Is robotic assistance an added value in minimally invasive mitral valve surgery? A meta-analysis from propensity score–matched series

Objectives: There is still ongoing debate about the benefits of robotic assistance (R-MVS) in comparison with video assistance (V-MVS) in minimally invasive mitral valve surgery. This study aims to update the current evidence. Methods: Three propensity score–matched studies published from 2011 to 2021 were included with a total of 1193 patients operated on from 2005 (R-MVS: 536, V-MVS: 657). Data regarding early mortality, postoperative event, and time-related outcomes were extracted and submitted to a meta-analysis using weighted random-effects modeling. Results: The incidence of early mortality, stroke, renal failure, conversion, atrial fibrillation, and prolonged ventilation were similar, all in the absence of heterogeneity. Reoperation for bleeding (odds ratio [OR]: 0.36, 95% confidence interval [CI] 0.16–0.81, p = 0.01) and the need for blood transfusion (OR: 0.30, 95% CI, 0.20–0.56, p = 0.001) were significantly lower in V-MVS group. Regarding time-related outcomes, there was evidence for important heterogeneity of treatment effect among the studies. Operative times were longer in R-MVS: differences in means were 20.7 min for cross-clamp time (95% CI, 9.07–32.3, p = 0.001), 20.7 min for cardiopulmonary bypass time (95% CI, 2.5–38.9, p = 0.03) and 40.2 min for total operative time (95% CI, 24.5–55.8, p < 0.001). Intensive care unit stay and hospital stay were reported in one study, and longer after R-MVS compared to V-MVS; the differences in means were 0.17 days (p = 0.005) and 0.6 days (p = 0.017), respectively. Total cost of both procedures was reported in an additional dedicated propensity score–matched series including 448 patients; it was 21% higher for R-MVS than for V-MVS. Conclusions: This meta-analysis showed excellent outcomes of both video and robotic techniques with low incidence of morbidity and mortality. However, there is no evidence for an added value of robotic assistance in comparison with video assistance; the drawbacks of mini access are reported higher regardless the induced over cost.