Longitudinal quality of life assessment following robotic mitral valve repair versus conventional sternotomy

Abstract

Objective

Robotic-assisted mitral repair has demonstrated excellent late outcomes without increased morbidity and mortality in experienced centers. Robust analysis of postoperative quality of life in large cohorts has been limited.

Methods

Between January 1, 2020, and April 1, 2024, 563 adult patients who underwent mitral repair for degenerative mitral regurgitation at our institution were retrospectively reviewed. Patient-Reported Outcomes Information System Global Health 10-question survey (PROMIS-10) physical and mental scores, as well as MacNew social scores were evaluated at baseline and serial follow-up at 1 month, 3 months, 6 months, and 1 year. Quality of life (QoL) metrics were evaluated longitudinally using a nonlinear multiphase mixed-effects regression model.

Results

A total of 1493 postoperative QoL measurements were available in 563 patients (247 robotic vs 316 sternotomy). Patients who received a robotic approach were younger than those who underwent sternotomy (age 58 ± 10 years vs age 66 ± 10 years; P < .001) with fewer comorbidities and higher baseline PROMIS-10 physical (55 robotic vs 51 sternotomy; P < .001) and mental (57 vs 53; P < .001) scores. There was no significant difference in temporal outcomes between groups (physical: P = .11; mental: P = .84; social: P = .55). Each metric in both groups surpassed the population norm and returned to preoperative baseline within 6 months (graphical abstract).

Conclusions

Postoperative QoL following mitral valve repair was excellent, regardless of approach. Patients who were selected for a robotic approach demonstrated higher baseline QoL metrics than those who received a sternotomy, but this did not translate to a comparative improvement on adjusted analyses and QoL for most patients returned to baseline by 6 months. The operative approach for mitral valve repair in patients who are candidates for a minimally invasive procedure should be tailored to surgeon experience in offering a safe, durable repair.

Graphical Abstract

Temporal trend of postoperative PROMIS-10 physical scores after mitral valve surgery.

Central Message.

Postoperative quality of life after mitral valve repair was excellent. Most patients returned to work at full capacity by 2 months and quality of life reached baseline levels by 6 months.

Perspective.

Robotic mitral valve repair has become a popular minimally invasive option relative to conventional sternotomy. In our series, postoperative quality of life was excellent, regardless of approach, and patient recovery was most significantly influenced by preoperative quality of life. The optimal approach to mitral valve repair should be tailored to surgeon experience in offering a safe, durable repair.

Mitral valve repair (MVr) is indicated in patients with severe degenerative mitral regurgitation (MR) and has demonstrated outstanding national outcomes with <1% mortality risk.¹ Minimally invasive techniques for MVr, such as robotic-assisted, hemisternotomy, and thoracotomy approaches have emerged in popularity over the past 2 decades, with a steady increase in utilization over the past few years.^2,3

Robotic MVr has demonstrated a comparable safety profile to a conventional sternotomy approach, with similar morbidity and mortality rates, and excellent durability.^4,5 The robotic approach has been associated with less postoperative atrial fibrillation and transfusion requirements, as well as shorter intensive care unit (ICU) and hospital stays.^4,6,7 At our center, patients who are offered a robotic approach have passed a rigorous physical and imaging screening algorithm and demonstrate significantly fewer comorbidities than their sternotomy counterparts.⁴

There has been an emerging interest in health-related quality of life (QoL) outcomes after cardiac surgery. Early studies have revealed a possible early improvement in physical QoL after robotic MVr, relative to sternotomy, although there has been limited validation in modern cohorts with an accounting of baseline QoL.⁸ The purpose of this study was to evaluate the impact of surgical approach (robotic vs sternotomy) on postoperative QoL in patients who undergo MVr for degenerative MR.

Patients and Methods

From January 1, 2020, to April 1, 2024, 563 adults with moderate-severe degenerative MR underwent isolated MV surgery via a robotic or conventional sternotomy approach and concurrently had available postoperative QoL data. Exclusion criteria were age younger than 18 years, mitral disease etiology other than degenerative, prior coronary artery bypass surgery, emergency status, severe mitral annular calcification (MAC), or stenosis. Patients who underwent concomitant procedures other than tricuspid valve repair or replacement, surgical ablation for atrial fibrillation, and closure of patent foramen ovale were also excluded (Figure E1).

