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Innovations in Minimally Invasive Heart Surgery


Cardiovascular diseases (CVDs) are the leading cause of death worldwide, taking approximately 17.9 million lives every year. The heart is a powerful muscle, pumping about 2 ounces of blood with each beat and beating over 3 billion times in the average lifetime. Cardiovascular disease is the umbrella term for all disorders affecting the heart or blood vessels, including conditions such as heart attack, stroke, atherosclerosis (clogged arteries), and heart valve defects. 


Many types of CVDs have to be treated with surgery, and in the past, many of the heart-specific problems had to be treated with open-heart surgery. This surgery requires extensive recovery, with a return to regular, unrestricted activity taking two to three months. In recent years, cardiac surgery technology has advanced rapidly, leading to new minimally invasive techniques that significantly shorten recovery times. Two examples of this leap forward in cardiac care are the transcatheter aortic valve replacement (TAVR) and robot-assisted mitral valve repair.


Calcific aortic stenosis, a condition where the aortic valve is calcified and can no longer operate as it should, affects approximately 2.5 million people in the U.S. over age 75. Before TAVR, severe aortic stenosis was treated via an open-heart surgery technique. Still, because patients who needed it were often old enough for the procedure to be life-threatening, many patients were unable to be operated on. Dr. Alain Cribier, a French cardiologist, postulated that a balloon could be delivered via catheter to the calcified aortic valves and then inflated to open the valves in a circular manner. Next, another catheter could deliver a stent and an artificial valve, which would be deployed by another expandable balloon. 


The first TAVR was performed in 2002 in France. The patient experienced remarkable hemodynamic improvement. Since this first success, TAVR has taken off as a reliable treatment for calcific aortic stenosis. TAVR procedures were expected to exceed 300,000 per year by 2025. Hospital stays after TAVR are short, usually only one to two days, with some patients even leaving the same day as the procedure. Complete recovery takes six to ten weeks.


Please watch this video to learn more about how the TAVR procedure is performed:


Mitral valve prolapse, also known as click-murmur syndrome, is the bulging of one or both of the mitral valve leaflets (flaps) into the left atrium during heart contraction. Here is a diagram of the mitral valve under normal function and during prolapse.


Image credit: Manhattan Cardiology


The leaflets of the mitral valve are connected to the papillary muscles inside the left ventricle via thin, strong cords called chordae tendineae. If the flaps are thickened or the cords are weakened, stretched, or ruptured, the flaps will not close properly and will allow blood to flow in the wrong direction through the valve. Before robot-assisted technology allowed for an exceedingly minimally invasive method of repairing the mitral valve, options for patients included a traditional sternotomy (open heart surgery) or a mini-thoracotomy performed without robotic assistance. A mini-thoracotomy involves a small chest incision without breaking ribs. While the latter provided similar short recovery times to robot-assisted mitral valve surgery, operating in such a limited working space without robotic assistance is technically demanding. 


Beginning in 1998, Alain Carpentier, a French cardiac surgeon, performed the first mitral valve operation using a prototype of the daVinci robotic system, which is still used today. The technique did not catch on at first because the robotic procedure was much longer than other available procedures, and the robotic system was very expensive. Significant improvements in robotic technology and favorable published results inspired renewed interest in robotic-assisted operations around 2017.


In modern robot-assisted mitral valve repair surgery, two cardiac surgeons work in tandem through several small chest incisions. The heart is temporarily stopped, and the patient is supported by a heart-lung bypass machine. One surgeon sits at a remote console and operates the robotic arms while viewing the heart in magnified high-definition 3D. The other surgeon stays by the operating table and ensures the safe movement of the robotic arms. After accessing the mitral valve via an incision in the left atrium of the heart, the surgeon identifies the source of the problem and repairs the valve. Recovery takes three days in the hospital, and there is significantly less pain than from open-heart surgery. These days, the price of the robot-assisted method can be similar to or lower than that of traditional open-heart surgery.


Please watch this video to learn more about how robot-assisted mitral valve repair is performed:


Many other incredible surgical techniques have been devised to treat cardiovascular disease. The goal of these new methods is to lessen the impact of these surgeries on patients’ lives, providing improved recovery times and less pain than traditional methods. Many procedures now allow patients to leave the hospital within days of major heart surgery, a medical miracle that improves countless lives every day.


Thank you for reading,

Ashby


Sources


Hiroto Kitahara and Husam H. Balkhy. “Minimally invasive mitral valve surgery with or without robotics: Examining the evidence.” Journal of Cardiac Surgery 37, no. 10 (August 2022): 3276-3278. doi: 10.1111/jocs.16854


John Gordon Harold. “Harold on History: The Evolution of Transcatheter Aortic Valve Replacement.” Cardiology Magazine (July 2017). https://www.acc.org/latest-in-cardiology/articles/2017/07/19/15/42/the-evolution-of-transcatheter-aortic-valve-replacement

Minoru Tabata, Ryota Nakamura, and Suguru Tatsuki. “Technical tips in non-robotic endoscopic mitral valve surgery: How to approach and expose the mitral valve.” Asian Cardiovascular & Thoracic Annals 30, no. 6 (July 2022): 645-652. doi: 10.1177/02184923221086060




Ulrich F. W. Franke, Franziska Huether, Mihnea Ghinescu, Melisa Ortega Gaviria, Magdalena I. Rufa, Marc Albert, Adrian Ursulescu, and Nora Goebel. “Robotically assisted mitral valve surgery— experience during the restart of a robotic program in Germany.” Annals of Cardiothoracic Surgery 11, no. 6 (November 2022): 596-604. doi: 10.21037/acs-2022-rmvs-18

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