[Computer assisted open heart surgery. First case operated on with success]

Robotic applications for intracardiac and endovascular procedures

The large incisions and long recovery periods that accompany traditional cardiac surgery procedures along with the constant patient demand for minimally invasive procedures have motivated cardiac surgeons to implement the robotic technologies in their armamentarium. The robotic systems have been utilized successfully in various cardiac procedures including atrial septal defect repair, left atrial myxoma resection, MAZE procedure and left ventricular lead placement, yet coronary artery bypass and mitral valve repair still comprise the vast majority of them. This review analyzes the development of the robot-assisted cardiac surgery in recent years, its outcomes, advantages, disadvantages, its patient selection criteria as well as its economic feasibility. Robotic endovascular surgery, albeit its limited applications, is presently considered an attractive alternative to conventional endovascular approaches. The increased flexibility and precision along with the wider range of accessible anatomy provided by the endovascular robotic systems, have increased the pool of patients that can be offered minimally invasive treatment options and have helped to overcome many limitations of the traditional endovascular procedures. With this review we aimed to summarize the applications of the commercially available endovascular robotic devices, as well as the limitations and the future perspectives in the field of endovascular robotic surgery.

Subvalvular techniques enhanced with endoscopic robotic mitral valve repair

Objective

Totally endoscopic intracardiac robotic surgery is generally limited to uncomplicated mitral valve surgery. With experience, our team has developed a more aggressive approach to robotic cardiac surgery that allows for repair of a broad spectrum of mitral valve pathologies. We report complex subvalvular procedural advancements associated with this approach secondary to enhanced team experience and capabilities.

Methods

All robotic mitral procedures performed by a 2-surgeon team in a quaternary care medical center from July 2011 to May 2022 were reviewed. Natural language-processing techniques were used to analyze operative reports for subvalvular repair techniques. Complex subvalvular techniques included papillary muscle repositioning, division of secondary anterior leaflet chordae, septal myomectomy, division of aberrant left ventricular muscle band attachments, and left ventricular patch reconstruction. The surgical experience was divided into 2 periods: early robotic experience (pre-2018) versus late (2018 onwards). Baseline demographics, outcomes, and subvalvular techniques were analyzed and compared.

Results

A total of 1287 intracardiac robotic operations were performed by a 2-surgeon team. Thirty-day mortality was 0.6% (8/1287). Mitral valve repair was performed in 1024 patients. The mean age was 61 years (range, 18-90 years), and 15% were >75 years old; 29 patients (2.8%) had previously undergone cardiac surgery. There was a significant increase with experience in the application of advanced subvalvular techniques between the early versus late period (52.3% [268/512] vs 74.2% [380/512] (P < .001)).

Conclusions

An experienced 2-surgeon team can perform progressively more complex robotic subvalvular repair techniques. These subvalvular techniques are a surrogate for team proficiency and capabilities.

Endoaortic balloon occlusion versus transthoracic cross-clamp for totally endoscopic robotic mitral valve surgery: a retrospective cohort study

Endoaortic balloon occlusion (EABO) and transthoracic cross-clamping have been shown to have comparable safety profiles for aortic occlusion in minimally invasive mitral valve surgery (MIMVS). However, few studies have focused exclusively on the totally endoscopic robotic approach. We sought to compare outcomes for patients undergoing totally endoscopic robotic mitral valve surgery with aortic occlusion via EABO and transthoracic clamping after a period where EABO was unavailable required us to use the transthoracic clamp. Retrospective review identified 113 patients who underwent robotic mitral valve surgery at our facility between 2019 and 2021 with EABO (n = 71) or transthoracic clamping (n = 42). Relevant data were extracted and compared. Preoperative characteristics were similar other than a higher rate of coronary artery disease [EABO: 69.0% (49/71) vs clamp: 45.2% (19/42), p = .02] and chronic lung disease [EABO: 38.0% (27/71) vs clamp: 9.5% (4/42), p < .01] in the EABO group. Median percutaneous cardiopulmonary bypass time, operative time, and cross-clamp time were comparable. Similar rates of postoperative bleeding complications were observed, and no aortic complications were observed. One patient in each group underwent conversion to an open approach. 30-day mortality and readmission rates were comparable. EABO and transthoracic clamp were associated with similar bleeding and aortic outcomes, and mortality and readmission rates were comparable at thirty days postoperatively. Our findings support the comparable safety of the two techniques, which is well documented in studies encompassing all MIMVS techniques, within the specific context of the totally endoscopic robotic approach.

Endoscopic Aortic Valve Replacement: Initial Outcomes of Isolated and Concomitant Surgery

BACKGROUND

The applicability of totally endoscopic surgical aortic valve replacement (AVR) in multivalve operations is unknown. This study describes an approach and perioperative outcomes of totally endoscopic isolated and concomitant AVR using various valve types.

METHODS

A total of 216 patients (114 male; mean age, 71.3 ± 11.3 years) underwent totally endoscopic AVR from May 2017 to October 2022 in a tertiary care center. The 3-port technique was used: a 3- to 4-cm main port without rib spreading, a 10-mm 3-dimensional endoscopic port, and a 5-mm left-hand port with femoral cannulations. Sutures were hand tied with a knot pusher. Descriptive analyses compared perioperative outcomes between patients with or without concomitant procedures.