Figure E1.

Consolidated Standards of Reporting Trials diagram.

Patient Screening

Patients were routinely screened preoperatively with routine laboratory work, chest radiography, transthoracic echocardiogram, computed tomography imaging of the chest, abdomen, and pelvis, and with coronary angiography or computed tomography angiography. Patients with severe coronary artery disease requiring concomitant coronary bypass grafting were excluded from consideration of robotic MVr candidacy. Similarly, patients with moderate-severe MAC, left ventricular dysfunction, pulmonary hypertension, moderate-severe aortic insufficiency, aortoiliac atherosclerosis, pectus excavatum, and femoral artery diameter <7 mm were excluded from robotic candidacy.

Surgical Techniques

For a robotic-assisted approach, a double lumen endotracheal tube is used for single left lung ventilation. The right femoral vessels are exposed for cannulation, and the right internal jugular vein is percutaneously cannulated. Access ports are placed in the right chest: left instrument port at the second interspace between the midclavicular and anterior axillary lines, right instrument port at the sixth interspace anterior axillary line, atrial retractor at the fourth interspace midclavicular line. A 40-mm anterolateral minithoracotomy is made at the fourth interspace and soft tissue is exposed for eventual access for a Chitwood aortic clamp. The central tendon of the diaphragm and posterior pericardium are taken through angiocatheters through the skin for retraction. The robot is docked after cross clamping and antegrade cardioplegia arrest. The approach to setup and robotic MVr is described in more detail in our prior works.⁹

At our center, the MVr strategy in patients with degenerative MR is individualized to the site of leaflet prolapse. Mitral annuloplasty is a cornerstone to our repair algorithm. In robotic cases, a running suture annuloplasty technique is used with a 35-mm posterior flexible band, whereby the band is removed from the template, and a semicontinuous running suture tends to crimp the band. For this reason, the band as implanted is actually smaller than a 35-mm band placed in the traditional fashion. The largest band is selected with the robotic approach to minimize the risk of mitral stenosis.

End Points

An institutional review board-approved questionnaire was periodically distributed and supplemented by telephone interview with patient consent and data available in Epic Systems Care Everywhere.

Patient QoL was examined by a hybrid questionnaire consisting of both the National Institutes of Health Patient-Reported Outcomes Measurement Information System (PROMIS)-10 and MacNew surveys distributed 7 days preoperatively, as well as 1 month, 3 months, 6 months, and 12 months postoperatively (Appendix E1).^10,11 A total of 1493 postoperative QoL questionnaires were available for 563 patients. The median follow-up time for questionnaire review was 6 months (3-12 months).

Preoperative work status was available in 79% (443 out of 563) of the study cohort. Of those previously employed with a full-time or part-time status (n = 263), return to work data were available for more than 99% (262 out of 263) of the cohort. Early return to work was defined as <1 month postoperatively. Return to work at full capacity was assessed at the 3-month follow-up visit.

Patients

Data on patient baseline characteristics, pathologic findings, operative details, echocardiography measures, hospital outcomes, and QoL metrics were retrieved from prospective quality registries, with additional information obtained from individual medical records review. This study was approved by the Cleveland Clinic Institutional Review Board (IRB#19-355; approval date October 29, 2024), with waiver of patient consent.

Statistical Analysis

Data Presentation and Software

Continuous variables were reported as mean ± standard deviation (SD) or equivalent 15th, 50th (median), and 85th percentiles for skewed distributions, and group comparisons were made using the nonparametric Wilcoxon rank-sum test. Categorical variables were expressed as frequencies and percentages and compared using χ² analysis. Cochran-Armitage trend test was used for timing of return to work for 3-category variables. SAS version 9.4 (SAS Institute Inc) and R version 4.3.1 (R Foundation for Statistical Computing) were used for statistical analyses.

Longitudinal and Time-Related Outcomes

To assess the temporal trend of individual postoperative QoL measures, patient-reported survey metrics were analyzed longitudinally. A nonlinear multiphase mixed-effects longitudinal regression model was to resolve a number of time phases to estimate temporal trends of PROMIS-10 physical, PROMIS-10 mental, and MacNew social scores.¹² SAS PROC NLMIXED was used to implement the temporal decomposition models.

