Robotic mitral valve repair in octogenarians: safety and clinical outcomes compared with younger patients

Introduction

With advances in robotic and catheter-based techniques, surgical treatment can now be performed with minimal invasion. In the field of robotic mitral valve (MV) repair, many reports have demonstrated the effectiveness of this approach (1,2). Although expectations for surgical intervention in mitral regurgitation (MR) are high, there are still no specific age-related guidelines for its surgical management.

Previously, octogenarians were considered to be at high risk for cardiac surgery (3). Consequently, catheter-based treatments were sometimes selected for octogenarians solely because of their age. However, catheter-based treatments raise concerns regarding their effectiveness and durability (4,5). By contrast, recent studies have demonstrated the safety of MV repair compared with MV replacement in older patients (6), as well as the safety of minimally invasive MV surgery in this population (7). We believe that establishing the safety of robotic MV surgery in older patients could expand treatment options. However, among studies demonstrating the efficacy of robotic surgery in older populations, few have compared outcomes between patients over 80 years old and younger patients. Therefore, the aim of this study was to evaluate the feasibility, early clinical outcomes, and postoperative functional status of robotic MV repair in octogenarian patients by comparing them with those of younger patients. We present this article in accordance with the STROBE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-0638/rc).

Methods

Study population

From September 2019 to September 2024, we retrospectively reviewed data from consecutive patients who underwent endoscopic robotic MV repair at Osaka Metropolitan University Graduate School of Medicine. Both patients with degenerative MR and those with functional MR were included in this study. All procedures were performed by a single surgeon. The exclusion criteria for robotic MV repair included a low ejection fraction, ischemic MR, severe pulmonary disease, shaggy aorta, coexisting advanced malignancy, and treatable coronary artery disease. In older and high-risk patients, treatment strategies were discussed by a multidisciplinary heart team including cardiologists, and mitral transcatheter edge-to-edge repair was selected when older patients had decreased cognitive function or required assistance with activities of daily living (ADL), transcatheter edge-to-edge repair was selected.

The patients were divided into two groups according to age. Patients aged ≥80 years were defined as the older group. For comparison, patients aged ≤65 years were classified as the younger group according to the World Health Organization definition of older individuals.

Transthoracic echocardiography was performed in all patients at our echocardiography laboratory preoperatively and at 1 week and 1 year postoperatively. Physical function was evaluated preoperatively and postoperatively by rehabilitation physicians.

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Osaka Metropolitan University Ethics Review Board (approval No. 2025-029), and individual consent for this retrospective analysis was waived.

Robotic procedure setup

The da Vinci Surgical System Si and Xi (Intuitive Surgical, Inc., Sunnyvale, CA, USA) were used for all patients. During anesthetic induction, a venous cannula was inserted into the right internal jugular vein under fluoroscopic guidance. A skin incision approximately 4 cm in length was made in the third or fourth intercostal space. Three da Vinci ports were then placed as shown in Figure 1 for the left arm, retractor arm, and right arm. An additional port for the flexible vent tube was inserted in the same intercostal space as the right-arm port. After systemic heparinization, an arterial cannula was placed in the femoral artery, and an additional venous cannula was inserted from the femoral vein into the right atrium under fluoroscopic guidance. Cardiopulmonary bypass was then initiated.

Figure 1 Standard da Vinci port configuration showing the 3rd, 4th, and 6th intercostal access sites.

Evaluation of physical function

Physical function in older patients was assessed using the Short Physical Performance Battery (SPPB). The SPPB consists of three components: the balance test, gait speed test, and chair stand test, each scored on a 4-point scale. Balance was evaluated using side-by-side, semi-tandem, and tandem stands held for 10 seconds. Gait speed was assessed using a 4-m walking test. The chair stand test measured the time required to rise from a seated position and sit down five times with the arms crossed over the chest.

The total SPPB score ranges from 0 to 12 points, with higher scores indicating better physical function (8). SPPB assessments were performed preoperatively and again before discharge by a rehabilitation physician.

