Questions About Preoperative Issues

This is a fantastic question. The truth is that most patients with isolated mitral valve disease are candidates for robotic mitral valve repair (but not all). There are some relative contraindications. These include: 1) Too high risk for standard surgery, 2) severe peripheral vascular disease or PVD, 3) Aneurysm of the ascending aorta (the large vessel as it leaves the heart), 4) prior surgery of the right side of the chest. Prior heart surgery is NOT a contraindication and in fact many such patients can be especially benefited from avoiding redo sternotomy. All of these relative contraindications are just that-it depends on the patient. If you come to see me we will do a thorough evaluation of your candidacy for the procedure.

My decision-making is based on the same priorities that yours likely are or should be: 1) survive the procedure with least chance of major complications!, 2) fix your problem, and lastly 3) have it done in the least invasive way possible without compromising goals #1/2

It depends on your condition. In the case of mitral valve regurgitation, avoiding salt and maintaining a normal blood pressure may be helpful. However, a leaky mitral valve is a physical, structural problem and medicines and lifestyle changes may have limited impact on the progression of the disease. That being said, eating healthy and maintaining a good exercise regimen are important for many reasons.

It depends on the disease but not everyone with heart disease needs surgery. For instance, mitral valve repair surgery is generally recommended for moderate to severe or severe mitral regurgitation. Lesser degrees of mitral regurgitation may not require surgery at this point. I believe strongly that a visit to an experienced mitral valve repair surgeon is an important thing for patients with mitral disease, even if surgery is not required. That is because many patients with clear indications for surgery are not referred today for a variety of reasons. The patient should make an informed decision on the risks, benefits, and alternatives to the various treatment options. Second opinions are also a good thing because they empower the patient. A good resource for patients is the American Heart Association website: www.heart.org and the American Heart Association Guidelines for the treatment of valve disease: AHA Valve Treatment Guidelines. The treatment guidelines can be confusing for non-medical folks but your cardiologist or surgeon can walk you through the appropriate algorithm for your condition..

Yes. That is the short answer. The long answer is that medicare and private insurance companies view robotics and other minimally invasive procedures the same as standard surgery. In other words, they pay the same amount to hospitals and doctors regardless of how the procedure is performed. Use of the robot does cost the hospital more but not you. The hospital usually makes up for this by the fact you may be discharged earlier making it basically cost neutral for them.

I have been doing roughly 100 robotic mitral valve repairs or similar procedures per year for many years which only a small handful of surgeons in the United States perform at that volume. I also do a lot of standard open heart surgical procedures. My expectation is that as more and more patients realize they don’t need to undergo sternotomy (breast plate divided) to have their mitral valve repaired, our volume will grow very high levels. That will be up to those I work for-the patients! If every patient in the was fully informed about this option my guess if most of them would want robotic endoscopic surgery. The problem is that many don’t know about it or are misinformed about it. Many cardiologist don’t have a good understanding of the capabilities of a high volume, high performance robotic cardiac surgery center versus surgical teams that either tried and abandoned the technique due to its complexity or who do it in low volumes.

My mitral valve repair rate is roughly 98%. Its rare for me to replace a valve unless the valve is severely damaged by rheumatic disease or if a previous replacement valve needs to be re-replaced. Of course, nothing is 100% and on rare occasions we do have repairs that are not successful. Any surgeon who tells you different is not being truthful. That being said, with mitral valve prolapse, you can expect a 95-99% chance of repair and a 90% chance of a durable repair based on my experience. Again, anyone who tells you that there is no chance of failure is simply not being honest with you. However, if you go to someone like me who does a high volume of repair surgery, your odds of a successful and durable repair are much greater than if you go to a low volume, low repair rate surgeon. The literature supports this.

Yes it is. The patient still is placed on the heart lung machine and the heart is “put to sleep” or “stopped” by a “drug” called cardioplegia. In a typical totally endoscopic robotic mitral valve procedure (or similar procedure), I use a catheter-based system to do these things using the peripheral arteries and veins.

The current robotic system from Intuitive Surgical (Da Vinci) has been approved since 2002. So the short answer is yes, it is standard of care and not experimental or part of a trial. Of course the “standard of care” is broad and includes open surgery, minimally invasive surgery, and robotics.

There are currently other companies building robotic systems and we don’t know if the FDA will require clinical trials for these new robotic systems or not but stay tuned.

First, you will have to come into the office to determine if your problem can be solved with robotic heart surgery techniques. If this is the case, we will schedule you for a few routine test and pick a date for surgery that fits your needs. If robotics is not appropriate for you, Dr. Guy performs and is experienced at doing almost all other types of cardiovascular surgeries of the chest. Robotic cardiac procedures typically last 3-4 hours and then you spend the night in the intensive care unit. If no complications occur, you will then spend 1-4 days (on average) on the floor and then be discharged home. The great advantage of robotic surgery is that many of the limitations you would have for 6 weeks after open surgery do not apply such as no driving or heavy lifting. You can usually drive after discontinuation of narcotic medication use. A few weeks after surgery, you will then visit again in the office and then see your cardiologist. If you live far away, special arrangements can be made to see you once before you leave town and then schedule a televideo visit (using skype) or telephone visit along with a visit to your local cardiologist. Return to work can be much earlier after robotics, as early as 2 weeks. However, every patient is different but these are the general expectations.

This is a tough one because we don’t really have a perfect replacement valve at the current time. This is one of the reasons why with mitral valve disease, I believe so strongly in repair as the first option for the vast majority of patients. For those limited number of patients for whom a mitral valve replacement is necessary, the options are a tissue valve (cow or pig usually) or a mechanical valve. Mechanical valves require a blood thinner called coumadin which has a 1-2%/year risk of significant bleeding or stroke. Of course, this depends on the patient and how closely they monitor their levels (INR-a measure of “blood thinness”). The advantage of a mechanical valve is that it can last for a lifetime although this is not 100% true-occasionally we do have to replace a mechanical valve that fails. A tissue valve has the advantage of not requiring coumadin long-term. However, it will fail over a period of time. Typically we tell patients 10 years in younger patients and 20 years in older patients. However, the truth is that it’s hard to know. I have seen tissue valves fail in 2 years and last 25 years. It depends on the patient. Younger patients with tissue valves tend to have them fail much more quickly. This is tough because younger patients are often the ones who want to stay off blood thinners. Most women who want to bear children should avoid mechanical valves and coumadin. There is a lot of talk about the ability to replace a failed surgically placed tissue valve with a catheter valve (TAVR) device. This is true and is currently being done. However, it is still a major procedure and we don’t know much about the durability of these procedures and how many times it can be done. With this procedure the old valve is left in place so one would assume there are only so many times this can be done.

There is hope on the horizon for tissue-engineered valves but nothing currently available and I would not advice delaying surgery because we have no idea how long these long-sought after valves will be available.