RESULTS

Of 216 patients, concomitant surgery was performed in 33 (15.2%) patients. Of the 33, 21 (63.6%) had a concomitant mitral procedure. A stented bioprosthesis was implanted in 165 (76.3%) patients, a mechanical valve in 22 (10.2%) patients, and a rapid deployment or sutureless valve in 29 (13.4%) patients. Median operation time and aortic cross-clamp time were 175 minutes (interquartile range; 150-194 minutes) and 78 minutes (interquartile range; 67-92 minutes) for isolated AVR, respectively. Thirty-day mortality occurred in 1 patient (0.5%). Two patients (0.9%) had conversion to sternotomy. Major neurologic events occurred in 3 patients (1.4%). The major adverse event rate was similar between patients with or without concomitant procedures.

CONCLUSIONS

Endoscopic AVR can safely address concomitant valve diseases.

Robotic and endoscopic mitral valve repair for degenerative disease

BACKGROUND

Minimally invasive mitral valve repair has been proven to be a safe alternative to open sternotomy and may be accomplished through classic endoscopic and robotic endoscopic approaches. Outcomes across different minimally invasive techniques have been insufficiently described. We compare early and late clinical outcomes across matched patients undergoing robotic endoscopic and classic endoscopic repair.

METHODS

From 2011 to 2020, 786 patients underwent minimally invasive mitral surgery, from which we were able to generate 124 matched patients (62 patients in each cohort). Clinical results were then compared between the two matched populations. Survival analysis was used to compare freedom from mortality to 10 years among matched classic endoscopic and robotic endoscopic mitral valve repair cohorts and to calculate freedom from moderate or severe mitral insufficiency at latest follow-up. Histograms of cardiopulmonary bypass (CPB) and aortic cross-clamp times were constructed, and mean bypass and cross-clamp times were compared between classic endoscopic and robotic endoscopic cohorts.

RESULTS

There was no difference in early or late mortality at 10 years in either cohort. Freedom from moderate or severe mitral regurgitation or mitral valve replacement at last echocardiogram was 86.4% vs. 73.5% at 10 years, P=0.97. Patients undergoing robotic endoscopic mitral repair had a significantly longer CPB run when compared to the classic endoscopic cohort, with 148 min of CPB in the robotic endoscopic cohort compared to 133 min in the classic endoscopic group, P=0.03. Overall post-operative length of stay was not statistically significant between the robotic endoscopic and classic endoscopic groups, 6.3±0.5 and 6.0±0.3 days, respectively. No patients in either cohort developed renal failure or wound infection. The classic endoscopic group had a slightly higher risk of prolonged ventilation when compared to the robotic endoscopic group, with three classic endoscopic patients remaining intubated >8 hours post-operatively, compared to a single patient in the robotic endoscopic group. There were no unplanned reoperations in either group. Rates of postoperative stroke were comparable between groups (three in the classic endoscopic cohort, and two in the robotic endoscopic cohort).

CONCLUSIONS

Index mitral valve surgery via a classic endoscopic approach yields similar clinical outcomes when compared to robotic endoscopic surgery. We demonstrate that both classic endoscopic and robotic endoscopic approaches allow repair of degenerative mitral valves with excellent short- and medium-term outcomes in a tertiary referral center.

Robotically assisted mitral valve surgery-experience during the restart of a robotic program in Germany

BACKGROUND

Following the first robotic-assisted mitral valve operations in Paris and Leipzig, the era of this innovative technique expired after a few years in Germany. At that time, the main arguments against robotic surgery within the German cardiac surgical community were low cost effectiveness and operative time utilization. Encouraged by favorable results, we re-started our robotic-assisted cardiac program as the first and only center in Germany in 2019.

METHODS

Between July 2019 and December 2021, 329 patients underwent robotic-assisted operations using the daVinci Xi system, including mitral and coronary operations, myxoma resection, atrial septal closure and stand-alone atrial ablation. Of these, 182 patients underwent mitral valve repair (MVR). Isolated MVR was performed in 96 patients (isolated mitral group, IMG) and 86 underwent concomitant operations, such as tricuspid valve repair, Cox-Maze IV, pulmonary vein isolation (PVI) and left atrial appendage (LAA) closure (complex mitral group, CMG). For cost analysis, the InEK calculation for 2020 was used.

RESULTS

MVR was successful (MR ≤I°) in all patients. Patients in the IMG had a hospital mortality of 1.0% (O/E ratio 0.69) and stroke rate of 2.0%. Four patients (4.0%) required conversion to sternotomy and 6 patients (6.0%) needed re-exploration for bleeding. Mortality was 3.5% (O/E ratio 0.74) in the CMG and stroke rate 2.3%. The conversion and bleeding rates were 4.6% each, respectively. The steep learning curve resulted in significant reduction of operating times greater than 25% in the IMG. Comparing the results of robotic-assisted procedures to minimally-invasive mitral surgeries (MIMS) in 2020, a reduction in length of hospital stay of almost 25% resulted in significantly lower costs for the medical service and medical infrastructure. However, within the German health service, overall cost for robotic-assisted procedures were more expensive compared to MIMS by 5% due to higher material costs.

