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

Abstract

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. 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. 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. 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.