Statistical analysis

Descriptive statistics for categorical variables are presented as absolute values and percentages, and continuous variables are shown as mean and standard deviation or median with interquartile range. All analyses were conducted using JMP version 13.0 (SAS Institute Inc., Cary, NC, USA), and a P value of <0.05 was considered statistically significant.

Results

Patient characteristics (Figure 2, Table 1)

Figure 2 Annual distribution of patients undergoing endoscopic robotic mitral valve repair at our hospital from 2019 to 2024, stratified by age group (<65, 65–80, >80 years). MVP, mitral valve repair; y.o., years old.

In total, 170 robotic MV repair procedures were performed at our hospital from September 2019 to September 2024. Among these, 16 MR cases were identified in patients over 80 years old and 101 cases in patients under 65 years old.

The mean age in the older group was 81.8±1.9 years, and all patients had New York Heart Association class >2 heart failure symptoms preoperatively. Compared with patients under 65 years old, more older patients had hypertension [14 (88%) vs. 51 (50%); P=0.006], dyslipidemia [6 (38%) vs. 14 (14%); P=0.03], respiratory disorders [4 (25%) vs. 2 (2%); P=0.003], and atrial fibrillation (AF) [9 (56%) vs. 13 (13%); P<0.001]. None of the patients in either group had undergone prior cardiac surgery or pacemaker implantation. Patients over 80 years old had higher EuroSCORE II values than those under 65 years [2.9±1.6 vs. 0.8±0.4; P<0.001].

Preoperative echocardiography showed that all older patients had severe MR, and 10 (63%) had at least moderate tricuspid regurgitation (TR). In the under-65 group, 94 patients (93%) had severe MR and 14 (14%) had at least moderate TR. While left ventricular dimensions were smaller in patients over 80 years old (left ventricular end-diastolic dimension: 49±5.9 vs. 55±5.6 mm, P<0.001; left ventricular end-systolic dimension: 29±4.9 vs. 33±5.8 mm, P=0.006), older patients had a larger left atrial volume index (60±28 vs. 42±17 mL/m²; P=0.005) and a higher TR pressure gradient (30.9±11.1 vs. 23.4±8.5 mmHg; P=0.003).

Intraoperative findings (Table 2)

Regarding MR etiology, atrial functional MR was more frequent in the older group [3 (19%) vs. 2 (2%); P=0.01]. Bilateral leaflet prolapse was observed in 4 older patients (25%) and in 28 patients under 65 years old (28%).

Smaller mitral annuloplasty rings were selected for older patients (30±0.62 vs. 32±0.25 mm; P=0.007). Most patients in both groups underwent loop-technique MV repair, although the proportion was lower in the older group [13 (81%) vs. 99 (98%); P=0.01]. Concomitant procedures were more common among older patients, including tricuspid valve repair [7 (44%) vs. 10 (10%); P=0.002], Maze procedures [7 (44%) vs. 10 (10%); P=0.002], and left atrial appendage closure [8 (50%) vs. 9 (9%); P<0.001]. There were no significant differences in operative time (297±37 vs. 283±51 min; P=0.21), cardiopulmonary bypass time (190±26 vs. 185±41 min; P=0.28), or cross-clamp time (127±25 vs. 125±38 min; P=0.48). All patients over 80 years old received intraoperative blood transfusions.

Postoperative data (Tables 3,4; Figure 3)

Figure 3 Changes in MR and TR grades before and after surgery. Distribution of MR grades in older patients (N=16) and TR grades in patients who underwent tricuspid valve repair (N=7) preoperatively, at 1 week, and at 1 year after surgery. MR, mitral regurgitation; TR, tricuspid regurgitation.

