Totally endoscopic robotic mitral valve repair represents the least invasive surgical therapy for mitral valve disease. Comparative results for robotic mitral valve surgery against sternotomy are impressive, repeatedly demonstrating shorter hospital stay, faster return to normal activities, less morbidity and equivalent mortality and mid-term durability. We lack data comparing robotic approaches to totally endoscopic minimally invasive mitral valve surgery using 3D vision platforms. In this review, we explore the advantages and disadvantages of robotic mitral valve surgery and share technical tips that we have learned to help teams embarking on their robotic journey. We consider factors necessary for the successful implementation of a robotic programme including the importance of training a dedicated team, with the common goal to avoid any compromise in either patient safety or repair quality during the learning curve. As experience grows with robotic techniques and more cardiac surgeons become proficient with this innovative technology, the volume of robotic cardiac procedures around the world will increase helped by the introduction of new robotic systems and patient demand. Well informed patients will increasingly seek out the opportunity of robotic valve reconstruction in reference centres in the hands of a few highly experienced robotic surgeons.

Graphical Abstract OBJECTIVES High body mass index (BMI) makes minimally invasive mitral valve surgery (MIMVS) more challenging with some surgeons considering this a contraindication. We sought to determine whether this is because the outcomes are genuinely worse than those of non-obese patients. METHODS This is a retrospective cohort study of all patients undergoing MIMVS ± concomitant procedures over an 8-year period. Patients were stratified into 2 groups: BMI ≥ 30 kg/m2 and BMI ˂ 30 kg/m2, as per World Health Organization definitions. Baseline characteristics, operative and postoperative outcomes and 5-year survival were compared. RESULTS We identified 296 patients (BMI ≥30, n = 41, median 35.3, range 30–43.6; BMI <30, n = 255, median 26.2, range 17.6–29.9). The groups were well matched with regard to baseline characteristics. There was only 1 in-hospital mortality, and this was in the BMI < 30 group. There was no difference in repair rate for degenerative disease (100% vs 96.3%, P > 0.99 respectively) or operative durations [cross-clamp: 122 min interquartile range (IQR) 100–141) vs 125 min (IQR 105–146), P = 0.72, respectively]. There were only 6 conversions to sternotomy, all in non-obese patients. There was no significant difference in any other perioperative or post-operative outcomes. Using the Kaplan–Meier analysis, there was no significant difference in 5-year survival between the 2 groups (95.8% vs 95.5%, P = 0.83, respectively). CONCLUSIONS In patients having MIMVS, there is insufficient evidence to suggest that obesity affects either short- or mid-term outcomes. Obesity should therefore not be considered as a contraindication to this technique for experienced teams.

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OBJECTIVES Pre-emptive strategies to manage the aortic complications of Marfan syndrome have resulted in improved life expectancy yet, secondary to the variation of phenotypic expression, anticipating the risk and nature of future aortic events is challenging. We examine rates of new aortic events and reinterventions in a Marfan cohort following initial aortic presentation. METHODS Retrospective cohort study of Marfan patients with aortic pathology presenting to our institution 1998–2018. Patients were grouped according to index event: aortic dissection or root aneurysm. Patients with aortic dissection were classified according to Debakey criteria. Incidence of new aortic events and frequency of reintervention were analysed. RESULTS One hundred and twenty-six aortic procedures were performed in 74 Marfan patients with a median follow-up of 7 years. Forty-seven patients had an index event of root aneurysm and 27 had aortic dissection. Following operative intervention in the aneurysm group, 7 patients developed Debakey III dissections raising the overall number of patients who developed dissection within this cohort to 34. Reinterventions were more frequent in the dissection group with full replacement of the native aorta in 5 patients. CONCLUSIONS After operative intervention on the proximal aorta, a proportion will develop distal pathology. A greater focus on factors contributing to future events, such as mapping genotypes to clinical course, may lead the way for targeted operative techniques and surveillance.

OBJECTIVES To compare patient-reported outcome measures of minimally invasive (MI) to sternotomy (ST) mitral valve repair. METHODS We included all patients undergoing isolated mitral valve surgery via either a right mini-thoracotomy (MI) or ST over a 36-month period. Patients were asked to complete a modified Composite Physical Function questionnaire. Intraoperative and postoperative outcomes, and patient-reported outcome measures were compared between 2 propensity-matched groups (n = 47/group), assessing 3 domains: ‘Recovery Time’, ‘Postoperative Pain’ (at day 2 and 1, 3, 6 and 12 weeks) and ‘Treatment Satisfaction’. Composite scores for each domain were subsequently constructed and multivariable analysis was used to determine whether surgical approach was associated with domain scores. RESULTS The response rate was 79%. There was no mortality in either group. In the matched groups, operative times were longer in the MI group (P < 0.001), but postoperative outcomes were similar. Composite scores for Recovery Time [ST 51.7 (31.8–62.1) vs MI 61.7 (43.1–73.9), P = 0.03] and Pain [ST 65.7 (40.1–83.1) vs MI 79.1 (65.5–89.5), P = 0.02] significantly favoured the MI group. Scores in the Treatment Satisfaction domain were high for both surgical approaches [ST 100 (82.5–100) vs MI 100 (95.0–100), P = 0.15]. The strongest independent predictor of both faster recovery parameter estimate 12.0 [95% confidence interval (CI) 5.7–18.3, P < 0.001] and less pain parameter estimate 7.6 (95% CI 0.7–14.5, P = 0.03) was MI surgery. CONCLUSIONS MI surgery was associated with faster recovery and less pain; treatment satisfaction and safety profiles were similar.