CONCLUSIONS

The re-establishment of robotic mitral valve surgery in Germany was successful with comparable results to MIMS in terms of mortality and morbidity. Robotic-assisted cardiac operations resulted in accelerated postoperative recovery with significant shortening of the hospital length of stay. The avoidance of liver injury is one focus for the future.

Historical evolution of robot-assisted cardiac surgery: a 25-year journey

Many patients and surgeons today favor the least invasive access to an operative site. The adoption of robot-assisted cardiac surgery has been slow, but now has come to fruition. The development of modern surgical robots took surgeons close collaboration with mechanical, electrical, and optical engineers. Moreover, the necessary project funding required entrepreneurs, federal grants, and venture capital. Non-robotic minimally invasive cardiac surgery paved the way to the application of surgical robots by making changes in operative approaches, instruments, visioning modalities, cardiopulmonary perfusion techniques, and especially surgeons' attitudes. In this article, the serial development of robot-assisted cardiac surgery is detailed from the beginning and through clinical application. Included are references to the historical and most recent clinical series that have given us the evidence that robot-assisted cardiac surgery is safe and provides excellent outcomes. To this end, in many institutions these procedures now have become a new standard of care. This evolution reflects Sir Isaac Newton's famous 1676 quote when referring to Rene Descartes, "If have seen further [sic] than others, it is by standing on the shoulders of giants".

Minimally invasive mitral valve surgery with or without robotics: Examining the evidence

Minimally invasive mitral valve surgery can be performed with or without robotic assistance. In this issue of the journal, Zheng et al. compare between these two approaches in a propensity‐matched study over a 5‐year period and show that the two techniques have similar successful short and mid‐term outcomes. Although we are proponents of the robotic approach, we agree with their conclusions and discuss in this commentary some of the previously published studies that have shown similar findings.

Evaluation of robotic-assisted mitral surgery in a contemporary experience

AIMS

To evaluate the safety/effectiveness of a recently established robotic-assisted mitral surgery program.

METHODS

Cohort study with prospective collection of clinical data of 59 consecutive recipients (May 2019-August 2021) of robotic-assisted (fourth-generation platform, DaVinci X) mitral valve repair for degenerative disease, using a totally endoscopic technique. Patients' selection was based on defined anatomical and clinical criteria. We established a dedicated multidisciplinary protocol to facilitate postoperative fast-tracking, and a systematic in-house clinical and echocardiographic follow-up at 3, 6, and 12 postoperative months.

RESULTS

All patients (89.8% men, average age 58 ± 12 years) received mitral valve repair; there was no operative mortality, one conversion to sternotomy (1.7%) and one stroke (1.7%). Extubation within the operative theater occurred in 28.8%; average mechanical ventilation time and ICU stay was 2.8 ± 4.1 and 32.5 ± 15.8 h (after exclusion of one outlier, learning-curve period, suffering from perioperative stroke); average postoperative hospital stay was 6.8 ± 3.4 days and 96.6% of patients were discharged home. One patient was transfused (1.7%); there were no other complications. Follow-up revealed stability of the results of mitral repair, with one (1.7%) persistent (>2+/4+) mitral regurgitation, and stability of coaptation height over time. We observed optimal functional results (class I was 98% at 3 months and 96% at 12 months). Quarterly case load consistently increased during the experience.

CONCLUSION

This initial experience suggests the reliability and clinical safety of a recently established local robotic-assisted mitral surgery. This strategy can facilitate faster postoperative recovery, and its positioning in the therapeutic armamentarium needs to be defined.

Robotic mitral valve repair: A single center experience over a 7-year period

BACKGROUND

We report the clinical and echocardiographic results of our experience in robotic mitral valve repair over a 7-year period. The outcomes of the earliest and the latest patients will be compared.

METHODS

Between March 2012 and October 2019, 226 patients underwent robotic mitral valve repair for severe mitral regurgitation in a single institution. The first 113 patients (Group 1) were operated between March 2012 and September 2015 and the last 113 patients (Group 2) between October 2015 and October 2019. Conventional techniques employed in open surgery were used. Clinical and echographic follow-up were 96.0% and 94.2% complete, respectively.

RESULTS

Successful mitral repair was achieved in all cases with no hospital mortality. The overall survival rate was 92.7 ± 2.8% and 91.0 ± 3.2% at 3 and 7 years, respectively, with no in between groups difference (p = 0.513). The overall freedom from mitral reoperation was 97.4 ± 1.2% at 3 and 7 years and was similar in both groups (p = 0.276). Freedom from mitral regurgitation Grade 2+ at 3 and 7 years were 89.1 ± 2.6% and 87.9 ± 2.8%, respectively, with no significant difference between groups (p = 0.056).

CONCLUSIONS

Developing a robotic mitral repair program can be done without compromising the safety and efficacy of repair. After a well-conducted training, robotic approach allows to perform simple and complex mitral repair using similar techniques as in conventional approach and without additional risk for the patient.

Multi-Spectrum Robotic Cardiac Surgery: Early Outcomes

Objective

The robotic cardiac surgery program at our current institution began in 2013 with an experienced and dedicated team. This review analyzes early outcomes in the first 1103 patients.

Methods

We reviewed all robotic procedures between July 2013 and February 2021. Primary outcomes were mortality and perioperative morbidity. Our robotic approach is totally endoscopic for all cases: off-pump for coronary and epicardial procedures, and on-pump with the endoballoon for mitral valve and other intracardiac procedures.

