Robotic mitral valve surgery in Latin America

Rheumatic heart disease remains the leading cause of mitral valve (MV) disease in developing countries (1). In Latin America, with population aging and socioeconomical development in the past decades, degenerative disease of the MV has become increasingly prevalent (2). Both rheumatic and degenerative disease can lead to severe MV dysfunction, often requiring surgical intervention. Treatment options include well established conventional and minimally invasive approaches and, most recently, transcatheter options. Within the range of minimally invasive procedures, robotic MV surgery has gained popularity since independently performed by Carpentier (3) and Mohr (4) in 1998. The operations were accomplished using the da Vinci Surgical System (Intuitive Surgical Inc., Sunnyvale, California, USA) which received FDA approval in 2002, quickly becoming the platform of choice for robotic-assisted cardiac surgery. The use of robotics for MV surgery in North America and Europe is well documented. A review from Bonatti and colleagues (5) demonstrated 0.4% mortality rate, 2.1% conversion rate and high repair success rates in 4,106 patients undergoing robotic MV repair in the US, Europe, and Asia. Similarly, Murphy (6) demonstrated a 0.9% mortality rate and high repair success rates in 1,257 MV cases performed robotically. With a mean follow-up of 50±26 months, this series showed 3.8% reoperation rate for recurrent mitral regurgitation. Conversely, the shortage of publications from Latin America poses a challenge for obtaining updated information regarding volume and results. Robotic cardiac surgery in Latin America started in 2010 with a series of successful cases performed at Hospital Israelita Albert Einstein in Sao Paulo, Brazil (7). The early experience included 51% of MV procedures showing low mortality and high repair rates in MV degenerative disease (7), mirroring the international practice. From 2010 to present, the pioneer group performed 120 cases in four different centers in Brazil, representing the largest experience in Latin America. Preliminary data from their registry showed that 70% of patients had MV surgery. Of these, 75% underwent valve repair due to myxomatous degeneration with a repair success rate of 98%. There were no intra-operative complications or conversions to full sternotomy and early mortality was reported in one case. Long-term survival was 98% and there were no reoperations for recurrent mitral regurgitation at long-term follow-up. Apart from the Brazilian data, Andrade and colleagues (8) recently published their experience with robotic cardiac surgery in Colombia, initiated in 2017. Of the six cases performed with the da Vinci Xi system, three had symptomatic severe mitral regurgitation secondary to P2 prolapse and underwent successful valve repair. At one-year follow-up, all patients were doing well, and no reoperations were required. Although many other countries in Latin America are known to have started their robotic programs, they are still in the beginning of their learning curve and have not yet reported early results. There are major limitations for adoption of robotic cardiac surgery in Latin America. Firstly, dedicated programs for surgical training are scarce. It has been suggested by Suri and colleagues (9) that surgical training can be best achieved in an apprentice or fellowship setting, which remains challenging as robotic surgery is limited to few centers with highly competitive programs. Mastering robotic MV surgery requires not only knowledge on robotic Robotic mitral valve surgery in Latin America