We read with great interest the article on running annuloplasty suture technique for robotically assisted mitral valve repair by Mihaljevic and colleagues. We congratulate them on their innovative approach to simplifying ring annuloplasty for robotic valve repair; they report impressive numbers and excellent results. Dedicated surgical instruments have been developed for minimally invasive and robotic cardiac surgery. Annuloplasty rings and bands have not been adapted to these approaches, however, and, as mentioned by Mihaljevic and colleagues, still require multiple suture placement and knot tying, which are somewhat difficult, tedious, and time-consuming in robotic valve repair. The multiple suture placement required for ring or band implantation has been facilitated with the use of nitinol U clips (Coales-cent Inc, Sunnyvale, Calif), as shown in an animal model. In a retrospective review of their clinical experience, however, Cook and associates failed to demonstrate a significant difference in the time to place a U clip versus a suture after controlling for the robotic-assisted suture tying learning curve.
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