Risk Factor Identification

A boosting approach (boostmtree package in R) based on marginal models for longitudinal data was used to analyze factors associated with postoperative PROMIS-10 physical scores. To model covariate-time interactions, a P-spline approach with smoothing parameters was used.¹³ Missing data in the covariates were imputed on the fly as a part of growing the forest object.¹⁴ Variable selection was conducted using a variable importance approach to separate the overall covariate main effects and a covariate-time interaction effect.¹⁵ The variables with highest variable importance were tested in the nonlinear mixed model. This method was used as an additional way to assess the shape of the relationship of PROMIS-10 physical score to covariates with the fewest assumptions. It provided a flexible alternative to model complex relationships of multiple covariates and their interactions with time. Partial dependency plots were used to describe the risk-adjusted relationship between the covariate of interest and the response by integrating out the effect of all other covariates.¹⁶ A complete list of variables considered is presented in Appendix E2.

Results

Baseline Characteristics

Patients who underwent a robotic approach procedure were younger than those who underwent a sternotomy (58 ± 10 years vs 66 ± 10 years; P < .001) with fewer comorbidities (Table 1). At baseline, robotic patients had higher PROMIS-10 physical (53.9 ± 7.9 vs 50.5 ± 8.3; P < .001) and mental (56.6 ± 7.6 vs 53.4 ± 9.0; P < .001) scores than sternotomy patients. MacNew social scores (6.1 ± 0.8 vs 5.9 ± 1.0; P = .12) were not significantly different.

Table 1.

Preoperative patient characteristics

Characteristic	Robotic (n = 247)	Sternotomy (n = 316)	P value
Valve structure and function
Mitral regurgitation grade
Moderate	16 (6)	32 (10)	.12
Severe	231 (94)	284 (90)
Tricuspid regurgitation grade
None	173 (70)	150 (47)	<.001
Mild	72 (29)	118 (37)
Moderate	2 (1)	45 (14)
Severe	0 (0)	3 (1)
Left heart morphology
Right ventricular systolic pressure (mm Hg)	28 ± 9	33 ± 12	<.001
Left ventricular end systolic diameter (cm)	3.2 ± 0.5	3.4 ± 0.6	.003
Left atrial diameter (cm)	4.4 ± 0.7	4.6 ± 0.8	.32
Ejection fraction (%)	63 ± 5	62 ± 6	.006
Demographics
Age (y)	58 ± 10	66 ± 10	<.001
Female	75 (30)	129 (41)	.01
Caucasian race	217/235 (92)	290/304 (95)	.14
Body mass index	25.5 ± 3.7	26.0 ± 5.1	.76
Symptoms and status
History of myocardial infarction	0 (0)	0 (0)	0
NYHA functional class			.002
I	53/237 (22)	61/311 (20)
II	179/237 (76)	221/311 (71)
III	5/237 (2)	29/311 (9)
IV	0/237 (0)	0/311 (0)
Cardiac comorbidities	0 (0)	2 (1)	.21
Atrial fibrillation	9 (4)	96 (30)	<.001
Peripheral artery disease	2 (1)	3 (1)	.86
Hypertension	115 (47)	173 (55)	.06
Noncardiac comorbidities
Insulin-treated diabetes	1 (1)	1 (1)	.86
Chronic obstructive pulmonary disease	13 (5)	37 (12)	.008
Smoking	51 (21)	90 (28)	.03
GFR	81 ± 17	79 ± 18	.046
Dialysis	0 (0)	1 (1)	0
MELD score	2.8 ± 3.4	4.3 ± 3.7	.056
Stroke	5 (2)	9 (3)	.53
Quality of life
PROMIS-10 score: Physical	53.9 ± 7.9	50.5 ± 8.3	<.001
PROMIS-10 score: Mental	56.6 ± 7.6	53.4 ± 9.0	<.001
MacNew social score	6.1 ± 0.8	5.9 ± 1.0	.12

NYHA, New York Heart Association; GFR, glomerular filtration rate; MELD, model for end-stage liver disease.