Results

There were 1103 robotic-assisted cardiac surgeries over 7 years. A total of 585 (53%) were off-pump totally endoscopic coronary artery bypasses, 399 (36%) intracardiac cases (including isolated and concomitant mitral valve procedures, isolated tricuspid valve repair, CryoMaze, atrial or ventricular septal defect repair, benign cardiac tumor, septal myectomy, partial anomalous pulmonary venous drainage, and aortic valve replacement); 80 (7%) epicardial electrophysiology-related procedures (epicardial atrial fibrillation ablation, left atrial appendage ligation, lead placement, and ventricular tachycardia ablation); and 39 (4%) other epicardial procedures (pericardiectomy, unroofing myocardial bridge). Mortality was 1.2% (observed/expected ratio, 0.7). In the totally endoscopic coronary artery bypass and intracardiac groups, mortality was 1.0% (observed/expected, 0.6) and 1.5% (observed/expected, 0.87), respectively. There were 8 conversions to sternotomy (0.7%) and 24 (2.2%) take-backs for bleeding. Mean hospital and intensive care unit lengths of stay were 2.74 ± 1.26 days and 1.28 ± 0.57 days, respectively.

Conclusions

This experience demonstrates that a robotic endoscopic approach can safely be used in a multitude of cardiac surgical procedures both on- and off-pump with excellent early outcomes. An experienced surgeon and team are necessary. Longer-term follow-up is warranted.

Robotic Cardiac Surgery in Europe: Status 2020

Background

European surgeons were the first worldwide to use robotic techniques in cardiac surgery and major steps in procedure development were taken in Europe. After a hype in the early 2000s case numbers decreased but due to technological improvements renewed interest can be noted. We assessed the current activities and outcomes in robotically assisted cardiac surgery on the European continent.

Methods

Data were collected in an international anonymized registry of 26 European centers with a robotic cardiac surgery program.

Results

During a 4-year period (2016–2019), 2,563 procedures were carried out [30.0% female, 58.5 (15.4) years old, EuroSCORE II 1.56 (1.74)], including robotically assisted coronary bypass grafting (n = 1266, 49.4%), robotic mitral or tricuspid valve surgery (n = 945, 36.9%), isolated atrial septal defect closure (n = 225, 8.8%), left atrial myxoma resection (n = 54, 2.1%), and other procedures (n = 73, 2.8%). The number of procedures doubled during the study period (from n = 435 in 2016 to n = 923 in 2019). The mean cardiopulmonary bypass time in pump assisted cases was 148.6 (63.5) min and the myocardial ischemic time was 88.7 (46.1) min. Conversion to larger thoracic incisions was required in 56 cases (2.2%). Perioperative rates of revision for bleeding, stroke, and mortality were 56 (2.2%), 6 (0.2 %), and 27 (1.1%), respectively. Median postoperative hospital length of stay was 6.6 (6.6) days.

Conclusion

Robotic cardiac surgery case numbers in Europe are growing fast, including a large spectrum of procedures. Conversion rates are low and clinical outcomes are favorable, indicating safe conduct of these high-tech minimally invasive procedures.

Robotic Mitral Valve Repair: A Decade of Experience with Echocardiographic Follow-up

BACKGROUND

Surgical approaches for mitral valve (MV) disease have evolved with the aim of developing minimally invasive techniques. While the safety of robotic procedures has been documented, there are limited data on long-term echocardiographic follow-up. This review demonstrates outcomes of 11 years of robotic MV repair at a single, tertiary institution.

METHODS

From 2008 to 2019, 843 patients underwent robotic MV repair at our institution. Repeated measures generalized least squares (GLS) modelling was used to assess the echocardiographic changes over time.

RESULTS

The median age was 58 years (IQR 50.8, 65.5) (591 males, 70.1%). Mechanism of MR was posterior leaflet prolapse in 479 (56.8%), bileaflet prolapse in 325 (38.6%), and anterior leaflet prolapse in 36 (4.3%). There were 3 early deaths (0.4%) and 24 early reoperations (2.8%). Echocardiographic follow up demonstrated left ventricular end systolic and diastolic dimensions, left atrial volume index and pulmonary pressure all continuously improvement up to 2 years postoperatively. Ejection fraction immediately declined postoperatively but then gradually improved to near normal over 2 years. Survival and freedom from reoperation at 10 years were 93% and 92.6%, respectively. When surveyed after dismissal, 93.4% reported their activity level at or above their peers and 93.3% reported no activity limitation from cardiac symptoms.

CONCLUSIONS

Robotic MV repair is safe and effective with excellent long-term results, including echocardiographic parameters that demonstrated early improvement in cardiac chamber size and maintenance of postoperative cardiac function. Exceedingly low mortality rates and freedom from reoperation are comparable to those of the standard open repair.

