valve pathology, and absence of pulmonary disease in order to tolerate single lung ventilation. All the patients with robotic assistance signed an informed consent.

This group of selected patients was matched retrospectively to a group of 25 patients who underwent mitral valve plasty performed through a median sternotomy. This matched group included patients operated before the introduction of the da Vinci system between January 2000 and February 2004. This group included patients only with P2 insufficiency and no other valvular or coronary pathology.

All patients were either symptomatic or had an enlargement of the left ventricle. Patients had posterior leaflet disease only, with severe (grade 3 or 4) mitral regurgitation with preserved ventricular function (ejection fraction > 0.30). The mitral valve was evaluated with echocardiography and quantitatively assessed preoperatively, intraoperatively, and postoperatively before discharge, and 2–3 months after surgery. The echocardiogram was done and read by two inhospital cardiologists and after discharge all echocardiograms were done both by the referring cardiologist and by one of the two inhospital cardiologists. Anesthesia was the same for each group with the only modification involving postoperative analgesia. All mini incision patients had percutaneous continuous analgesia for the first 48 h.

All data were prospectively collected. A Student's t-test for continuous variables and {chi} 2 analysis for categorical variables were performed to determine statistical significance.

2.1.1 Surgical technique
In the minimal invasive group, the patients were placed in the supine position slightly rotated as for a lateral thoracotomy with the right arm extended and kept along the body. A double lumen endotracheal tube was inserted with right lung deflation. A left radial arterial catheter was placed and external defibrillator patches were placed on the thoracic cage.

After systemic heparinization the right femoral vessels were cannulated percutaneously with a 21F cannula in the vein and a 17F cannula in the artery. Additionally, a 17F wire-bound cannula was inserted in the right internal jugular vein for optimal drainage as with one venous cannula the total calculated flow could not be reached. Cardiopulmonary bypass was instituted and cooling to 33 °C rectal temperature was obtained. A 4–5 cm lateral incision was made in the 5th intercostals space. A 30° angled camera was placed in the same intercostals space slightly more anterior. Two ports were placed, one in the 3rd intercostals space mid-axillary and one in the 6th or 7th intercostals. Continuous CO2 irrigation was maintained in the pleural cavity through a separate port until aortic declamping was done. The heart was arrested with cold crystalloid cardioplegia in the aortic root repeated every 30 min and associated with cold topical pericardial saline irrigation. The ascending aorta was cross-clamped with a transthoracic aortic cross-clamp placed in the 2nd intercostals space mid-axillary line. The left atrium was opened longitudinally and a left atrial retractor was inserted (Heartport, Inc., Redwood City, CA, USA).

The mitral valve was then analyzed after three annular stitches were placed one at each commissures and one posterior in the middle of the annulus. This maneuver allows traction and brings the mitral valve toward the incision. In both groups, the operative technique was performed according to Carpentier principles, quadrangular resection of the prolapsed segment, and reapproximation of the two leaflets with a running suture and ring annuloplasty. We did not use artificial chordae or nitinol clips for annulus repair. The main difference between the two groups concerning the intracardiac repair was in the placement of a physio ring (Carpentier-Edwards, Edwards life science, Irvine, CA, USA) predominantly in the sternotomy group and an open ring (Sorin, Saluggia, Italy) in the minimal invasive group. The choice of an open ring in the latter group was due to the absence of anterior annulus sutures placement which we felt would shorten operative time in the minimal invasive group.

The da VinciTM Surgical system (Intuitive Surgical, Inc.) was used to open the atrium, to place the annular stitches of 2/0 Ethibond sutures (Ethicon, Somerville, NJ, USA), to perform the repair and to close the atrium. An open band annuloplasty was performed systematically in the mini invasive group, whereas in the sternotomy group either an open band or a closed ring was placed. De-airing was done in the following sequence. We aspirated on both the aortic cardioplegia line as well as through a left atrial line as both lung ventilation was performed and the heart was being filled. At the same time continuous CO2 irrigation was being maintained, after ventilation had been resumed we then clamped the left atrial line and aspirated only on the ascending aorta line. We monitored the presence of air on the TEE and declamped the aorta after visualizing the absence of air in the left heart cavities.

