Minimally Invasive Videloscopic Mitral Valve Surgery: The Current Role of Surgical Robotics

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Abstract
Objective: Recently, the efficacy of video-assisted mitral valve surgery has been demonstrated. The evolution of this technology has been relatively rapid. In this article we review this development and predict the future of endoscopic and robotic-enabling technology for cardiac valve operations. Methods: A new video-assisted mitral valve operation is described and results discussed. The majority of each valve operation was done through assisted vision and near endoscopically. Cardiopulmonary bypass was established via femoral cannulation, and blood cardioplegic arrest induced using a now porcutaneous, transthoracic cross-clamp. A 5 to 6-cm minithoracotomy was used in each patient. Videoscopy was helpful for suture placement, chord reconstruction, leaflet resection, knot tying, and valve ring or prosthesis positioning. A voice-activated robotic arm was used to direct the comera in many instances. Results: Thus far a total of 110 patients have undergone this operation successfully with a 0.9% operative mortality. Our early series (N = 31), published with cost data, is reviewed in detail. Cardiopulmonary perfusion and cross-clamp times for all 100 patients were longer than for conventional sternotomy patients at 158 ± 3.9 and 110 ± 3.6 minutes, respectively, versus 121 ± 4.6 and 90 ± 4.6 (N = 105); however, there have been less complications. Operative, perfusion, and arrest times have fallen progressively to 144 ± 4.5 and 90 ± 4.5, respectively (N = 55 Aesop 3000 cases). Complex repairs and replacements have become routine with anterior leaflet pathology addressed. Bleeding, ventilatory times, blood transfusions, and hospital stay have been reduced. One patient required reoperation for a technically failed repair and two renal patients had late endocarditis. We have used voice-activated, robotic (Aesop 3000) assistance for camera control in 51 of these patients. This addition has decreased camera motion artifact and lens cleaning, while providing direct “cerebral-eye” tracking of instruments for the surgeon. We were the first in the United States to apply the DaVinci articulated wrist robot to do a complete mitral repair and have done multiple repair with this articulated wrist device. Conclusions: From this and other work reviewed, we conclude that video-assisted and computer-assisted robotic techniques are safe and may be the pathway to truly endoscopic mitral valve operations. We are encouraged regarding the use of this new technology for mitral valve operations.

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