Operative Data

The posterior leaflet was the most common site of prolapse in both groups (P = .49) (Table 2). Concomitant tricuspid valve repair was performed in 1% (n = 3) of patients who underwent a robotic approach, relative to 28% (n = 88) of patients who underwent a sternotomy approach (P < .001). Surgical ablation was also performed less frequently via a robotic approach (2% [n = 4]; 32% [n = 100]; P < .001). Patients who underwent a robotic approach procedure had longer cardiopulmonary bypass times (P < .001) with no significant difference in aortic crossclamp times (P < .001), relative to their sternotomy counterparts. Robotic patients also required less frequent intraoperative (12% [n = 30] vs 24% [n = 76]; P < .001) and postoperative blood product transfusions (7% [n = 18] vs 13% [n = 41]; P = .029).

Table 2.

Operative characteristics

Characteristic	Robotic (n = 247)	Sternotomy (n = 316)	P value
Repair type			.49
Posterior	191 (77)	232 (73)
Anterior	13 (5)	23 (7)
Bileaflet	43 (17)	61 (19)
Concomitant procedures
Tricuspid valve repair	3 (1)	88 (28)	<.001
Atrial fibrillation ablation∗	4 (2)	100 (32)	<.001
Cardiopulmonary bypass time (min)	116 (96, 158)	93 (70, 124)	<.001
Aortic crossclamp time (min)	68 (52, 94)	72 (51, 98)	.36
Intraoperative blood product transfusion	30 (12)	76 (24)	<.001
Intra-aortic balloon pump	2 (1)	0 (0)	.11

Values are presented as n (%) or median (15th, 85th).

^∗Cox-maze IV or pulmonary vein isolation.

There was no operative mortality in this series, and major complication rates were not significantly different between groups (Table 3). Patients who underwent a robotic approach had significantly lower rates of postoperative atrial fibrillation (20% [47 out of 237] vs 34% [72 out of 220]; P < .001) than sternotomy patients and experienced shorter ICU (27 hours [22-54 hours] vs 32 hours [23-76 hours]; P < .001) and hospital stays (4 days [3-5 days] vs 5 days [4-7 days]; P < .001). There was no significant difference in postoperative MR grade between groups because the majority of patients were discharged with no MR (94% [n = 232] vs 96% [n = 303]; P = .22), whereas the remaining few were discharged with mild MR (5% [n = 13] vs 4% [n = 13]). Two patients who underwent robotic mitral repair with anterior neochord placement for A2 and A3 flail, respectively, developed moderate MR after surgery. One of these patients ultimately required MVr via full sternotomy due to thrombus and scar formation around the mitral annular band.

Table 3.

Postoperative outcomes

Characteristic	Robotic (n = 247)	Sternotomy (n = 316)	P value
Postoperative mitral regurgitation grade
None	232 (94)	303 (96)	.22
Mild	13 (5)	13 (4)
Moderate	2 (1)	0 (0)
ICU length of stay (h)	27 (22, 54)	32 (23, 76)	<.001
Postoperative length of stay (d)	4 (3, 5)	5 (4, 7)	<.001
30-d Mortality	0 (0)	0 (0)	0
In-hospital mortality	0 (0)	0 (0)	0
Prolonged ventilation	2 (1)	1 (1)	.43
Postoperative blood product transfusion	18 (7)	41 (13)	.029
Postoperative atrial fibrillation	47/237 (20)	72/220 (34)	<.001
Major complication
Pacemaker	2 (1)	6 (2)	.28
Reoperation for bleeding	5 (2)	3 (1)	.28
Sepsis	0 (0)	0 (0)	–
Renal failure requiring dialysis	0 (0)	0 (0)	–
Stroke	0 (0)	0 (0)	–
Mediastinitis	0 (0)	0 (0)	–

Values are presented as n (%) or median (15th, 85th). ICU, Intensive care unit.