Minimally invasive gastrointestinal surgery: From past to the future

The improvement of the science and art of surgery began over 150 years ago. Surgical core tasks, “cutting and sewing” with hand and direct contact with the organs, have remained the same. However, in the 21st century, there has been a shifting paradigm in the methodology of surgery. The joint union between innovators, engineers, industry, and patient demands resulted in minimally invasive surgery (MIS). This method has influenced the techniques in every aspect of abdominal surgery, such as surgeons are not required to direct contact or see the structures on which they operate. Advances in the endoscope, imaging, and improved instrumentations convert the essential open surgery into the endoscopic method. Furthermore, computers and robotics show a promising future to facilitate complex procedures, enhance accuracy in microscale operations, and develop a simulation to improve the ability to face sophisticated approaches. MIS has been replacing open surgery due to improved survival, fewer complications, and rapid recoveries in recent years. Minimally invasive surgery's further research in diagnostic and therapeutic modalities is under investigation to achieve genuinely “noninvasive” surgery. Thus, MIS has gained interest in recent days and has been improving with promising outcomes.

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Minimally invasive surgery has interfered with multiple aspects of the surgical approach.

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Advancement in the endoscope, imaging, and other instrumentations shifting the current methodological conventional surgery.

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The benefit over risk is the promising primary outcome to achieve an exceptional quality of life.

Comparison of Perioperative Outcomes Using the da Vinci S, Si, X, and Xi Robotic Platforms for BABA Robotic Thyroidectomy

Background and Objectives: Robotic thyroidectomy via the bilateral axillo-breast approach (BABA), first introduced in Korea in 2008, has become a standard method of thyroid removal worldwide. The introduction of robotic surgical systems has enabled more patients to benefit from BABA robotic thyroidectomy, with good postoperative and excellent cosmetic results. To date, no studies have compared the benefits of the four currently available da Vinci robotic systems (S, Si, X, and Xi) for BABA robotic thyroidectomy. To determine the da Vinci model most suitable for BABA robotic thyroidectomy, the present study compared the perioperative outcomes in patients who underwent BABA robotic thyroidectomy using the four da Vinci models. Materials and Methods: This retrospective study evaluated outcomes in patients (n = 750) who underwent BABA robotic thyroidectomy using the four da Vinci systems from 2013 to 2019. The clinicopathologic data, including operation time, were compared. Substudy A compared the da Vinci models S and Si from 2013 to 2017, and substudy B compared models Si, X, and Xi from 2018 to 2019. Results: Substudy A, comparing the da Vinci S and Si systems, found no statistically significant differences between the two groups, whereas substudy B found that operation time was shorter in patients who underwent BABA robotic thyroidectomy with the da Vinci Xi system than with the Si and X systems. Conclusions: The da Vinci model Xi system can benefit patients undergoing BABA robotic thyroidectomy by shortening the operation time.

The role of robotic technology in minimally invasive surgery for mitral valve disease

INTRODUCTION

Robotic mitral valve surgery has developed for more than 20 years. The main purpose of robotic assistance is to use multiwristed instruments for surgical endothoracic maneuvers on the mitral valve without opening the chest. The surgeon controls the instruments remotely from a console but is virtually immersed into the operative field.

AREAS COVERED

This review outlines indications and contraindication for the procedure. Intra- and postoperative results as available in the literature are reported. Further areas focus on the technological development, advances in surgical techniques, training methods, and learning curves. Finally we give an outlook on the potential future of this operation.

EXPERT OPINION

Robotic assistance allows for the surgically least invasive form of mitral valve operations. All variations of robotic mitral valve repair and replacement are feasible and indications have recently been broadened. Improved dexterity of instrumentation, 3D and HD vision, introduction of a robotic left atrial retractor, and adjunct technology enable most complex forms of minimally invasive mitral valve interventions through ports on the patient's right chest wall. Application of robotics results in significantly reduced surgical trauma while maintaining safety and outcome standards in mitral valve surgery.

Commentary: Robotic Techniques in Cardiac and Thoracic Surgery (Innovations, May/June 2020)

This is a response to the papers in the May/June issue of Innovations focused on robotic techniques in cardiac and thoracic surgery. Successful robotic surgery relies on a high level of preparation and communication from each member of the operating room. The lack of a team approach can result in not only failure to establish and/or sustain a robotic program, but more importantly, in serious consequences at the detriment to patient care and safety. While these are salient points, the authors of this commentary wish to highlight that the first robot-assisted mitral valve surgery in North America was performed at NYU Langone Health using the Zeus robotic surgical system. Although that robotic platform had several disadvantages that limited its clinical advancement, an appreciation for this history in robotic cardiac surgery is important if we as cardiothoracic surgeons seek to move toward a future of expanding robotic surgery within the ever-changing landscape of cardiac surgery.

Robot-assisted beating-heart surgery for atrial septal defect repair in a case of situs inversus totalis with dextrocardia

BACKGROUND

This paper describes a case of a patient with situs inversus totalis (SIT) and dextrocardia in which robotic atrial septal defect (ASD) repair was successfully performed in a beating heart.

METHODS AND RESULTS

A 45-year-old female patient who had SIT and dextrocardia was diagnosed with secundum ASD 5 years ago. Because of progressive dyspnoea, fatigue, and obvious cough, she came to our hospital for surgical treatment. Transthoracic echocardiography showed the defect located in the middle and lower segments of the atrial septum with a maximum diameter of 27 mm, with a left-to-right shunt. Transcatheter ASD closure could not be performed because there was not enough tissue surrounding the defect. After communicating with the patient, we performed robotic ASD repair in a beating heart using the da Vinci surgical system. The operation was successful, and the patient recovered quickly.

