The Robot Effect: How Surgical Approach Relates to Guideline-Directed Management of Concomitant Diseases During Mitral Valve Repair.

BACKGROUND

Candidates for robotic-assisted mitral valve repair (R-MVr) sometimes have concomitant atrial fibrillation (AF) and/or tricuspid valve regurgitation (TR). We investigated the effect of concomitant AF and/or moderate or greater TR on choice between R-MVr and median sternotomy (MS-MVr) and the effect of surgical approach on guideline-directed management of AF and TR.

METHODS

From 2015-2024, patients in the STS Adult Cardiac Surgery Database who underwent MVr for degenerative mitral regurgitation with/without concomitant tricuspid valve repair (TVr), surgical ablation (SA), and/or left atrial appendage occlusion (LAAO) by either robotic or sternotomy approach were identified. Multivariable logistic regression was performed to assess our primary outcomes.

RESULTS

The study included 17,169 patients (8,203 MS-MVr, 8,966 R-MVr). Concomitant AF was present in 3,245 (18.9%) and moderate or greater TR in 2,565 (14.9%). Patients with AF (OR 0.51, 95% CI [0.45-0.58]), TR (OR 0.50 [0.43-0.58]) or both (OR 0.38 [0.31-0.47]) were less likely to receive R-MVr vs. MS-MVr. Compared to MS-MVr, patients undergoing R-MVr with AF less frequently had concomitant SA (OR 0.44 [0.35-0.55]) or LAAO (OR 0.40 [0.31-0.52]) and those with TR less frequently had TVr (OR 0.25 [0.19-0.32]). Operative outcomes were similar between MS-MVr and R-MVr with concomitant SA, LAAO, and/or TVr.

CONCLUSIONS

Surgeons are more likely to perform MS-MVr than R-MVr for patients with AF and/or TR, while guideline-directed management of AF and TR are less common with R-MVr, demonstrating a complex relationship between concomitant conditions and surgical approach. Patients deserve a steadfast commitment to guideline directed care, irrespective of surgical approach.