“Minimally invasive robotic mitral valve surgery.”
Atluri, P. and Y. J. Woo (2011).
Expert Review of Medical Devices8(1): 115-120.
Over the past two decades, significant advances have been made in mitral valve surgery. Cardiac surgeons have successfully repaired degenerative and ischemic regurgitant mitral valves via a traditional midline sternotomy. In recent years, alternate incisions have yielded minimally invasive approaches to the mitral valve. Technological advances have made robotically assisted minimally invasive mitral valve surgery feasible. Decreased pain, more rapid return to work, diminished blood loss and reduced length of hospitalization have been witnessed following robotic mitral valve surgery when compared with a traditional sternotomy. Equivalent long-term mortality and freedom from recurrent mitral regurgitation are evident between mitral valve repair performed via a traditional sternotomy and minimally invasive and robotic techniques. As a result, an increasing number of patients and referring cardiologists are seeking minimally invasive approaches to mitral valve surgery.
“Robotic totally endoscopic triple coronary artery bypass grafting on the arrested heart: report of the first successful clinical case.”
Bonatti, J., A. Rehman, et al. (2010).
Heart Surgery Forum13(6): E394-396.
Robotic technology enables “port only” totally endoscopic coronary artery bypass grafting (TECAB). During early procedure development only single bypass grafts were feasible. Because current referral practice for coronary bypass surgery mostly includes multivessel disease, performance of multiple endoscopic bypass grafts is desirable. We report a case in which a patient received a right internal mammary artery bypass graft to the left anterior descending artery and a left internal mammary artery jump graft to 2 obtuse marginal branches. The procedure was performed through 5 ports on the arrested heart using the daVinci S robotic surgical system. This is the first reported triple bypass grafting procedure using an arrested heart approach.
“Learning curve analysis of mitral valve repair using telemanipulative technology.”
Charland, P. J., T. Robbins, et al. (2010).
Journal of Thoracic and Cardiovascular Surgery.
Objective: To determine if the time required to perform mitral valve repairs using telemanipulation technology decreases with experience and how that decrease is influenced by patient and procedure variables. Methods: A single-center retrospective review was conducted using perioperative and outcomes data collected contemporaneously on 458 mitral valve repair surgeries using telemanipulative technology. A regression model was constructed to assess learning with this technology and predict total robot time using multiple predictive variables. Statistical analysis was used to determine if models were significantly useful, to rule out correlation between predictor variables, and to identify terms that did not contribute to the prediction of total robot time. Results: We found a statistically significant learning curve (P < .01). The institutional learning percentage† † Learning percentage: the percentage decrease in operative time each time case number doubles. Example: If the learning percentage is 50% and case 1 takes 100 minutes to perform, case 2 will take 50 minutes, case 4 will take 25 minutes, case 8 will take 12.5 minutes, case 16 will take 6.25 minutes, and so on until the asymptote is reached. derived from total robot times‡ ‡ Total robot time: starts when the da Vinci Surgical System connects to the patient and ends when the da Vinci Surgical System disconnects from the patient. for the first 458 recorded cases of mitral valve repair using telemanipulative technology is 95% (R<sup>2</sup> = .40). More than one third of the variability in total robot time can be explained through our model using the following variables: type of repair (chordal procedures, ablations, and leaflet resections), band size, use of clips alone in band implantation, and the presence of a fellow at bedside (P < .01). Conclusions: Learning in mitral valve repair surgery using telemanipulative technology occurs at the East Carolina Heart Institute according to a logarithmic curve, with a learning percentage of 95%. From our regression output, we can make an approximate prediction of total robot time using an additive model. These metrics can be used by programs for benchmarking to manage the implementation of this new technology, as well as for capacity planning, scheduling, and capital budget analysis. © 2010 The American Association for Thoracic Surgery.
“Is an intraaortic balloon pump a contraindication to robotic totally endoscopic coronary artery bypass?”
Kon, Z. N., E. Lehr, et al. (2010).
Heart Surgery Forum13(6): E399-401.
Background: The success of robotic totally endoscopic coronary artery bypass (TECAB) in recent years has led to the expansion of the procedure to patients with more severe disease. Outcomes with these patients have not yet been well characterized, and no reports on TECAB performed in patients with a preoperatively placed intraaortic balloon pump (IABP) are available. We present our initial experience with this patient population.Patients and Methods: We evaluated 5 patients with unstable angina or impaired left ventricular function requiring a preoperatively placed IABP who underwent TECAB using the daVinci telemanipulation system. Procedures were performed either on the beating heart using an endostabilizer (n = 2) or on the arrested heart using remote access perfusion and aortic balloon endoocclusion (n = 3). The median patient age was 67 years (range, 41-73 years), with a median preoperative ejection fraction of 43% (range, 26%-58%) and median EuroSCORE of 5 (range, 3-8).Results: There were no major intraoperative technical issues. The median length of stay in the hospital and intensive care unit was 8 days (range, 5-13 days) and 66 hours (range, 41-142 hours), respectively. There were no intraoperative or 30-day mortalities.Conclusions: This early experience suggests that TECAB is feasible in patients with a preoperatively placed IABP. Both the beating heart and arrested heart versions can be used in this patient population, further broadening the spectrum of applicability of this procedure.
