Commentary: Surgical treatment of atrial fibrillation at the time of cardiac surgery: Just do it (2021)

Central MessageRobotic mitral valve repair has advantages like excellent visualization and agile instrumentation. However, minimally invasive surgery is only appropriate when it does not sacrifice safety or quality.See Article page 75.Almeida and colleagues1Almeida A. Tutungi E. Moten S. Chen Y. Minimally invasive and robotic approaches to mitral valve: robotic is best..J Thorac Cardiovasc Surg Tech. 2021; 10: 75-79Scopus (4) Google Scholar were tasked with answering a question: What is the best minimally invasive mitral valve operation?1Almeida A. Tutungi E. Moten S. Chen Y. Minimally invasive and robotic approaches to mitral valve: robotic is best..J Thorac Cardiovasc Surg Tech. 2021; 10: 75-79Scopus (4) Google Scholar In arguing in favor of a robotic approach, the authors highlight the robotic platform’s articulating instruments, dynamic left atrial retractor, and 3-dimensional camera, which provide clear advantages over a traditional right thoracotomy approach. These features give expert mitral surgeons access to the entire toolbox of mitral repair techniques, such that essentially any degenerative mitral valve repair could be repaired with a robotic approach. The authors also cite several large series that demonstrate the safety, efficacy, and durability of robotic mitral valve repair. With the caveat that robotic mitral surgery is not right for every program, these are compelling arguments for the superiority of robotics over other minimally invasive mitral approaches.That being said, the question: What is the best minimally invasive mitral valve operation? is fundamentally misguided. Just as each mitral valve repair technique must be used in an appropriate valve to achieve a perfect repair, minimally invasive surgical approaches need to be used in carefully selected patients to achieve perfect outcomes.It is our philosophy that minimally invasive surgery is only appropriate when it can be offered without sacrificing safety or quality. We have adopted a conservative screening algorithm, which we use to counsel patients about the most appropriate, data-driven approach for each patient’s anatomy and physiology.2Chemtob R.A. Wierup P. Mick S.L. Javorski M.J. Burns D.J.P. Blackstone E.H. et al.A conservative screening algorithm to determine candidacy for robotic mitral valve surgery.J Thor Cardiovasc Surg. 2020; (December 17, 2020 [Epub ahead of print])Abstract Full Text Full Text PDF Scopus (8) Google Scholar Patients with greater-than-mild aortic regurgitation, left ventricular dysfunction, or pulmonary hypertension are offered open surgery to optimize myocardial protection through antegrade and retrograde cardioplegia. Patients with more-than-minimal mitral annular calcification are offered open surgery in the event that extensive debridement and reconstruction of the atrioventricular grove is required. Patients with significant aortoilliac calcification are offered open surgery because of the risk of stroke with femoral cannulation and retrograde perfusion of the descending aorta, and patients with small-caliber femoral arteries are offered open surgery because of the risk of distal limb complications. In a series of 1000 patients with isolated degenerative mitral valve disease, this algorithm qualified 60% of patients for robotic surgery. There were no mortalities in the robotic or sternotomy groups, and the rates of stroke were similar (0.5% for robotic and 1.0% for sternotomy).2Chemtob R.A. Wierup P. Mick S.L. Javorski M.J. Burns D.J.P. Blackstone E.H. et al.A conservative screening algorithm to determine candidacy for robotic mitral valve surgery.J Thor Cardiovasc Surg. 2020; (December 17, 2020 [Epub ahead of print])Abstract Full Text Full Text PDF Scopus (8) Google ScholarWe do find that many patients are referred to our center specifically for robotic mitral valve surgery, and many are offered open surgery for the reasons stated above. In these patients, we offer a hemisternotomy approach, with a J-shaped incision in the right fifth intercostal space. This approach, performed through a 10-cm or smaller skin incision, is cosmetically superior to a standard sternotomy and allows for central aortic cannulation with direct cannulation of the coronary sinus for delivery of retrograde cardioplegia. A full sternotomy approach is generally reserved for patients with challenging body habitus, including pectus excavatum, patients undergoing concomitant coronary bypass surgery, or patients with severe mitral annular calcification.It is also essential to discuss the complex value proposition of robotic mitral surgery. In an analysis of 1290 patients undergoing mitral valve surgery at our center, Mihaljevic and colleagues3Mihaljeic T. Koprivanac M. Kelava M. Goodman A. Jarrett C. Williams S.J. et al.Value of robotically assisted surgery for mitral valve disease.JAMA Surg. 2014; 149: 679-686Crossref PubMed Scopus (41) Google Scholar found that the increased operative cost of robotic mitral surgery—driven by upfront capital investment and maintenance of equipment—was mitigated by lower postoperative hospital costs and greater patient benefit, in terms of shorter recovery and earlier return to work. However, this analysis predicts that the cost of robotic mitral valve surgery is only comparable to conventional approaches in high-volume centers; that is, those with volumes of at least 55 to 100 robotic cases per year.3Mihaljeic T. Koprivanac M. Kelava M. Goodman A. Jarrett C. Williams S.J. et al.Value of robotically assisted surgery for mitral valve disease.JAMA Surg. 2014; 149: 679-686Crossref PubMed Scopus (41) Google ScholarRobotics have changed the game for mitral valve surgeons, who can now perform the full spectrum of mitral valve repair techniques through very small incisions. However, it is essential that we never compromise patient outcomes for the sake of a minimally invasive approach. Robotic mitral valve repair has advantages like excellent visualization and agile instrumentation. However, minimally invasive surgery is only appropriate when it does not sacrifice safety or quality. Robotic mitral valve repair has advantages like excellent