Longitudinal QoL Assessment

PROMIS-10 physical scores

In patients who underwent a robotic approach to MVr, the estimated PROMIS-10 physical scores at 1, 3, 6, and 12 months postoperatively were 48, 52, 55, and 58, respectively, in the unadjusted parametric analysis. Patients who received a sternotomy had significantly lower unadjusted estimates of 46, 50, 53, and 56 at the same timepoints (P = .008). These are represented graphically alongside the population norm of 50 (Figure 1). After adjusting for preoperative PROMIS-10 physical scores (P < .001), there was no significant difference in postoperative PROMIS-10 physical scores on adjusted analysis (P = .11). The return to average preoperative baseline PROMIS-10 physical score was 6.2 months for patients who underwent a robotic approach, relative to 2.7 months for patients who received a sternotomy. The adjusted effect of preoperative PROMIS-10 physical scores on postoperative scores at 1 and 12 months is demonstrated in Figure E2, as preoperative scores were directly associated with postoperative scores.

Figure 1.

Longitudinal changes in postoperative quality of life physical domain: Patient-Reported Outcomes Information System Global Health 10-Question Survey physical score (robotic = red line, sternotomy = blue line) relative to the population norm (black dashed line).

Figure E2.

Partial dependency plot of the adjusted effect of preoperative Patient-Reported Outcomes Information System Global Health 10-Question Survey physical score on postoperative score at 1 month (green) and 12 months (red).

PROMIS-10 mental scores

Parametric estimates of the PROMIS-10 mental scores at 1, 3, 6, and 12 months postoperatively were 53, 55, 56, and 57 after a robotic approach, and 52, 53, 55, and 56 after sternotomy, respectively (P = .02). After adjusting for preoperative PROMIS-10 mental scores (P < .001) there was no significant difference in postoperative PROMIS-10 mental scores on adjusted analysis (P = .84). These are represented graphically alongside the population norm of 50 (Figure 2). The return to average preoperative baseline PROMIS-10 mental score was 7.0 months for patients who underwent a robotic approach, relative to 2.4 months for patients who received a sternotomy.

Figure 2.

Longitudinal changes in postoperative quality of life mental domain: Patient-Reported Outcomes Information System Global Health 10-Question Survey mental score (robotic = red line, sternotomy = blue line) to the population norm (black dashed line).

MacNew social scores

Parametric estimates of the MacNew social scores at 1, 3, 6, and 12 months postoperatively were 5.4, 5.9, 6.3, and 6.7 after a robotic approach, and 5.2, 5.8, 6.2, and 6.6 after sternotomy, respectively (P = .11). Similar results were observed on the adjusted analysis (P = .55). These are represented graphically alongside the population norm of 5.2 (Figure 3). The return to average preoperative baseline MacNew social score was 5.8 months for patients who underwent a robotic approach, relative to 5.1 months for patients who received a sternotomy.

Figure 3.

Longitudinal changes in postoperative quality of life social domain: MacNew social score (robotic = red line, sternotomy = blue line) relative to the population norm (black dashed line).

Return to work

The majority of patients who underwent a robotic approach to MVr were working full- or part-time before surgery (72% [144 out of 201]), relative to approximately half of patients who underwent a sternotomy approach (49% [119 out of 242] (P < .001). Of those previously employed who returned to work at full capacity by 3 months, there was no significant difference in early return to work between patients who underwent robotic (34% [40 out of 117]) or sternotomy (25% [22 out of 88]) approaches (P = .16).

At 1 month (1-4 weeks), 2 months (5-8 weeks), and 3 months (9-12 weeks) postoperatively, 24% (n = 62), 64% (n = 168), and 78% (n = 205) of patients, respectively, returned to work in full capacity. By the end of the survey period at the 3-month follow-up visit, most patients in both groups returned to work at full capacity (81% [117 out of 144] robotic vs 75% [88 out of 118] sternotomy). There was no significant difference in trend between the groups for time to return to work (P = .07 Cochran-Armitage trend test for trend).

Discussion

This study provides a comprehensive longitudinal analysis of postoperative QoL after robotic MVr, relative to conventional sternotomy, at a single, high-volume center. In this retrospective study of 563 patients, postoperative QoL was excellent, regardless of approach (Figure 4). Most patients experienced return to their preoperative baseline by 6 months, and returned to work within 2 months.

Figure 4.

Graphical abstract.

The interest in minimally invasive approaches for mitral repair has increased dramatically in recent years. Prior studies, both on an institutional and national basis, have reported less postoperative atrial fibrillation and blood product transfusion requirements, as well as shorter ICU and hospital stays with robotic MVr, relative to a conventional sternotomy approach.^4,5,7,17 We observed similar results in this study, as the robotic MVr approach did not increase morbidity or mortality, and was associated with improved short-stay outcomes. There was no significant difference in repair success, and 95% of patients in either group had no MR on their transthoracic echocardiogram before discharge.

