Future directions
This paper focused on percutaneous mitral valve repair with the
MitraClip device, which is the only percutaneous technology accepted by
the US Food and Drug Administration (FDA). However, there are other
approaches to edge-to-edge mitral valve repair under development, such
as PASCAL, valve clamp, and mitral stitch. The PASCAL mitral valve
repair system adopts a transseptal approach. It involves a 22-French
guide with a maneuverable catheter and an implanted catheter. It
achieves its best position via a central spacer created to occupy the
regurgitant orifice area, along with two paddles and two clasps that
hold separate valve leaflets.1,2 Such techniques,
which aim to resolve the challenges posed by existing techniques, are
currently being studied.3
The various advantages of minimally invasive surgery over conventional
techniques have made minimally invasive surgery thrive in the past few
years. However, there are still many difficulties associated with it,
such as the restricted field of view, decreased maneuverability of the
instruments, increased skill requirement, and higher costs.
Robots have been used in an attempt to solve some of the aforementioned
challenges, and some success has been seen with the da Vinci SP
(Intuitive Surgical, Sunnyvale, California, USA) robotic
system.69 However, the utility of robotic systems is
still unable to prove significant improvements clinically. One study
comparing robotic approach against minimally invasive surgery, found
that robotic intervention had higher rates of transfusion (15% compared
to 5% rates in MIMVS), as well as higher chances of developing atrial
fibrillation post-surgery. Moreover, it is immensely expensive, which
further strains the resources of the NHS.70
Ways to enhance the success of minimally invasive surgery and reduce its
postoperative complications need to be explored further. The paper by
Gillinov et al. analysing robotic mitral valve repair in 1000 patients
described a decrease in stroke risk (which is originally linked to long
CPB time) after the first 500 cases, from 2% to 0.8%. This sheds a
light on the importance of the learning curve among surgeons and how
this may pose an impediment in adopting robotic mitral valve surgery as
a conventional approach.71