Robotic Mitral Valve Repair: Clinical Recommendations
Primary Recommendation
Robotic mitral valve repair (MVR) should be performed for patients with isolated mitral valve disease, particularly posterior leaflet prolapse, at high-volume centers (>140 mitral operations annually) by experienced surgeons who have completed a graduated training pathway and maintain adequate case volume (≥20 robotic cases/year). 1
Patient Selection Criteria
Ideal Candidates
- Isolated mitral valve disease without significant aortic pathology is the optimal indication for robotic MVR 1
- Posterior leaflet prolapse represents the best anatomical substrate, with expected repair success rates >90% 1
- Patients meeting ACC/AHA Class I indications: chronic severe primary mitral regurgitation with symptoms, or asymptomatic disease with LV dysfunction (LVEF <60% or LVESD ≥40mm) 1
- Asymptomatic severe primary MR with new-onset atrial fibrillation or pulmonary hypertension (PA systolic pressure >50 mmHg) 1
Relative Contraindications (Early in Learning Curve)
- Significant aortic, iliac, or femoral disease preventing safe retrograde arterial perfusion 2
- Left ventricular ejection fraction <25% 2
- Severe right ventricular dysfunction 2
- Pulmonary artery pressure >70 mmHg 2
- Aorta >4 cm if endoaortic balloon being used 2
- Significant mitral annular calcification 2
Critical caveat: Previous cardiac surgery is NOT a contraindication and may actually favor the robotic approach by avoiding repeat sternotomy complexities 1
Institutional and Surgeon Requirements
Volume-Outcome Relationship
Hospital volume is the single most critical determinant of success. Centers performing >140 mitral operations annually achieve 77% repair rates versus 48% at low-volume centers (<36 cases/year), with 50% lower hospital mortality at highest-volume centers 1. Your program must perform at least 20 robotic-assisted MIMVRs annually to maintain proficiency 2, 3.
Mandatory Training Pathway
Do not attempt robotic MVR without completing this graduated progression 2, 3:
Preclinical Phase:
Clinical Progression:
- Master peripheral cannulation and perfusion with TEE guidance during planned sternotomy cases 2, 3
- Perform mitral operations through progressively smaller thoracotomies to gain comfort with videoscopic exposure 2, 3
- Start robotic cases with the simplest patients (isolated posterior leaflet prolapse) 3
- Avoid concurrent procedures (ASD closure, Cox-maze, tricuspid repair) until consistently achieving shorter clamp times with isolated repairs 2, 3
Team Development:
Expected Outcomes and Benchmarks
Operative Metrics
- Expect longer operative times initially: CPB time approximately 127 minutes, cross-clamp time 88 minutes in experienced hands 4
- Robotic approach adds 11-42 minutes CPB time and 16-26 minutes cross-clamp time compared to other approaches 5
- Track your learning curve: Document time for each operative step and pursue progressive improvement 2, 3
Clinical Outcomes
- Repair success should approach 100% for posterior leaflet prolapse 6, 5, 4
- Operative mortality must be <1% 1
- Hospital stay: 4-5 days (shorter than sternotomy by 1-2 days) 5, 7
- Immediate postoperative echocardiography should show none/trivial MR in 98% of patients 6
Long-Term Durability
- 95% freedom from reoperation at 15-20 years 1
80% freedom from recurrent moderate-severe MR at 15-20 years 1
- These outcomes are equivalent to sternotomy when performed by experienced surgeons 1, 5
Technical Considerations
Repair Techniques
- All classic repair principles apply: use polytetrafluoroethylene suture (preferred over polypropylene for easier robotic tying) 2
- Standard techniques include trapezoidal/triangular resections, sliding plasties, chordal transfers/replacements, edge-to-edge approximations, and ring annuloplasty 6
- Consider autoknotting devices to secure annuloplasty ring sutures and reduce cross-clamp times 2
Port Placement
- Three robotic ports plus working port (4 cm) and camera port through right chest 2, 4
- Left robotic port, robotic retractor port, right robotic port, working port, and camera port configuration 2
De-airing Protocol
- The "CO2-tight" port-access approach introduces less air 2
- Use ascending aortic vent and left ventricular vents as primary de-airing tools 2
- Remove robotic instruments and re-expand lungs before external defibrillation if needed 2
Complications and Management
Stroke Prevention
- Careful preoperative CT angiography assessment of vasculature identifies high-risk patients 2
- Meticulous de-airing prevents air-related cerebrovascular injury 2
- Expected stroke rate: 0.7% 6
Postoperative Hemorrhage
- Inspect all robotic ports deliberately before closure 2
- Chest tube output >100 cc/hour warrants concern 2
- Consider videoscopic re-exploration in stable patients, but perform early sternotomy (even in ICU) if hemodynamically unstable 2
- Expected reoperation for bleeding rate: 2.3% 6
Atrial Fibrillation
- Robotic approach has the lowest occurrence of postoperative atrial fibrillation compared to all other approaches 5
- Pacing wires usually unnecessary for isolated robotic MVR 2
Quality Assurance Requirements
Mandatory Monitoring
- Establish a registry tracking cases, outcomes, and complications 2, 3
- Perform baseline transthoracic echocardiography before discharge 8
- Critical evaluation of successes and failures is essential for program growth 2, 3
- Understand and comply with hospital robotic committee requirements 2
Red Flags for Program Failure
Team failure results from: poor patient selection, inadequate mitral procedural volume, too rapid progression toward robotics, inconsistent tableside assistance, limited TEE experience, and inadequate institutional support 2, 3. Address these proactively.