Robotic aortic valve replacement (RAVR) may offer an alternative to transcatheter aortic valve implantation (TAVI) as a minimally invasive option for the treatment of symptomatic aortic valve disease.
This was the viewpoint offered by Vinay Badhwar (West Virginia University, Morgantown, USA) at the European Association of Cardio-Thoracic Surgery (EACTS) 2024 annual meeting (9–12 October, Lisbon, Portugal), where he reported longitudinal outcomes from the first 300 consecutive patients undergoing RAVR across 10 established robotic cardiac surgery programmes at centres in the USA, Europe, Saudi Arabia, Brazil and Australia covering 2020–2024.
“As we all know minimally invasive surgical and transcatheter options for the management of symptomatic aortic valve disease are increasingly sought by providers as well as patients, but the debate continues as the incursion of transcatheter therapies enters into low to intermediate risk,” Badhwar said.
The RAVR procedure is performed in a similar fashion to robotic mitral valve surgery, with the patient positioned in the same way and accessed via a 3cm transaxillary right lateral mini thoracotomy. Importantly, according to Badhwar, the RAVR procedure facilitates the use of a traditional rather than a sutureless aortic valve prosthesis—for which there is a larger pool of available long-term outcome data—whilst also allowing concomitant mitral or tricuspid valve procedures, as well as arrhythmia therapies such as left atrial appendage closure.
At EACTS 2024, Badhwar reported 30-day and one-year echocardiographic and clinical outcomes for the first 300 patients to undergo the procedure up until July of 2024, but commented that since that timepoint, “we are now well over 300 cases”.
Patients had an average age of 67 years, with a mean predictive risk of mortality of 1.6% according to Society of Thoracic Surgeons (STS) criteria. All of the patients had severe aortic stenosis, 44.7% had bicuspid valves, and nearly 40% greater or equal to moderate aortic insufficiency. Over 10% had a concomitant aortic root enlargement, whilst 17% had concomitant procedures.
The overall 30-day and one-year outcomes detailed at EACTS 2024 showed that the operative mortality rate stood at 0.7%, with a stroke rate of 1%, 1.7% experienced renal failure, 4.3% required prolonged ventilation, and 2.3% required pacemaker implantation, with Badwhar noting that this was seen to be “much higher” in trials of TAVI in low-risk patient groups. Reoperation for bleeding was required in 8.3% of patients, whilst median length of stay stood at five days.
The mean aortic valve gradient stood at 9mmHg at 30 days, increasing to 10mmHg at one year, with prosthetic/paravalvular leak (PVL) of 2+ reported in only two patients (<1%) across both timepoints. None had PVL of 3-4+.
“In centres with an established robotic programme, RAVR does appear to be reproducible and safe, with both 30-day and one-year outcomes that are at least equivalent to those of open surgery, with a lower trend, perhaps of stroke and pacemaker rates,” said Badhwar of the results. “A comment is that as transcatheter aortic procedures are being offered to lower and lower risk patients and perhaps even bicuspid disease, RAVR may provide an important alternative option for the management of symptomatic aortic valve disease and consideration in our global heart teams.”
Following his presentation of the results, Badhwar was asked about the learning curve involved with picking up the robotic aortic procedure. He offered the recommendation that centres should start their practice with mitral procedures before graduating into the aortic valve.
Upon studying the first 50 RAVR procedures, Badhwar said that his team noticed a drop-off on the time needed for suture placement, aortotomy closure, and securing of the valve after the first 10 cases.
Sabine Bleiziffer (Herz- und Diabeteszentrum NRW, Bad Oeynhausen, Germany), a moderator of the late-breaking science session at EACTS 2024 where Badhwar presented the data asked what further evidence would be needed to establish RAVR as a treatment for aortic valve disease, and whether randomised trials pitting the procedure head-to-head against TAVI should be considered.
Badhwar commented that his team will be publishing institutional data in the coming months comparing RAVR and TAVI. “What we did find in a comparative analysis, albeit institutional, was that there was obvious superiority of RAVR over TAVI,” he commented.
