Mitral surgery: The endgame

To the Editor:

Dr Castillo-Sang reported speakers bureau Edwards LifeSciences and CryoLife. Dr Voeller reported speakers bureau for CryoLife. Dr Ailawadi reported consultant for Admedus, Medtronic, Edwards Lifesciences, Abbott, AtriCure, CryoLife, and Gore.

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.

We read with great interest the invited opinion paper by Almeida and colleagues¹ in the last edition of JTCVS Techniques. The authors compared 2 forms of minimally invasive mitral valve surgery: minithoracotomy with or without endoscopic assistance and robotic-assisted.

The authors generalize the universal application of the robot to perform highly complex mitral surgery, an experience unique to highly select centers, while many centers around the world have made minithoracotomy mitral reconstruction the cornerstone of their repair programs.

Outcomes

Minithoracotomy is the minimally invasive approach with the largest experience in the world (Figure 1). While robotic outcomes have been shown to carry equivalent quality as median sternotomy, the minithoracotomy approach has been shown to be superior to sternotomy and robotic approaches.² Moreover, only minithoracotomy has prospective data comparing it with sternotomy.³ Furthermore, minithoracotomy can be performed with excellent outcomes even in complex and high-risk patients.⁴

Figure 1.

Left, Operating room setup for a minimally invasive mitral valve operation through a minithoracotomy endoscopic assisted. Right, A picture of a patient on postoperative day 10.

Adoption and Economics

Beyond outcomes, economics are a major driver of adoption of minimally invasive techniques. In an era of economic uncertainty, one cannot assume all mitral centers in developed countries, much less economically disadvantaged ones, will be able to afford robotic platforms. The authors argue that most centers already have a robot, but this statement is inaccurate. Centers with robots often do not have dedicated cardiothoracic or cardiac robots. In North America, the robot is typically shared by several specialties. This shared asset leads to hospital systems purchasing more devices and the cost is passed on as higher overhead/capital costs.

Almeida and colleagues¹ correctly point out the increased range of motion of robotic platforms, but this has not been a handicap for minithoracotomy surgeons already performing complex mitral interventions including extensive resectional techniques, neochordal reconstructions, leaflet augmentation, and decalcification.

The Endgame

Unfortunately, only a select number of surgeons perform any form of mitral minimally invasive surgery regularly, and the majority use the minithoracotomy approach.⁵ The minimally invasive mitral surgery options comparison is not a zero-sum nor winner-take-all proposition, and this is where Almeida and colleagues' conclusion that Valve Centers of Excellence must be able to offer “percutaneous, robotic and open therapies” cannot apply to all centers. Minithoracotomies (direct or endoscopic) have an edge over robotic, and the adoption rate proves it. Centers must offer transcatheter, open, and any form of effective minimally invasive mitral surgery that can be used in a large proportion of patients. We must remember our real goal in mitral surgery must be to (1) offer excellent surgical outcomes, (2) perform mitral procedures with the least intrusion into patients' lives as possible, and (3) be able to compete with percutaneous therapies. Both minithoracotomy and robotic approaches (in very select robotic centers) can provide these goals.