CONCLUSION

As a minimally invasive approach, robotic cardiac surgery has many advantages and is feasible and safe in suitable patients.

Robotic Transanal Total Mesorectal Excision (RTaTME): State of the Art

Total mesorectal excision (TME) is the gold standard technique for the surgical management of rectal cancer. The transanal approach to the mesorectum was introduced to overcome the technical difficulties related to the distal rectal dissection. Since its inception, interest in transanal mesorectal excision has grown exponentially and it appears that the benefits are maximal in patients with mid-low rectal cancer where anatomical and pathological features represent the greatest challenges. Current evidence demonstrates that this approach is safe and feasible, with oncological and functional outcome comparable to conventional approaches, but with specific complications related to the technique. Robotics might potentially simplify the technical steps of distal rectal dissection, with a shorter learning curve compared to the laparoscopic transanal approach, but with higher costs. The objective of this review is to critically analyze the available literature concerning robotic transanal TME in order to define its role in the management of rectal cancer and to depict future perspectives in this field of research.

Comparison of robotic and conventional sternotomy in redo mitral valve surgery

BACKGROUND/PURPOSE

Redo operation for mitral valve surgery carries higher risks than first time cardiac surgery. The adhesion between sternum and heart, and also the complexity of second time operation make the redo operation more difficult. The robotic surgery carries some benefit in terms of magnification, assisted by the scope view and precise movement of the instruments. We compared the results of our robotic redo mitral valve surgeries with those of conventional re-sternotomy.

METHODS

Medical records of patients who underwent redo mitral valve surgeries between 2012 and 2019 at our hospital were retrospectively analyzed. Demographic data, patients' medical histories, presenting symptoms, image analyses, echocardiogram data, operative procedures and postoperative clinical outcomes were collected through chart review.

RESULTS

A total of 67 redo mitral valve surgeries, including 23 robotic and 44 re-sternotomy procedures were performed. There were no differences in age, previous operation times, and intervals to previous surgery. Comorbidities of both groups were similar. There was no surgical mortality in the robotic group, and it was 9.0% in the re-sternotomy group (p = 0.287). Operation time was shorter in the robotic group (176 vs. 321 min; robotic vs. re-sternotomy, p＝0.0279). Blood transfusion was lower in the robotic group (1 vs. 2 units; robotic vs. re-sternotomy, p = 0.01189). The ventilation time, ICU stay time, and recheck bleeding rate were similar in both groups.

CONCLUSIONS

In select patients, robotic redo mitral valve surgery is safe and feasible. It could offer low operative mortality. It is associated with shorter operative times, than re-sternotomy and provides equal immediate operative results.

Computer-assisted valve in valve in a deteriorated Mosaic valve using a library of bioprostheses

Valve-in-valve (ViV) procedures have emerged from an off-label procedure to a safe and efficient alternative to redo aortic valve replacement in the treatment of symptomatic structural valve deterioration (SVD). During ViV procedures, optimal placement of the transcatheter heart valve (THV) inside the degenerated bioprosthesis is of paramount importance regarding complications such as device embolization, coronary obstruction, periprosthetic regurgitation, residual gradients, and mitral valve injury, but also for the attainment of optimal hemodynamics. In the case of the Mosaic (Medtronic, Minneapolis, MN) valve, the limited radiopaque landmarks represent a challenge to a reproducible, optimal implantation. Such implantation may require multiple contrast injections and transesophageal echocardiogram (TEE) guidance. We herein describe a computer-assisted ViV procedure inside a deteriorated Mosaic valve, achieving reproducible optimal placement using a preacquired library of bioprostheses 3D models. Our approach suggests an evolving paradigm in ViV procedures, from safe and efficient toward optimal therapy for symptomatic SVD.

Totally endoscopic mitral valve surgery: early experience in 188 patients

INTRODUCTION

Totally endoscopic technique has been widely used in cardiac surgery, and minimally invasive totally endoscopic mitral valve surgery has been developed as an alternative to median sternotomy for many patients with mitral valve disease. In this study, we describe our experience about a modified minimally invasive totally endoscopic mitral valve surgery and reported the preliminary results of totally endoscopic mitral valve surgery. The aim of this retrospective study is to evaluate the results of totally endoscopic technique in mitral valve surgery.

MATERIAL AND METHODS

We retrospectively reviewed the profiles of 188 patients who were treated for mitral valve disease by modified totally endoscopic mitral valve surgery at our institution between January 2019 and December 2020. The procedure was performed under endoscopic right minithoracotomy and with femoro-femoral cannulation using the single two-stage venous cannula.

RESULTS

A total of 188 patients underwent total endoscopic mitral valve surgery. Fifty-six patients had concomitant tricuspid valvuloplasty, 11 patients underwent concomitant ablation of atrial fibrillation and atrial septal defect repair was performed in three patients. Only one patient postoperatively died of multi-organ failure. Two patients were converted to median sternotomy. Except for one patient underwent operation to stop the bleeding from the incision site, no other serious complications nor reintervention occurred during the follow-up period.

CONCLUSIONS

The modified totally endoscopic mitral valve surgery performed at our institution is technically feasible and safe with the same efficacy as reported studies.