Relative to conventional sternotomy, robotic MVr has been associated with increased resource utilization and longer procedural times that have been offset by shorter hospital stays.^18,19 This is consistent with the results from our study because the median cardiopulmonary bypass time was 23 minutes longer in patients who underwent a robotic approach (P < .001). The majority of patients in both groups underwent MVr for posterior leaflet prolapse, and there was no significant difference in aortic crossclamp time (P = .36), despite the increased operative complexity of sternotomy patients in the form of concomitant procedures: tricuspid valve repair (P < .001) and ablation for atrial fibrillation (P < .001). Although this may reflect the learning curve and necessary time afforded to complete a robotic MVr, it may also be attributed to the robotic setup (eg, switching instruments and repositioning robotic atrial retractors) that occurs during myocardial ischemic time. In this study, all operations were performed by a group of 5 experienced staff surgeons who offer both robotic-assisted and full sternotomy approaches to MVr. All surgeons employed a standardized setup and approach with routine pre- and intraoperative input from senior surgeons, which minimized variability.

Prior literature has demonstrated comparatively improved quality of life after robotic, relative to conventional sternotomy, MVr.⁸ However, prior analysis has been limited due to evaluation of postoperative QoL at a single timepoint and lack of robust evaluation encompassing preoperative QoL metrics. In this study, postoperative QoL was evaluated preoperatively, as well as postoperatively at serial timepoints. Patients who underwent a robotic MVr had significantly higher unadjusted postoperative PROMIS-10 physical scores than their sternotomy counterparts (P = .008). However, there was no significant difference after accounting for baseline scores. Analysis of partial dependency plots demonstrated that higher preoperative scores were directly associated with higher postoperative scores. Patients who underwent a robotic approach had a significantly lower prevalence of preoperative baseline comorbidities such as age (58 ± 10 years vs 66 ± 10 years; P < .001), New York Heart Association functional status (P = .002), and chronic obstructive pulmonary disease (5% [n = 13] vs 12% [n = 37]); P = .008). Therefore, these patients at baseline assumed higher PROMIS-10 physical (53.9 ± 7.9 vs 50.5 ± 8.3; P < .001) and mental (56.6 ± 7.6 vs 53.4 ± 9.0; P < .001) scores than patients who underwent a sternotomy approach. This is consistent with our prior data and the results of our validated screening algorithm for robotic MVr candidates.^4,9 Our results also demonstrate that a robotic approach, relative to sternotomy, did not provide a faster return to baseline QoL (PROMIS-10 physical: 6.2 vs 2.7 months; PROMIS-10 mental: 7.0 vs 2.4 months; MacNew social: 5.8 vs 5.1 months). Although the effort to return to baseline in the robotic cohort may be prolonged due to excellent baseline function, it is notable that the estimated PROMIS-10 physical scores in both groups were below the population norm at 1 month postoperatively. A rapid increase in physical recovery was captured between the 1- and 3-month intervals, mirroring the return to work data.

In this study, patients who underwent robotic-assisted MVr were more likely to be employed full- or part-time than those who underwent a sternotomy approach to MVr (72% [144 out of 201] vs 49% [119 out of 242]; P < .001). This may be reflective of the underlying differences in the baseline fitness of this cohort because patients who underwent a robotic-assisted approach were an average of 8 years younger (P < .001) with fewer baseline comorbidities and higher preoperative physical and mental QoL metrics (P < .001). Although prior works have reported that robotic-assisted MVr was associated with faster return to work times for patients during the postoperative period, we did not observe a significant difference in this study.^8,19 Further evaluation is recommended in larger cohorts because there was a potential trend toward earlier return to work times for patients who underwent a robotic approach (P = .07). However, this was not significantly different during the first month because 34% (40 out of 117) of patients in the robotic cohort returned to work within the first 4 weeks of surgery, relative to 25% (22 out of 88) in the sternotomy cohort (P = .16). The majority of patients in both groups returned to work by 8 weeks postoperatively (64% [168 out of 263]).

