Fresh From the OR, a Heart Surgeon Chats With Users

Dr. Mihaljevic: This is a very good question because decline in ejection fraction after mitral valve repair is actually very common and an expected finding.

The decline in ejection fraction does not implicate a decline in heart function. Patients with severe leakage of the mitral valve have falsely elevated ejection fraction prior to the surgery. So the repair of the mitral valve eliminates this false impression and unmasks and reveals a true ejection fraction, which is oftentimes lower.

hillm: Is robotic surgery ever done "off pump"? If not, how long is the time used on the heart-lung machine?

Dr. Mihaljevic: Robotic surgery can be done off pump—but only for bypass operations. All heart valve operations with the robot are done on pump since the heart has to be stopped and the heart chambers opened in order to get to the valves. The average time required for mitral valve repair is approximately 19 minutes.

hillm: Are there specific complications or concerns with a robotic surgery that are different from a conventional surgery?

Dr. Mihaljevic: There are no specific complications related to robotic surgery. Since the only difference between the two surgeries is the size of the incision, the surgery itself is done in the same way—the only difference is we are using robotic instruments instead of conventional ones.

The risk of death or mortality for robotic mitral valve repair at our institution is 1 in 1,000.

michael48: Do you find that patients with chronic controlled AF who have the repair see correction of the AF from the repair alone, or do they find that the Maze needs to be done no matter what?

Dr. Mihaljevic: In those patients, Maze needs to be done in conjunction with mitral valve repair. Mitral valve in isolation is not a cure for atrial fibrillation.

namaste1: What other minimally invasive approaches are available for leaky valve problems?

Dr. Mihaljevic: Other than robotic surgery, the operation can be done through the partial division of the breastbone or an incision on the right side of the chest. After review of your records and test results, all of these options are discussed with you by your surgeon.

hillm: What are the immediate restrictions after having a robotic heart surgery? Driving? Restrictions on lifting items of a certain weight?

Dr. Mihaljevic There are no restrictions in terms of driving after surgery. We only advise a patient not to drive as long as they take narcotic pain medications, which are usually required during the first week after surgery.

Most of our patients resume their regular activities within two weeks of surgery, including lifting.

hillm: If a patient had breast cancer, mastectomy with radiation to the chest, and now has mitral valve issues, would robotics still be an option?

Dr. Mihaljevic: Absolutely. Robotics may be an especially attractive solution to patients who had previous radiation to the chest because of a lesser chance of wound infection when using a small incision on the side of the chest instead of a sternotomy, which is division of the breastbone.

CCH: How many robotic procedures are performed at Cleveland Clinic in a year?

Dr. Mihaljevic: We have done 70 mitral valve repairs in the first 10 months of this year and we anticipate to complete 120 mitral valve repairs by the end of the year. In addition, we plan to do other types of robotically assisted heart surgery this year.

CCH: Thank you, Dr. Mihaljevic, for chatting with us today. It was very informative.

Dr. Mihaljevic: Thank you for having me today.

CCH: Thanks for joining us, everyone!