Unilateral Pulmonary Edema After Robotically Assisted Mitral Valve Repair Requiring Veno-Venous Extracorporeal Membrane Oxygenation

Unilateral pulmonary edema (UPE) is an uncommon yet potentially life-threatening complication of minimally invasive cardiac surgery (MICS). Most frequently described after robotically assisted mitral valve (MV) repair, it is characterized by right lung edema, hypoxemia, hypercapnia, pulmonary hypertension, and hemodynamic instability beginning minutes-to-hours after separation from cardiopulmonary bypass (CPB). The authors describe a severe case with refractory hypoxemia requiring veno-venous (VV) extracorporeal membrane oxygenation (ECMO) after robotically assisted MV repair.

Minimally Invasive Mitral Surgery: Patient Selection and Technique

In most patients, minimally invasive approaches to mitral valve surgery are technically possible. However, in practice, patient selection is critical to mitigate safety concerns when performing the procedure. In this article, we describe our approach to preoperative assessment for minimally invasive mitral valve surgery candidacy, as well as discussing the technical aspects of procedure execution.

Robotic mitral valve surgery: a review and tips for safely negotiating the learning curve

Totally endoscopic robotic mitral valve repair represents the least invasive surgical therapy for mitral valve disease. Comparative results for robotic mitral valve surgery against sternotomy are impressive, repeatedly demonstrating shorter hospital stay, faster return to normal activities, less morbidity and equivalent mortality and mid-term durability. We lack data comparing robotic approaches to totally endoscopic minimally invasive mitral valve surgery using 3D vision platforms. In this review, we explore the advantages and disadvantages of robotic mitral valve surgery and share technical tips that we have learned to help teams embarking on their robotic journey. We consider factors necessary for the successful implementation of a robotic programme including the importance of training a dedicated team, with the common goal to avoid any compromise in either patient safety or repair quality during the learning curve. As experience grows with robotic techniques and more cardiac surgeons become proficient with this innovative technology, the volume of robotic cardiac procedures around the world will increase helped by the introduction of new robotic systems and patient demand. Well informed patients will increasingly seek out the opportunity of robotic valve reconstruction in reference centres in the hands of a few highly experienced robotic surgeons.

Robotic versus port-access mitral repair: A propensity score analysis

BACKGROUND

Port-access (PORT) and robotic (ROBO) mitral repair are well established, but differences in patient selection and outcomes are not well documented.

METHODS

A retrospective analysis was performed on 129 ROBO and 628 PORT mitral repairs at one institution. ROBO patients had 4 cm nonrib spreading incisions with robotic assistance, while PORT patients had 6-8 cm rib spreading incisions with thoracoscopic assistance. Propensity score analysis matched patients for differences in baseline characteristics.

RESULTS

Unmatched ROBO patients were younger (58 ± 11 vs. 61 ± 13, p = .05), had a higher percentage of males (77% vs. 63%, p = .003) and had less NYHA Class 3-4 symptoms (11% vs. 21%, p < .01), less atrial fibrillation (19% vs. 29%, p = .02) and less tricuspid regurgitation (14% vs. 24%, p = .01). Propensity score analysis of matched patients showed that pump time (275 ± 57 vs. 207 ± 55, p < .0001) and clamp time (152 ± 38 vs. 130 ± 34, p < .0001) were longer for ROBO patients. However, length of stay, postoperative morbidity, and 5-year survival (97 ± 1% vs. 96 ± 3%, p = .7) were not different. For matched patients with degenerative valve disease, 5-year incidence of mitral reoperation (3 ± 2% vs. 1 ± 1%), severe mitral regurgitation (MR) (6 ± 4% vs. 1 ± 1%), or ≥2 + MR (12 ± 5% vs. 12 ± 4%), were not significantly different between ROBO versus PORT approaches. Predictors of recurrent moderate MR were connective tissue disease, functional etiology, and non-White race, but not surgical approach.

CONCLUSIONS

In this first comparison out to 5 years, robotic versus port-access approach to mitral repair had longer pump and clamp times. Perioperative morbidity, 5-year survival, and 5-year repair durability were otherwise similar.

An analysis of the learning curve for robotic-assisted mitral valve repair

BACKGROUND

Many cardiac surgeons receive training for sternotomy-based cardiac surgical operations in residency programs and only a few education programs offer training specifically in minimally invasive cardiac surgery. In this report, we aimed to search and analyze the learning curve for robotic-assisted mitral valve (MV) repair in cardiac surgeons.

METHOD

Between January 2010 and July 2019, 60 robotic-assisted isolated MV repair surgeries were performed with DaVinci Robotic Systems in our center. Different kinds of surgical techniques were used. The assessment of the learning curve was based on cardiopulmonary bypass (CPB) and transthoracic aortic clamp (CC) times.

RESULT

There were 23 (38.3%) men and 37 (61.7%) women with a mean age of 48.3 years. The lesions of the MV were posterior leaflet prolapsus (n = 42, 70.0%), anterior leaflet prolapsus (n = 8, 13.3%), Barlow disease (n = 3, 5%), and annular dilatation (n = 7, 11.6%). The patients underwent notochordal implantation (n = 27, 45%), quadrangular or triangular resection (n = 23, 38.3%), isolated ring annuloplasty (n = 7, 11.7%), resection, and leaflet reduction (n = 2, 3.3%) or edge to edge repair (n = 1, 1.7%). The maturation of the learning curve appeared to be about 30 cases. The statistical analysis showed that the mean CPB and CC times for the first 30 cases were greater compared with the 30 after learning curve (155.3 vs. 118.9 min [p = .00], 102.3 vs. 80 min [p = .00], respectively). There was no case of conversion to open surgery. No perioperative mortality was observed.

