How to Prevent Stroke in Robotic Mitral Valve Surgery

P0133 

Abstract Submission 

Ryuta Seguchi (1), Go Watanabe (1), Norihiko Ishikawa (1), Kazuto Miyata (1), Takafumi Horikawa (1), Toru Koakutsu (1), Daiki Yoshiyama (1), Shigeyuki Tomita (1), Toshiya Ohtsuka (1)

(1) NewHeart Watanabe Institute, Tokyo, NA

Ryuta Seguchi    -  Contact Me
NewHeart Watanabe Institute

Go Watanabe    -  Contact Me
NewHeart Watanabe Institute

Norihiko Ishikawa    -  Contact Me
NewHeart Watanabe Institute

Kazuto Miyata    -  Contact Me
NewHeart Watanabe Institute

Takafumi Horikawa    -  Contact Me
NewHeart Watanabe Institute

Toru Koakutsu    -  Contact Me
NewHeart Watanabe Institute

Daiki Yoshiyama    -  Contact Me
NewHeart Watanabe Institute

Shigeyuki Tomita    -  Contact Me
NewHeart Watanabe Institute

Toshiya Ohtsuka    -  Contact Me
NewHeart Watanabe Institute

Ryuta Seguchi    -  Contact Me
NewHeart Watanabe Institute

Objective: Because of restricted patient positioning and limited cannulation sites, totally endoscopic robotic mitral valve repair carries a unique risk of cerebral hypoperfusion, particularly in the right upper watershed territory, which lies farthest from the femoral arterial cannula in the left decubitus position. After encountering strokes localized to this "zone of risk," we established a protocol for stroke prevention. This study evaluates the efficacy of our strategy to preserve cerebral perfusion in the right upper hemisphere.
Methods: Between May 2014 and September 2025, 1,578 patients underwent robotic mitral valve repair at our institution. Beginning with the 464th case, the following cerebral-protection protocol was implemented:
1. Right axillary arterial cannulation, not only in patients with aortic atherosclerosis (calcification > 50% of circumference) but also in those with small iliac arteries (diameter < 7 mm);
2. Releasing robotic ports from the chest wall and placing the patient in the Trendelenburg position during cardiopulmonary-bypass weaning or when upper-extremity perfusion pressure fell < 50 mmHg during cardiac arrest;
3. Minimizing cardiopulmonary-bypass duration.
Outcomes before (Group A, n = 463) and after (Group B, n = 1,115) protocol implementation were compared.
Results: Mean age was 54 ± 12 years in Group A and 58 ± 12 years in Group B; females accounted for 33% and 34%, respectively. Right axillary arterial cannulation was performed significantly more frequently in Group B (1.7% vs 29.1%; p < 0.001). Cardiopulmonary-bypass time was shorter in Group B (124 ± 25 vs 99 ± 31 min; p < 0.001). The overall incidence of stroke decreased significantly after protocol implementation (1.7% vs 0.45%; p = 0.026, Fisher's exact test; odds ratio [Group B vs A] = 0.26; 95% CI, 0.07–0.89). The incidence of right cerebral infarction also decreased (1.3% vs 0.27%), although the difference did not reach statistical significance (p = 0.09; odds ratio = 0.21; 95% CI, 0.05–0.95), showing a consistent trend toward reduction.
Conclusions: The right upper hemisphere is particularly vulnerable to ischemic injury during robotic mitral valve repair because of restricted positioning and perfusion disadvantage from femoral cannulation. Our protocol-combining selective axillary cannulation, strategic positioning, and shortened extracorporeal circulation-markedly reduced stroke incidence and offers a practical approach for cerebral protection.

Other - Robotic and Minimally Invasive cardiac surgery