Sixty-eight-year-old Jim Watkins of Overland Park, Kansas, knew he had a heart murmur. Diagnosed with benign mitral valve prolapse in 2000, he was told by his cardiologist not to worry about it but to have a follow-up every three years or so. In the fall of 2013, Watkins and his wife started planning a European trip for the following spring, but that December, a routine echocardiogram revealed moderate-to-severe mitral valve leakage and marked leaflet regurgitation.
“They wanted me to have open-heart surgery before Christmas,” Watkins says, “but I wasn’t ready.”
Exploring alternatives, Watkins learned that minimally invasive robotic repair was an option that offered faster recovery and minimal scarring. The Midwest hospitals that could do it, however, had months-long waits. Deciding to expand his geographic search criteria, Watkins found Johns Hopkins cardiac surgeon Kaushik Mandal, a valve disease specialist with expertise in minimally invasive repairs.
When Watkins phoned Mandal’s office, he didn’t have high hopes, but Mandal returned the call within five minutes. A few weeks later, Watkins was aboard a plane to Baltimore. On Valentine’s Day, he underwent robotic surgery to repair his mitral valve and was discharged a week later with no restrictions. In May, he and his wife traveled across Europe.
But the ending in Watkins’ case masks the nuanced decisions that preceded it, Mandal says, because not everyone is a good candidate for the robotic approach. In fact, Johns Hopkins has stringent patient-selection criteria to ensure optimal results and maximum safety.
Besides being in good overall health, the ideal candidate has no lung disease, Mandal explains, because the right lung is collapsed repeatedly for several minutes at a time during the procedure. In addition, the peripheral arteries must be free of plaque and calcification because the lung-and-heart bypass machine used during the procedure can destabilize plaque, leading to stroke or myocardial infarction. This is why, in addition to a stress echocardiogram and a physical, Watkins underwent a CT angiogram to rule out not only significant arterial pathology and peripheral artery disease, but also leaflet calcification.
“Patients with notable calcium deposits on their valve leaflets should have a traditional open-chest operation,” Mandal says. And since echocardiography is notorious for missing calcifications, a cardiac CT scan is essential, he adds.
To further minimize Watkins’ intraoperative risk, the Johns Hopkins team monitored oxygen saturation in his legs and brain during the procedure.
Another critical variable is early referral, Mandal says, because “once a patient develops symptoms, the valve may be salvageable but the outcomes are not as great.”
The robot can be used in repairing leaky or stenotic valves, closing atrial septal defects, excising cardiac tumors or treating ablation-resistant atrial fibrillation. However, ventricular and coronary artery bypass surgery may be more suitable for the traditional sternotomy approach, Mandal says, because even though the robot offers excellent intraoperative visualization, it deprives the surgeon of critical tactile feedback.
“I think of the robot as a million-dollar scissors,” Mandal says. “The decision to use it and whom to use it on is mine. Safety is paramount.”