Limitations

The operations were performed at a single institution, which may limit generalizability to other centers. This study was subject to selection bias in the surgeon selection of robotic MVr candidates, as well as nonresponse bias, in that only patients with available QoL data were evaluated. Therefore, it is possible that comparative QoL may be over- or underreported. Further research is required on the influence of preconditioning and preoperative optimization, as well as standardized postoperative treatment and recovery protocols that were not evaluated in this study. QoL follow-up of patients who underwent MVr was incomplete, although data were sufficient to characterize the QoL up to 1 year postoperatively. Return to work data were collected as part of routine follow-up and categorized by 4-week intervals with limited further granularity. Despite the limitations associated with this study, it is among the largest reported series of patients to evaluate postoperative QoL after robotic MVr and implements a novel approach to the temporal study of QoL in these patients.

Conclusions

Postoperative QoL following MVr was excellent, regardless of approach. Patients who were selected for a robotic approach demonstrated higher baseline QoL metrics than those who received a sternotomy, but this did not translate to a comparative improvement on adjusted analyses. Postoperative QoL metrics in most patients returned to baseline by 6 months and surpassed the population norm. The operative approach for MVr in patients who are candidates for a minimally invasive procedure should be tailored to surgeon experience in offering a safe, durable repair.

Webcast

You can watch a Webcast of this AATS meeting presentation by going to: https://www.aats.org/resources/longitudinal-quality-of-life-a-9525.

Conflict of Interest Statement

Dr Gillinov serves as consultant to Edwards Lifesciences, Medtronic, Abbott, ClearFlow, Artivion, AtriCure, Baxter, and Johnson and Johnson; Dr Burns serves as consultant to Edwards Lifesciences and Medtronic; and Dr Blackstone serves as consultant to Edwards Lifesciences and Abiomed. All other authors reported no conflicts of interest.

The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.

Appendix E1. Quality of Life Questionnaires

• 1.Please answer the following questions by marking a single response to each question.

In general, would you say your health is:

Excellent Very Good Good Fair Poor.

In general, would you say your quality of life is:

Excellent Very Good Good Fair Poor.

In general, how would you rate your physical health?

Excellent Very Good Good Fair Poor.

In general, how would you rate your mental health, including your mood and your ability to think?

Excellent Very Good Good Fair Poor.

In general, how would you rate your satisfaction with your social activities and relationships?

Excellent Very Good Good Fair Poor.

In general, please rate how well you carry out your usual social activities and roles. (This includes activities at home, at work and in your community, and responsibilities as a parent, child, spouse, employee, friend etc.).

Excellent Very Good Good Fair Poor.

To what extent are you able to carry out your everyday physical activities such as walking, climbing stairs, carrying groceries, or moving a chair?

Completely Mostly Moderately A little Not at all.

In the past 7 days…How often have you been bothered by emotional problems such as feeling anxious, depressed, or irritable?

Never Rarely Sometimes Often Always.

In the past 7 days…How would you rate your fatigue on average?

Never Mild Moderate Severe Very severe.

In the past 7 days…How would you rate your pain on average?

1 Worse Pain Imaginable 2 3 4 5 No Pain.

• 2.We would now like to ask you some questions about how you have been feeling during the last 2 weeks. Please check the box that matches your answer.

MacNew Questionnaire Health-related quality of life instrument.

• 1.How often during the last 2 weeks have you felt worthless or inadequate? (2)
• ❑All of the time
• ❑Most of the time
• ❑A good bit of the time
• ❑Some of the time
• ❑A little of the time
• ❑Hardly any of the time
• ❑None of the time
• 2.How often during the last 2 weeks have you felt as if you are more dependent than you were before your heart problem? (11)
• ❑All off the time
• ❑Most of the time
• ❑A good bit of the time
• ❑Some of the time
• ❑A little of the time
• ❑Hardly any of the time
• ❑None of the time
• 3.How often during the last 2 weeks have you felt that you were unable to do your usual social activities or social activities with your family? (12)
• ❑All off the time
• ❑Most of the time
• ❑A good bit of the time
• ❑Some of the time
• ❑A little of the time
• ❑Hardly any of the time
• ❑None of the time
• 4.How often during the last 2 weeks have you felt as if others no longer have the same confidence in you as they did before your heart problem? (13)
• ❑All off the time
• ❑Most of the time
• ❑A good bit of the time
• ❑Some of the time
• ❑A little of the time
• ❑Hardly any of the time
• ❑None of the time
• 5.How often during the last 2 weeks have you felt unsure of yourself or lacking in self-confidence? (15)
• ❑All off the time
• ❑Most of the time
• ❑A good bit of the time
• ❑Some of the time
• ❑A little of the time
• ❑Hardly any of the time
• ❑None of the time