Postoperative echocardiography was performed at 1 week and 1 year after surgery in all patients. MR grade was evaluated in 16 older patients, whereas TR grade was assessed in 7 older patients who underwent tricuspid valve repair (Figure 3). At 1 week, among older patients, mild MR was observed in one patient (6%), trivial MR in nine (56%), and no residual MR in six (38%). All older patients who underwent tricuspid valve repair had no more than mild TR at 1 week. At 1 year postoperatively, mild MR was observed in eight older patients (50%) and trivial MR in eight (50%). Mild TR was present in four older patients (57%) and trivial TR in three (43%) at 1 year.

With regard to postoperative complications, small numbers of patients developed new-onset AF [2 (13%) vs. 4 (4%); P=0.19], pneumothorax [2 (13%) vs. 2 (2%); P=0.09], and phrenic nerve palsy [0 (0%) vs. 1 (1%); P>0.99] in the two groups. The length of hospitalization was longer in the older group (14±5 vs. 10±3 days; P=0.001), although all patients in both groups were discharged home.

SPPB scores were available for 13 of the 16 older patients on retrospective review. There were no significant differences between preoperative and postoperative scores in any component (balance, gait speed, or chair stand). In 9 of the 13 patients, postoperative scores were unchanged. In the remaining four patients, scores decreased by at least 1 point, but all patients were still discharged home.

The mean follow-up period was 36±19 months, and no deaths and readmissions due to heart failure occurred during follow-up in the older group.

Discussion

The present study demonstrated several important findings. First, robotic MV repair in carefully selected octogenarians was feasible and resulted in favorable early clinical outcomes, with all older patients being discharged home without major postoperative complications. Second, concomitant procedures, including tricuspid valve repair and AF surgery, could be safely performed when indicated. Third, postoperative physical performance assessed using the SPPB was preserved, suggesting that robotic surgery may help maintain ADL in older patients.

Minimally invasive MV repair is increasingly selected for the treatment of MR. At our institution, we generally choose robotic MV repair for MR when patients do not meet any exclusion criteria. The efficacy and safety of robotic MV repair have already been described in several reports (1,2). However, few studies have specifically evaluated the effectiveness and safety of robotic MV repair in older patients with MR. Although transcatheter MV repair is an option for older or high-risk patients who are considered unsuitable for surgery, we have encountered several reoperation cases following failed catheter-based procedures. Feldman et al. (4) reported that patients treated with catheter-based approaches for functional or degenerative MR had significantly higher rates of recurrent MR and reoperation over a 5-year follow-up period than those who underwent surgical repair. Akansel et al. (5) similarly reported that after failed transcatheter MV repair, approximately 90% of reoperations required MV replacement, and the overall 1-year survival rate after reoperation was 75%. These findings suggest that transcatheter repair may be insufficient for achieving durable control of MR.

In clinical practice, we often face the dilemma of choosing between robotic surgery and catheter treatment for older patients with MR, and clear age-based selection criteria have not yet been established. Some studies have reported that cardiac surgery carries a higher risk in octogenarians (3), and catheter-based therapies may therefore be selected primarily because of patient age. At our institution, treatment decisions are made by a heart team, and robotic MV repair is generally considered for older patients with preserved ADL. If the safety of robotic surgery can be demonstrated more clearly, robotic MV repair may be more actively considered even in older patients.

In this study, we compared patients under 65 years with those over 80 years and examined differences between the two groups. Because individuals aged ≥65 years are generally defined as older according to the World Health Organization definition, patients aged ≤65 years were selected as the comparison group to represent a relatively younger population with lower expected surgical risk. We believed that comparing postoperative outcomes with younger patients aged ≤65 years would more clearly demonstrate the effectiveness of robotic surgery. Older patients had significantly more hypertension, hyperlipidemia, and respiratory dysfunction as comorbidities. Nearly half of the older patients had AF, compared with approximately 10% of younger patients. Preoperative echocardiography showed a significantly worse TR grade in the older group. We speculate that the high prevalence of AF contributed to both the higher TR grade and higher TR pressure gradient in these patients. These comparisons suggest that preoperative risk was greater in the older group than in patients under 65 years.