visualization and agile instrumentation. However, minimally invasive surgery is only appropriate when it does not sacrifice safety or quality. See Article page 75. See Article page 75. Almeida and colleagues1Almeida A. Tutungi E. Moten S. Chen Y. Minimally invasive and robotic approaches to mitral valve: robotic is best..J Thorac Cardiovasc Surg Tech. 2021; 10: 75-79Scopus (4) Google Scholar were tasked with answering a question: What is the best minimally invasive mitral valve operation?1Almeida A. Tutungi E. Moten S. Chen Y. Minimally invasive and robotic approaches to mitral valve: robotic is best..J Thorac Cardiovasc Surg Tech. 2021; 10: 75-79Scopus (4) Google Scholar In arguing in favor of a robotic approach, the authors highlight the robotic platform’s articulating instruments, dynamic left atrial retractor, and 3-dimensional camera, which provide clear advantages over a traditional right thoracotomy approach. These features give expert mitral surgeons access to the entire toolbox of mitral repair techniques, such that essentially any degenerative mitral valve repair could be repaired with a robotic approach. The authors also cite several large series that demonstrate the safety, efficacy, and durability of robotic mitral valve repair. With the caveat that robotic mitral surgery is not right for every program, these are compelling arguments for the superiority of robotics over other minimally invasive mitral approaches. That being said, the question: What is the best minimally invasive mitral valve operation? is fundamentally misguided. Just as each mitral valve repair technique must be used in an appropriate valve to achieve a perfect repair, minimally invasive surgical approaches need to be used in carefully selected patients to achieve perfect outcomes. It is our philosophy that minimally invasive surgery is only appropriate when it can be offered without sacrificing safety or quality. We have adopted a conservative screening algorithm, which we use to counsel patients about the most appropriate, data-driven approach for each patient’s anatomy and physiology.2Chemtob R.A. Wierup P. Mick S.L. Javorski M.J. Burns D.J.P. Blackstone E.H. et al.A conservative screening algorithm to determine candidacy for robotic mitral valve surgery.J Thor Cardiovasc Surg. 2020; (December 17, 2020 [Epub ahead of print])Abstract Full Text Full Text PDF Scopus (8) Google Scholar Patients with greater-than-mild aortic regurgitation, left ventricular dysfunction, or pulmonary hypertension are offered open surgery to optimize myocardial protection through antegrade and retrograde cardioplegia. Patients with more-than-minimal mitral annular calcification are offered open surgery in the event that extensive debridement and reconstruction of the atrioventricular grove is required. Patients with significant aortoilliac calcification are offered open surgery because of the risk of stroke with femoral cannulation and retrograde perfusion of the descending aorta, and patients with small-caliber femoral arteries are offered open surgery because of the risk of distal limb complications. In a series of 1000 patients with isolated degenerative mitral valve disease, this algorithm qualified 60% of patients for robotic surgery. There were no mortalities in the robotic or sternotomy groups, and the rates of stroke were similar (0.5% for robotic and 1.0% for sternotomy).2Chemtob R.A. Wierup P. Mick S.L. Javorski M.J. Burns D.J.P. Blackstone E.H. et al.A conservative screening algorithm to determine candidacy for robotic mitral valve surgery.J Thor Cardiovasc Surg. 2020; (December 17, 2020 [Epub ahead of print])Abstract Full Text Full Text PDF Scopus (8) Google Scholar We do find that many patients are referred to our center specifically for robotic mitral valve surgery, and many are offered open surgery for the reasons stated above. In these patients, we offer a hemisternotomy approach, with a J-shaped incision in the right fifth intercostal space. This approach, performed through a 10-cm or smaller skin incision, is cosmetically superior to a standard sternotomy and allows for central aortic cannulation with direct cannulation of the coronary sinus for delivery of retrograde cardioplegia. A full sternotomy approach is generally reserved for patients with challenging body habitus, including pectus excavatum, patients undergoing concomitant coronary bypass surgery, or patients with severe mitral annular calcification. It is also essential to discuss the complex value proposition of robotic mitral surgery. In an analysis of 1290 patients undergoing mitral valve surgery at our center, Mihaljevic and colleagues3Mihaljeic T. Koprivanac M. Kelava M. Goodman A. Jarrett C. Williams S.J. et al.Value of robotically assisted surgery for mitral valve disease.JAMA Surg. 2014; 149: 679-686Crossref PubMed Scopus (41) Google Scholar found that the increased operative cost of robotic mitral surgery—driven by upfront capital investment and maintenance of equipment—was mitigated by lower postoperative hospital costs and greater patient benefit, in terms of shorter recovery and earlier return to work. However, this analysis predicts that the cost of robotic mitral valve surgery is only comparable to conventional approaches in high-volume centers; that is, those with volumes of at least 55 to 100 robotic cases per year.3Mihaljeic T. Koprivanac M. Kelava M. Goodman A. Jarrett C. Williams S.J. et al.Value of robotically assisted surgery for mitral valve disease.JAMA Surg. 2014; 149: 679-686Crossref PubMed Scopus (41) Google Scholar Robotics have changed the game for mitral valve surgeons, who can now perform the full spectrum of mitral valve repair techniques through very small incisions. However, it is essential that we never compromise patient outcomes for the sake of a minimally invasive approach. Minimally invasive and robotic approaches to mitral valve: Robotic is bestJTCVS TechniquesVol. 10PreviewAsking the question “What is the best minimally invasive mitral valve operation?” is fraught with the same problems as asking, “What is the best … city, …car, …football team?” etc. It depends not only on what factors one considers important but also on how one weights each of those. Full-Text PDF Open Access