The two groups of patients were done with the same cardiopulmonary system and temperature was lowered to 34 °C. The main difference was the cannulation site for the minimal invasive group. Mild aspiration was applied to the venous reservoir and we did not snare the vena cava in either group.


   3. Results
Top
 Abstract
 1. Introduction
 2. Material and methods
 3. Results
4. Discussion
 Appendix A
 References
 
All procedures were performed by the same surgeon for the sternotomy, and for the console surgeon in the minimal invasive group. The mean age of the patients was identical in groups, as well as the EuroSCORE and ventricular function (Table 1 ). Myxomatous degeneration with P2 prolapse was the cause of the mitral valve insufficiency in all patients. Chordal rupture involving the posterior leaflet was also present in 28 (56%) patients. All patients had posterior leaflet resection and placement of a ring annuloplasty. Sizing of the annulus was performed through the intercostals access and the annuloplasty ring placed varied from 28 to 32 mm. Table 2 details several individual components of the operation. The major difference between the two groups was the increased aortic cross-clamp time in the mini invasive group, due essentially to the placement of the annuloplasty ring. All knots were tied with a knot pusher through the mini incision.


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  		Table 1. Demographic data
 

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  		Table 2. Operative data
 
Table 3 details various postoperative data. There were no differences between the two groups in terms of extubation time, intensive care unit stay, bleeding and transfusions requirement. Table 4 outlines the various complications in both groups, valve- or non-valve-related. There were no deaths, one reoperation for bleeding in both groups. There was one conversion to an extended thoracotomy to control a small left atrial appendage bleeder in the mini invasive group. Three patients experienced lymphocele of the right groin and one patient required surgical drainage. Two patients in each group experienced transient ischemic vascular emboli, due to small thrombi on the annuloplasty band which disappeared with heparin treatment. One of these patients in the mini invasive group experienced a left ulnar artery thrombus originating from a small annular band thrombus which disappeared with anticoagulation treatment. One patient had a thoracentesis for late postoperative pleural effusion.


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  		Table 3. Postoperative data
 

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  		Table 4. Postoperative complications
 
Postoperative echocardiography showed two patients in both groups with 2+ regurgitation. All other patients had a competent mitral valve repair with no insufficiency.

One patient in the sternotomy group was reoperated 6 months postoperatively for a massive 3+ regurgitation. On reexploration the ring was detached from the posterior annulus, and repair was possible with an excellent result.

All patients were in NYHA Class I and remained so at 12 and 24 months follow-up. The follow up was somewhat longer for the sternotomy group as these patients were operated before the mini invasive group. Length of stay for the mini invasive group was 2 days less than the sternotomy group (7 days vs 9 days). This is due to the fact that most patients with the mini invasive group were discharged directly at home whereas the sternotomy patients were sent in a cardiac rehabilitation unit, and therefore remained in the hospital until a rehab bed was available.


   4. Discussion
Top
 Abstract
 1. Introduction
 2. Material and methods
 3. Results
 4. Discussion
Appendix A
 References
 
Mitral valve repair performed through a sternotomy remains the gold standard, with simple or complex repair feasible with excellent long-term results [18,19]. However, many authors have reported excellent results for both simple and complex mitral valve repair through a mini thoracotomy incision with robotic assistance [20–22]. These results are independent of the type of aortic cross-clamping either endovascular or transthoracic [23]. Both techniques have their advantages and their pitfalls. The major advantage of using trans aortic cross-clamping is the short learning curve because the techniques and skills are familiar to all cardiac surgeons. One of the disadvantages of the technique is its invasiveness and the possibility of atrial injury as experienced in our series in one patient. There is no published data to our knowledge comparing robotic approach and endoscopic approach. However, in our experience, open direct minimal approach or an endoscopic approach is somewhat more difficult then the robotic approach. This is due to a 2D vision which is less optimal than the 3D. Another disadvantage is the absence of degree of flexion with conventional endoscopic instruments as compared with robotic instruments.