The relationship between AF and MR or TR has been previously described. Abe et al. (9) reported that the prevalence of MR or TR was approximately 30% among patients with longstanding persistent AF and that patients with both atrial functional MR and TR had the poorest prognosis. Our earlier report also demonstrated the benefits of addressing both MR and TR in the same operation (10). McCarthy et al. (11) similarly showed a close relationship between preoperative AF and late TR recurrence after degenerative MR surgery. In their study, patients with AF who did not undergo tricuspid annuloplasty were more likely to develop moderate or severe TR during follow-up, and progression to moderate or greater TR was associated with increased long-term mortality (11). In our study, 56% of older patients had AF and 63% had moderate or severe TR. We treated 16 patients over 80 years old with MR and performed concomitant procedures using the same indications as in younger patients when TR caused by annular dilation or AF was present. Tricuspid annuloplasty was performed in seven older patients (44%), and echocardiography at 1 week after surgery and at the 1-year follow-up showed that MR and TR were reduced to no more than mild in all cases.

Although the rate of concomitant procedures was higher in octogenarians, the operation time and cardiopulmonary bypass time did not differ significantly between older patients and those under 65 years. This may be explained by the higher prevalence of atrial functional MR in octogenarians. In such cases without leaflet prolapse, ring annuloplasty alone is typically performed, whereas degenerative MR often requires more complex repair techniques, such as loop technique combined with annuloplasty. Consequently, MV repair in octogenarians may require less operative time, partially offsetting the increased complexity associated with concomitant procedures.

All older patients were discharged home without postoperative major complications, despite a higher rate of blood transfusion and a longer hospitalization period. We assessed ADL in older patients using the SPPB, in which decreased ADL was defined as a decline in the SPPB score (8). In this study, none of the three SPPB components showed significant pre- to postoperative change. In most cases, postoperative SPPB scores were unchanged compared with preoperative values. Four patients experienced a decrease of 1 point or more; however, all retained sufficient functional ability and were discharged home. These findings suggest that robotic surgery may be an effective approach for preserving physical performance and ADL in older patients. Although the conventional perioperative advantages of robotic surgery, such as reduced transfusion requirements and shorter hospital stay, were not observed in this study, preservation of postoperative functional status may represent an important benefit in older patients. On the other hand, the high transfusion rate may reflect our perioperative management strategy in older patients, which prioritizes the prevention of postoperative deterioration. In addition, many octogenarians had AF and were receiving anticoagulation therapy. Consequently, older patients are more likely to present with preoperative anemia, which may contribute to a lower threshold for transfusion.

We also had no deaths or reoperations during the follow-up period. We consider these results satisfactory compared with those of previous reports (1,2,4,10). Because robotic surgery is minimally invasive, it may represent a feasible treatment option that helps avoid postoperative decline in ADL, particularly in older patients. These findings suggest that robotic MV repair may be a reasonable surgical options for carefully selected older patients with MR.

Limitations

This study has several limitations. First, this was a retrospective study conducted at a single institution, which may limit the generalizability of the finding. Second, the sample size, particularly in the group of patients aged over 80 years, was relatively small. Third, because surgical indications were determined by a heart team and robotic surgery was primarily selected for patients with preserved functional status, selection bias may have influenced the results. Finally, the follow-up period was relatively short and longer-term outcomes, including survival and durability of valve repair, should be evaluated in future studies.

Conclusions

Robotic MV repair in carefully selected octogenarians was feasible and associated with favorable early outcomes. Concomitant procedures, including tricuspid valve repair and AF surgery, were safely performed without deterioration of postoperative physical performance. Robotic surgery may represent a reasonable treatment option for older patients with MR.

Acknowledgments

We thank Edanz (https://jp.edanz.com/ac) for editing a draft of this manuscript.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-0638/rc

Data Sharing Statement: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-0638/dss

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-0638/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-0638/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Osaka Metropolitan University Ethics Review Board (approval No. 2025-029), and individual consent for this retrospective analysis was waived.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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