“Robotic cardiac surgery.”
Lehr, E. J., E. Rodriguez, et al. (2010).
Current Opinion in Anaesthesiology.
PURPOSE OF REVIEW: To outline current techniques in robotic cardiac surgery and to report the recent results. RECENT FINDINGS: Robot-assisted surgery is the latest iteration toward less-invasive surgical procedures. Cardiac surgeons have slowly adopted robotic techniques into their armamentarium. In particular, robotic mitral valve surgery has evolved over the last decade and become the preferred method of mitral valve repair and replacement at certain specialized centers worldwide because of excellent results. Robotic single-vessel and double-vessel total endoscopic coronary artery bypass grafting procedures have likewise been standardized on the beating and arrested heart. Other cardiac procedures are in various stages of evolution. Results to date have matched the outcomes of major trials for sternotomy-based procedures. In addition, patients may benefit from shorter hospital stays and experience faster return to full activity. SUMMARY: Stepwise progression of robotic technology and procedure development will continue to make robotic operations simpler and more efficient, which will encourage more surgeons to take up this technology and extend the benefits of robotic surgery to a larger patient population. Long-term results are needed to determine whether robotic techniques could become the new standard in cardiac surgery.
“Robotic Coronary Artery Bypass Grafting.”
Liao, K. K. (2010).
Operative Techniques in Thoracic and Cardiovascular Surgery15(3): 194-205.
“Totally thoracoscopic repair of atrial septal defect without robotic assistance: A single-center experience.”
Ma, Z. S., M. F. Dong, et al. (2010).
Journal of Thoracic and Cardiovascular Surgery.
OBJECTIVE: The recent advent of robotically assisted surgery has enabled totally endoscopic repair of atrial septal defects and patent foramen ovale. This study investigates the feasibility and safety of totally endoscopic repair of an atrial septal defect through small incisions on the chest without robotic assistance. METHODS: Forty patients (23 female patients; average age, 15.4 +/- 8.7 years; age range, 6-47 years) with secundum-type ASDs were selected for this study. Cardiopulmonary bypass was achieved peripherally. Through 3-port incisions in the right chest, pericardiotomy, bicaval occlusion, atriotomy, and ASD repair were performed by a surgeon through a thoracoscopy. RESULTS: The cardiopulmonary bypass and aortic crossclamp times were 56.2 +/- 21.1 and 38.3 +/- 8.6 minutes, respectively. The length of stay in the intensive care unit was 23.0 +/- 4.1 hours. There were no mortalities and no major complications in this cohort. Patients were discharged from the hospital 4 to 6 days after the operation. Transesophageal echocardiographic analysis immediately after the operation and at 30 days showed complete closure of the defect without residual shunt. CONCLUSIONS: Totally endoscopic atrial septal defect repair can be achieved without a robotically assisted surgical system. This technique is safe and effective and can be used as a therapeutic option for ASD.
“Robotic repair of posterior mitral valve prolapse versus conventional approaches: Potential realized.” Mihaljevic, T., C. M. Jarrett, et al. (2011).
Journal of Thoracic and Cardiovascular Surgery141(1).
Objective: Robotic mitral valve repair is the least invasive approach to mitral valve repair, yet there are few data comparing its outcomes with those of conventional approaches. Therefore, we compared outcomes of robotic mitral valve repair with those of complete sternotomy, partial sternotomy, and right mini-anterolateral thoracotomy. Methods: From January 2006 to January 2009, 759 patients with degenerative mitral valve disease and posterior leaflet prolapse underwent primary isolated mitral valve surgery by complete sternotomy (n = 114), partial sternotomy (n = 270), right mini-anterolateral thoracotomy (n = 114), or a robotic approach (n = 261). Outcomes were compared on an intent-to-treat basis using propensity-score matching. Results: Mitral valve repair was achieved in all patients except 1 patient in the complete sternotomy group. In matched groups, median cardiopulmonary bypass time was 42 minutes longer for robotic than complete sternotomy, 39 minutes longer than partial sternotomy, and 11 minutes longer than right mini-anterolateral thoracotomy (P < .0001); median myocardial ischemic time was 26 minutes longer than complete sternotomy and partial sternotomy, and 16 minutes longer than right mini-anterolateral thoracotomy (P < .0001). Quality of mitral valve repair was similar among matched groups (P = .6, .2, and .1, respectively). There were no in-hospital deaths. Neurologic, pulmonary, and renal complications were similar among groups (P > .1). The robotic group had the lowest occurrences of atrial fibrillation and pleural effusion, contributing to the shortest hospital stay (median 4.2 days), 1.0, 1.6, and 0.9 days shorter than for complete sternotomy, partial sternotomy, and right mini-anterolateral thoracotomy (all P < .001), respectively. Conclusions: Robotic repair of posterior mitral valve leaflet prolapse is as safe and effective as conventional approaches. Technical complexity and longer operative times for robotic repair are compensated for by lesser invasiveness and shorter hospital stay.
Tilz, R. R., A. Rillig, et al. (2010).
European Heart Journal.