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