Robotic mitral valve repair: algorithmic approach in degenerative mitral valve disease.

Degenerative mitral valve disease is the most common reason for surgical referral of patients with mitral regurgitation (MR) (1). The most recent guidelines strongly recommend mitral valve repair (MVR) over replacement because of higher survival, better preservation of left ventricular function and greater freedoms from endocarditis, thromboembolism, and anticoagulant-related hemorrhage (1). Robotic MVR was introduced in the late1990s with the goal of improving technical precision of less invasive surgical mitral valve reconstruction. When compared to other less invasive approaches, the advantages of robotic MVR include three-dimensional views of the valve pathology and better maneuverability of the endoscopic instruments. A 69-year-old lady was referred to our institution for evaluation and management of mitral and tricuspid valve regurgitation (TR). She had been experiencing worsening shortness of breath over the previous 6 months, and she was in New York Heart Association (NYHA) functional class II at the time of surgery. Her past medical history was significant for basal cell carcinoma of the lower lip; however, there was no history of concomitant cardiovascular disease. Physical examination revealed blood pressure of 135/73 mmHg and pulse of 85 BPM. A V/VI holosystolic murmur was detected at the fifth left intercostal space (ICS) radiating to the axilla. Transthoracic echocardiography (TTE) demonstrated a mildly dilated left atrium, normal left and right ventricles with a left ventricular ejection fraction (LVEF) of 63%, and right ventricular systolic pressure (RVSP) of 22 mmHg. There was 4+ MR and 3+ TR with normal aortic and pulmonary valves. The patient underwent thorough perioperative screening for potential robotic mitral and tricuspid valve repair, including coronary angiography to exclude coronary artery disease, thoraco-abdominal computed tomography (CT) scan to ensure feasibility and safety of peripheral perfusion and intraoperative transesophageal echocardiography (TEE) to delineate mitral valve anatomy in detail.