The mitral valve is one of four heart valves that lies between the left atrium and the left ventricle, and it’s the heart valve that most commonly develops disease. Repair is often needed for something called mitral valve prolapse, or primary mitral valve degeneration, where the valve doesn’t close completely and blood can leak backward.
Minimally-invasive surgery to repair the mitral valve has evolved quite a bit over the years. Much of that recent evolution was spearheaded by cardiac surgeon, Arnar Geirsson, MD, an expert in the robotic approach. He developed the robotic mitral valve repair program at Yale and has joined the Columbia faculty to lead the robotic cardiac surgery program and mitral valve surgery program at Columbia/NewYork-Presbyterian.
We discuss how robotic repair works and why it’s a great option for most people who need surgical intervention for mitral valve disease.
How often does mitral valve disease require surgery?
Mitral valve prolapse affects about 2 percent to 3 percent of the population. And many with symptoms require intervention. So classically, surgical repair of the mitral valve is kind of the gold standard. But there are some nuances to it, which is why the surgery really needs to be done at high-volume centers or by high-volume surgeons to ensure they have great results and good repairs.
Is that because the procedure itself is complicated?
The operation doesn't take that long, but it is complicated to get good results. And it takes experience, generally, to do that. And it's typically said that a surgeon should do about 35 to 50 of these a year to be pretty good at it.
What about people who do not have symptoms? Do they ever require surgery?
The majority of people who have severe mitral regurgitation have some type of symptoms. But there's still a significant portion, especially younger patients, who are relatively fit and can actually tolerate severe mitral regurgitation without much symptoms for quite some time, sometimes for years.
Many may not even know they have it. And eventually, the heart is just unable to keep up with the volume load, or it starts to negatively affect their heart in general.
Let’s talk about the repair options. What are the differences between an open, laparoscopic, and robotic approach?
The classical way is to do this through an open-heart operation sternotomy. Then there are two common other ways to do it: right thoracotomy, minimally invasively, and the robotic mitral.
The fourth option nowadays is to do MitraClip [a transcatheter repair where a tiny device is inserted through a tube and placed on the mitral valve to treat leakage]. At the moment, that is only indicated for patients who are considered to be high operative risk. So young patients, or even some people who are younger than 80 years old, generally should just go under operation or a robotic mitral. Because the durability of the MitraClip is less, and it’s less effective than surgery to reduce regurgitation.
I will say, that is being debated, though.
Does that mean that robotic repair is an option for people in the higher-risk category, too?
Yes. We've certainly done people over 80, who would be considered intermediate to high risk, and have done quite well. If, for some reason, they haven't been a good candidate for MitraClip, we've done a robotic repair with good results. And they tolerate it similarly. Most people only stay three to four days in the hospital after robotic [repair].
Really, I would say the mass majority of people are good candidates for robotic repair.
How does the robotic procedure work? Where are the incisions made?
We make about a one-inch incision on the right side of the chest, and then there are four additional tiny eight millimeter holes that we use. Going through the back door, basically.
Is that difficult to do with the space limitations of a closed chest?
Well, there are two components. First of all, you have to be, I think, very good at repairing the valve before you do this. But mastering the robotic techniques does take some experience. To develop it from scratch requires probably 40, or 50 cases to be considered pretty good. But once you master the techniques, you can repair any type of valve. And I would argue you can actually do them better. The techniques that you use are quite like doing it open, just the access and the trauma to the patients is much less. Use of blood products, pain, and just general mobility into overall recovery, it's much faster with robotic.
Generally, how do you talk to patients about their options when they need this type of repair?
If it’s just an isolated repair of the mitral valve plug, we can actually also do tricuspid and surgical ablation quite easily with that stuff. Then we offer them robotic repairs unless there's some significant contraindication not to do it. If you have coronary artery disease or aortic valve disease, you probably should do a sternotomy because you need to address the other stuff.
If there are some other congenital malformations or prior chest surgery, then it's kind of relative. Sometimes we avoid that. If there's significant atherosclerotic disease of the blood vessels, then it's probably better to do a sternotomy. So, there are things that we look at specifically to see if there's any reason not to do a robotic repair. Because you want to have us still do it safely and have good outcomes.
I would say in my practice, maybe 10 or 15 percent of people who come looking for robotic repair end up with a sternotomy for one reason or another, because we think they're not good candidates. Otherwise, the first choice is to offer people robotic.
What else do you want patients to know about robotic mitral repair before evaluating their options?
I want them to know, first of all, it's a very safe procedure. And it's less traumatic, faster recovery, less use of blood product resources, and shorter stays in the hospital. Most people can be back to work within four weeks, some people even two weeks. And cosmetically, it's very appealing. I mean, those tiny incisions instead of a large scar.
Now at Columbia, we have the full spectrum of therapy for mitral valve disease. And I think that's important. There’s an excellent transcatheter option, booster repair, and replacement. There's a standard open surgical option to do mitral valve operation, now certainly robotics. So, people can get the best therapy, however you do it.
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