The seven degrees of freedom of the robotic wrists greatly facilitates all the placement of the annular sutures and the valvular repair. The movements of the hands of the console surgeon are somewhat similar to an open technique, since the endo wrists are designed to mimic regular long instruments manipulated by hands. Finally, in the endoscopic approach the camera is placed lateral to the two trocars and to the incision providing a vision completely different than a classical approach. Also, the placement of the anterior commissures stitches as well as the left annular sutures are brought in front of the camera, and it then requires a special maneuver to retract these stitches which are obstructing the view. In the robotic approach, a triangulation is performed as the camera is placed more anteriorly and in the middle of the trocars. The final vision obtained is similar to conventional surgery and to all other laparoscopic set up either urological or general surgery. In the robotic approach as the camera is placed at the center of the trocars, the annular sutures do not interfere with the vision and also help in the reconstruction as they allow pulling the annulus and the valve toward the lateral incision.

And therefore, this technique of robotic manipulation is very similar to conventional surgery in terms of vision and surgical gestures which facilitates the learning curve compared to an endoscopic approach. One of the remaining problems with this technique is the increased aortic cross-clamp and extra corporeal time. This does not seem to affect patients in the published literature; however, all patients are highly selected usually young with good ejection fraction. Therefore, this represents one limit of the technique, if one would like to extend the indications for older and more complex repairs. It seems that in all the reported series, the increased time is due mostly to the placement of the annular sutures associated with knot tying. It will be interesting to see if this time can be decreased with the availability of new sutures material [24]. In our series, we opted deliberately to place an open ring in the minimal invasive technique essentially in order to avoid placement of the anterior annulus sutures. Although it is clearly possible to place a closed ring with robotic assistance, in order to decrease time and also to avoid potential injury on the aortic valve we chose an open band. We also have switched currently to an open band in all our mitral valve plasty patients done by sternotomy for the same reasons. This does not seem to affect our preliminary results as compared to plasty performed with a closed ring.

Even though we did not show any difference in terms of extubation time, and ICU stay between the two groups, the patients with the minimal invasive approach described an incisional pain which subsided quicker and allowed an earlier return to a normal daily activity. In order to provide hard data we are currently sending a detailed questionnaire to all patients operated with a minimal approach. Our preliminary results show that patients are able to go back to their daily routine activities 2 weeks after discharge with minimal pain and functional limitation.

However, long-term follow-up is needed in order to compare the reoperations rate at distance between the two approaches.

In our hand we feel that this technique is safe for simple mitral valve repair. Only when new techniques of annular placement will shorten aortic cross-clamping time equivalent to conventional surgery, will it be safe to perform more complex repairs with the robotic approach.


   Appendix A
Top
 Abstract
 1. Introduction
 2. Material and methods
 3. Results
 4. Discussion
 Appendix A
References
 
Conference discussion

Dr A. Moritz (Frankfurt, Germany): We have a good experience with the Chitwood approach, and we heard at this meeting Fred Mohr's experience with about a thousand patients. So I think the comparison should be more between minimal invasive approaches, either being a partial sternotomy or a Chitwood type of approach versus robotic surgery. If you think the idea of minimal invasive mitral surgery is good, there is a very well-established standard now to do it either from a small thoracotomy or through a partial sternotomy.

I personally do not think or do not see a chance to really improve the good results we have with this limited incisions. For any type of robotic surgery you need at least a 4-cm incision. At least, all ports currently being produced for this type of procedure essentially need about this length of skin incision. For the Chitwood approach you need 6–7 cm incision. So you’re trade of a 3 cm of skin incision versus a really complicated procedure.

Dr Folliguet : You’re saying basically not to use the robotic and video assistance.

Dr Moritz : No, we do it directly as Fred Mohr does it. We personally do not see a need for video. Sometimes it's helpful. But through a regular 7-cm incision you can do mitral valve surgery with good results without any support.

Dr Folliguet : Well, this is not really our experience, maybe we have to learn more. But we feel that in our hands the robotic with a 3D vision and, again, the seven degrees of freedom is much more rapid and easier to learn than just conventional endoscopy surgery. I did not present, but we have experience with about 15 patients, either ASD or mitral valve repair through the way you describe, and the procedure times were much longer than use the da Vinci. This is why we moved to the robotic approach.


   Footnotes
 
{star} Presented at the joint 19th Annual Meeting of the European Association for Cardio-thoracic Surgery and the 13th Annual Meeting of the European Society of Thoracic Surgeons, Barcelona, Spain, September 25–28, 2005.


   References
Top
 Abstract
 1. Introduction
 2. Material and methods
 3. Results
 4. Discussion
 Appendix A
 References
 

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