Having a robot involved in your heart surgery may sound pretty high-tech—or even scary. The whole idea could leave you thinking you’d like more of a human touch. But the surgeons who perform robotic operations on the mitral valve, one of the heart’s major valves, are seeing benefits with this approach.
“Patients tend to do much better,” says Arnar Geirsson, MD, chief of Yale Medicine Cardiac Surgery and director of the Robotic Mitral Valve Repair Program, the only program of its kind in New England and one of just a few in the country. “And surgeons have reached a point where we can do this safely—as well as or better than we can with an open surgery, from a technical and safety standpoint.”
The mitral valve guides blood from the lungs to the heart and the rest of the body. For people who need a mitral valve repair, studies have shown that robotic surgery may be better than other minimally invasive approaches for many reasons—it is associated with less bleeding, trauma, chance of infection, and need for blood products, Dr. Geirsson says.
Dr. Geirsson has been fascinated with the mitral valve for most of his career, and also directs a robust mitral valve program at Yale that performs 250 procedures a year, including both open and minimally invasive surgeries, and offers medical therapies. Doctors there are conducting research to learn more about what causes mitral valve problems on a cellular level.
They began offering robotic mitral valve surgeries toward the end of 2018 and have since done more than 100 of them, which Dr. Geirsson considers a milestone—all of them had good results, no major complications, and zero mortality, he says.
Dr. Geirsson answered our questions about the rapidly changing field of treatment for mitral valve diseases and what it means for patients.
What is the mitral valve and who is at risk for problems?
The mitral valve is a major heart valve located between the lungs and the left ventricle. Its job is to ensure that blood will flow in the right direction—from the lungs, through the heart, and into the body. Like all heart valves, it has “leaflets” that act like small gates that open and close as blood flows through them.
Mitral valve prolapse is the most common mitral valve problem, affecting 1 to 2% of the population. It’s mostly in people around the ages of 50, 60, and 70, but we have had patients in their 20s and late 80s. Prolapse means the valve’s two flaps are “floppy” and don’t close tightly. Many people won’t notice symptoms, but some—maybe 20 to 30%—develop regurgitation, when the blood flows backward—in the wrong direction. This can cause heart failure symptoms like shortness of breath and arrhythmias.
Fortunately, in most cases, mitral valve prolapse can be repaired.
Where does the robot come in?
The robot is the DaVinci Xi. It looks something like a computer tower with multiple arms for tools that hold instruments and cameras. A patient is brought into the operating room and put under general anesthesia, and we make five tiny incisions on the right side of the chest. The surgeon takes a seat at a console that allows him or her to use controls to operate the robot remotely, guiding its arms through the incisions.
Using the robot allows for a wide range of motion that a human hand would not be able to achieve, and it takes away any tremors you may have in your hands, so there is better precision. The magnification is three-dimensional and high definition, so you see structures in more detail. This is especially important for the mitral valve, which can be difficult to visualize properly during an open operation.
What is a robotic mitral valve surgery like for the patient?
Sometimes, when patients are wheeled into the operating room, they see the equipment and ask questions about it, but during the surgery they are asleep. A mitral valve repair can take from two to four hours, depending on the complexity of the operation.
We use a heart-lung bypass machine [to take over the heart’s pumping action during the surgery], but we don’t split the breast bone, or “crack the chest,” which we would need to do in an open surgery. This decreases the recovery time significantly and eliminates the long scar down the chest.
Patients have breathing tubes, but most of the time those tubes are removed prior to leaving the operating room. So, that’s more comfortable for them—they don't need to wake up in the intensive care unit with a breathing tube, as they would for traditional surgery.
How is a surgery with a robot better?
From my standpoint, there are two reasons why it’s better to do mitral valve surgery robotically. First, the robot is a less invasive option, so patients recover more quickly than they would otherwise. Most people stay only two to four days in the hospital, and they are back at work in three or four weeks.
The second is that, from the surgeon’s viewpoint, I believe you actually do a better mitral valve repair with a robot. That’s partly because we have refined this surgery so much over the years. Robotic surgeries were introduced about 20 years ago—cardiac surgeons drove their initial development.
But in the early days, there were only a handful of surgeons in the world doing this at a reasonable volume, and they were hampered by the technical limitations in the early robots. But there have been newer generations of robots, and they are easier to use and navigate. Of course, some of this is also the surgeon’s experience.
Robotic surgeries for mitral valve repair are not offered everywhere, correct?
Robotic surgeries are what put Yale on the map for mitral valve. So, now we are developing a more comprehensive mitral valve program, basically, where anybody with mitral valve disease can be evaluated and assessed for surgical treatment, transcatheter treatment, or medical therapy. And we are doing various kinds of research related to those things.
One thing the program provides is the MitraClip, correct?
Yes. The MitraClip is FDA-approved, but it’s a fairly new technology. Ryan Kaple, MD, is an interventional cardiologist here who is doing an increasing number of these procedures. The leaflets, or flaps, in the mitral valve should be connected together, but they can separate. You use the clip to reconnect them so the mitral valve will close more completely.
This is an outstanding procedure for elderly people or those who have had a previous heart operation and who are considered too high-risk for a surgical repair. It is done under general anesthesia, but the only incision is a little stick in the groin; we use a catheter to guide the clip up through the vein to the heart. We can operate while the heart is beating, so there is no need for a heart-lung machine.
Another thing is APOLLO, for people who need valve replacements.
Yes, Yale has the only program in Connecticut participating in APOLLO. This is a randomized clinical trial that is testing the Medtronic Intrepid™ replacement system, and it’s for patients with severe mitral valve regurgitation who need their valve replaced and who would have more than a low risk for complications with open heart surgery.
So, we use transcatheter mitral valve replacement (TMVR), a minimally invasive approach done through small incisions, using the Intrepid™ system, which compresses replacement valves inside a hollow catheter that is inserted between the ribs to the heart. We can do this while the heart is beating. Once the valve is in place, it is expanded to support the damaged mitral valve so that it can function properly again.
APOLLO is important, since there is not yet an FDA-approved TMVR technology.
What if you need a mitral valve procedure, and you feel like all of this is starting to sound confusing. Is there just one critical question you should ask?
I would ask about your surgeon’s experience. These are complex surgeries, so you want to go to a place that does a lot of these procedures. You want a surgeon who does a high number of these surgeries—which, according to clinical studies, is somewhere in the range of 25 or 35 mitral valve operations a year. There's a certain art to surgery for the mitral valve, but once a surgeon has performed these surgeries over and over for years, they have the judgment they need to repair it effectively.
At Yale, we have a high-volume mitral valve program, and we have experience in surgical repair or replacement, as well as transcatheter repair or replacement. We emphasize a team that includes cardiac surgeons, interventional cardiologists, cardiac physician assistants, nurses, anesthesiologists, perfusionists, and cardiac imaging specialists, among others. We have put in extra effort to build our robotic program.
Using the robot takes training, but by now it’s intuitive for us. The whole operation flows very easily. It’s really a pleasure to be in the operating room for a robotic repair—it’s a low-stress environment, because everybody knows what they're doing.
How do you explain all this to patients?
We know the prospect of undergoing any heart surgery is difficult. I want patients to know that the mitral valve is an important heart valve that should keep blood flowing in the proper direction. Then I describe, in general terms, why some people develop a mitral valve disease, and tell them it’s not their fault and that we can fix it.
After surgery, most people notice a difference in their quality of life and ease of doing things—sometimes immediately, or at least in the next two weeks after recovery. When we are able to do a much less invasive procedure, they’re usually very satisfied, because they recover quickly and their heart functions normally again.