• 6.During the last 2 weeks, how much have you been limited in doing sports or exercise as a result of your heart problem? (17)
• ❑Extremely limited
• ❑Very limited
• ❑Limited quite a bit
• ❑Moderately limited
• ❑Somewhat limited
• ❑Limited a little
• ❑Not limited at all
• 7.In general, during the last 2 weeks how much have you been restricted or limited as a result of your heart problem? (20)
• ❑Extremely limited
• ❑Very limited
• ❑Limited quite a bit
• ❑Moderately limited
• ❑Somewhat limited
• ❑Limited a little
• ❑Not limited at all
• 8.How often during the last 2 weeks have you felt unsure as to how much exercise or physical activity you should be doing? (21)
• ❑All off the time
• ❑Most of the time
• ❑A good bit of the time
• ❑Some of the time
• ❑A little of the time
• ❑Hardly any of the time
• ❑None of the time
• 9.How often during the last 2 weeks have you felt as if your family is being overprotective toward you? (22)
• ❑All off the time
• ❑Most of the time
• ❑A good bit of the time
• ❑Some of the time
• ❑A little of the time
• ❑Hardly any of the time
• ❑None of the time
• 10.How often during the past 2 weeks have you felt as if you were a burden to others? (23)
• ❑All off the time
• ❑Most of the time
• ❑A good bit of the time
• ❑Some of the time
• ❑A little of the time
• ❑Hardly any of the time
• ❑None of the time

• 11.How often during the past 2 weeks have you felt excluded from doing things with other people because of your heart problem? (24)
• ❑All off the time
• ❑Most of the time
• ❑A good bit of the time
• ❑Some of the time
• ❑A little of the time
• ❑Hardly any of the time
• ❑None of the time
• 12.How often during the past 2 weeks have you felt unable to socialize because of your heart problem? (25)
• ❑All off the time
• ❑Most of the time
• ❑A good bit of the time
• ❑Some of the time
• ❑A little of the time
• ❑Hardly any of the time
• ❑None of the time
• 13.In general, during the last 2 weeks how much have you been physically restricted or limited as a result of your heart problem? (26)
• ❑Extremely limited
• ❑Very limited
• ❑Limited quite a bit
• ❑Moderately limited
• ❑Somewhat limited
• ❑Limited a little
• ❑Not limited at all
• 3.We would like to ask you some questions about your return to work after your surgery or procedure. Please check the box that matches your answer.

1. Were you working before your heart surgery or vascular surgery?

• ❑Full time
• ❑Part time
• ❑Not working

2. Are you back to work at your full capacity?

• ❑Yes
• ❑No

3. If yes, when did you return to work at your full capacity?

• ❑1 to 4 weeks after surgery
• ❑5 to 8 weeks after surgery
• ❑9 to 12 weeks after surgery

Appendix E2. Variables Considered in the Multivariable Analysis

Demographics

Female, Race (Black, White, Other), Age, Body Mass Index.

Symptoms and Ventricular Function.

New York Heart Association Functional Class, LV Ejection Fraction.

Pathology and Echo.

Degree of Tricuspid Valve Regurgitation, Pulmonary Valve Regurgitation.

Cardiac Comorbidity.

Atrial Fibrillation/Flutter, Congestive Heart Failure, Prior Cardiac Surgery, Hypertension, Chronic Obstructive Pulmonary Disease, Smoking.

Preoperative QOL.

PROMIS-10 Physical, PROMIS-10 Mental, MacNew Social.

Operative.

Cardiopulmonary Bypass Time, Aortic Crossclamp Time.

Postoperative Complications.

Postoperative Atrial Fibrillation.

Length of Stay.

Hospital Length of Stay, Operative Length of Stay.