Jessai Flores, Illustrations Editor

Cardiac surgeons at Yale New Haven Hospital have performed 200 robotic-assisted mitral valve procedures with a 100 percent success rate, meaning that no procedures were converted to an open surgery.

Arnar Geirsson, surgeon-in-chief of cardiac surgery at the Yale New Haven Health system, performed the hospital’s first robotic mitral valve replacement surgery in 2018. YNHH is the only hospital that performs robotic-assisted mitral valve surgeries in New England and has become one of the leading university-affiliated hospitals for robotic-assisted cardiac surgery in the United States. Geirsson’s team published a study on 200 consecutively successful robotic-assisted mitral valve procedures for degenerative mitral regurgitation in the Annals of Cardiothoracic Surgery. It was accepted for publication on Aug. 2. 

“Robotic cardiac surgery is an emerging field of practice that is significantly safer and less invasive than traditional heart surgery,” Geirsson wrote to the News. “Tiny robotic instruments are inserted and controlled through very small cuts in the patient’s chest, thereby eliminating the need to cut the breastbone and open the chest widely to reach the heart. While traditional heart surgery may leave a ten-inch scar, robotic cardiac surgery leaves just a few one-inch scars under the armpit or below the breast.”

In a patient with mitral valve regurgitation, the valve between the left heart chambers does not close completely. This allows blood to leak backwards across the valve instead of circulating the body, resulting in symptoms of tiredness or shortness of breath. Severe mitral valve regurgitation can cause heart rhythm problems or heart failure and often requires surgery to correct.

The less invasive nature of robotic-assisted mitral valve repairs leads to a quicker recovery period. Patients can be up and walking hours after surgery, with many able to go home soon after. In a few weeks, patients are able to resume their full spectrum of daily activities. 

Traditional operating methods require breaking the sternum — a bone that requires two months to heal — in order to access the heart. In contrast, robotic-assisted mitral valve repair patients may begin driving cars two weeks post-surgery.

The robotic-assisted mitral valve repair, which requires a much smaller incision than the traditional approach, is less painful for the patient. While patients require opioids to manage pain after open mitral valve repairs, patients with a robotic-assisted repair only need over-the-counter medications. In 2019, an estimated 9.7 million people misused prescription pain medications according to the U.S. department for health and human services. As such, reducing opioid prescriptions has the potential to save lives.

Repairing mitral valves with robots also changes the experience of the surgeon in the operating room, as the procedure requires different tools and techniques.

“The surgeon uses tiny robotic instruments that are remotely-controlled.” said Andrea Amabile, first author on the paper. “The surgeon sits at a console which is separated from the operating table. [Surgeons] sit there, involved in a 3D representation of what [they] see inside the chest of the patient.”

The robot provides a surgeon with superior visualization, according to Michael LaLonde, coordinator for the Robotic Mitral Valve Program at the hospital. He said that the robot arms each have an endowrist that provides 360 degrees of freedom, enabling the surgeons to manipulate their instruments in a minimally invasive way that is not supported by an open procedure. 

Amabile explained that two robots are in the operating room at YNHH and serve as huge systems that immerse the surgeon inside of the heart. The lead surgeon uses one machine, the assistant uses the other and a video stream of the surgery is projected onto a tv screen. This method facilitates collaboration as it ensures that the entire team has a clear view of the operation.

However, LaLonde cautions that it may take some time for robotic-assisted mitral valve repair to become the standard of care. The procedure is tricky and often becomes the specialty of surgeons. Smaller hospitals with lower volumes of patients may not have the chance to perform the surgery enough times necessary for adapting to a new robotic-assisted approach.

“In developing the program, it took us over a year and over 50 training sessions to become proficient enough to feel comfortable working on a valve in a human being,” LaLonde said. “Nationally, about 15 percent of mitral values are now repaired using the robotic technique.”

At the hospital, however, the residents are learning. Since the entire surgery is visualized by the robotic arms within the patient, residents have a unique opportunity to rewatch the procedure with the same level of resolution that the lead surgeon had during the operation. 

These recordings have proven to be a very effective educational and training modality, according to LaLonde. 

“During my rotation on cardiac surgery, I was able to see both types of procedures,” said Alyssa Morrison MED ’24, a data collector for the paper. “From my experience on the wards and from the research papers we were able to publish, [we observed that] patients had a shorter length of stay with the robotic procedure, which is incredible.” 

The first robotic-assisted mitral repair surgery was performed in 1998.