CONCLUSION

The maturation of the learning curve for robotic-assisted MV repair appeared to be about 30 cases in our group of patients. This study had encouraging results for surgeons who desire to start a robotic mitral surgery program.

A conservative screening algorithm to determine candidacy for robotic mitral valve surgery

OBJECTIVE

Patient selection for robotically assisted mitral valve repair remains controversial. We assessed outcomes of a conservative screening algorithm developed to select patients with degenerative mitral valve disease for robotic surgery.

METHODS

From January 2014 to January 2019, a screening algorithm that included transthoracic echocardiography and computed tomography scanning was rigorously applied by 3 surgeons to assess candidacy of 1000 consecutive patients with isolated degenerative mitral valve disease (age 58 ± 11 years, 67% male) for robotic surgery. Screening results and hospital outcomes of those selected for robotic versus sternotomy approaches were compared.

RESULTS

With application of the screening algorithm, 605 patients were selected for robotic surgery. Common reasons for sternotomy (n = 395) were aortoiliac atherosclerosis (n = 74/292, 25%), femoral artery diameter <7 mm (n = 60/292, 20%), mitral annular calcification (n = 83/390, 21%), aortic regurgitation (n = 100/391, 26%), and reduced left ventricular function (n = 126/391, 32%). Mitral valve repair was accomplished in 996. Compared with sternotomy, patients undergoing robotic surgery had less new-onset atrial fibrillation (n = 144/582, 25% vs n = 125/373, 34%; P = .002), fewer red blood cell transfusions (n = 61/601, 10% vs 69/395, 17%; P < .001), and shorter hospital stay (5.2 ± 2.9 days vs 5.9 ± 2.1 days; P < .001). No hospital deaths occurred, and occurrence of postoperative stroke in the robotic (n = 3/605, 0.50%) and sternotomy (n = 4/395, 1.0%; P = .3) groups was similar.

CONCLUSIONS

This conservative screening algorithm qualified 60% of patients with isolated degenerative mitral valve disease for robotic surgery. Outcomes were comparable with those obtained with sternotomy, validating this as an approach to select patients for robotic mitral valve surgery.

Minimally invasive mitral valve repair

Minimally invasive mitral valve (MV) repair is being increasingly performed over the last 2 decades due to the constantly growing patient demand, since it offers a shorter recovery, less restriction and faster return to normal physical activities, reduction in pain, and superior cosmetic results. However, such procedures have to be performed through small incisions which limit visualization and the freedom of movement of the surgeon, in contrast to conventional operations that are performed through a sternotomy. Therefore, special long surgical instruments are required, and visualization is usually enhanced with advanced port-access two-dimensional (2D) or three-dimensional (3D) thoracoscopic cameras. This makes performance of a minimally invasive MV repair more challenging for the surgeon and is thereby associated with a steep learning curve. Nonetheless, the vast majority of patients who require MV repair are usually good candidates for this less invasive technique, though adequate patient selection is of utmost importance for success. Concomitant cardiac procedures such as ablation surgery for atrial fibrillation or right-sided interventions such as tricuspid valve surgery, heart tumor resection, and atrial septal defect closure can easily be performed using this approach. Short- and long-term results after minimally invasive MV repair are excellent and comparable with those achieved through a sternotomy approach. There are few drawbacks associated with minimally invasive MV repair such as the high technical demands of working through a constrained space and development of complications associated with peripheral cannulation and seldom unilateral pulmonary edema. Nonetheless, high-volume centers have been able to achieve similar operating times, postoperative complication rates, and mid-/long-term outcomes to those obtained through conventional sternotomy. Up-to-date evidence is needed in order to improve recommendations supporting minimally invasive MV repair. Future innovations should concentrate on decreasing complexity and improving reproducibility of minimally invasive procedures in low-volume centers.

Analysis of the logistical, economic and minimally invasive cardiac surgical training difficulties in India

Significant advances have been made in minimally invasive cardiac surgery (MICS) over the past 3 decades. However, the acceptance and practice of MICS continue to remain low in the developing world owing to several challenges. This study aimed to analyse the logistical, economic and training difficulties in MICS with a special focus on the Indian scenario. A systematic review of the current literature on MICS with an emphasis on these challenges was performed. MICS has been shown to have clear cost-benefit advantage that stems from shorter ICU and hospital stay, lesser transfusion requirements and avoidance of sternal wound complications. However, only limited reports are currently available detailing the economic and training challenges for the application of MICS in the developing world, particularly India. Though several challenges exist in widening MICS practice in India, these can be overcome through a target-oriented approach.

Totally endoscopic mitral valve repair using a three-dimensional endoscope system: initial clinical experience in Korea

Background

The lack of depth perception is a significant challenge in two-dimensional (2D) video-assisted/directed minimally invasive cardiac surgery (MICS). Accordingly, restoration of stereoscopic vision is potentially beneficial, and we present a single center experience of a three-dimensional (3D) endoscope system in cardiac surgery without robotic assistance.

Methods

We retrospectively reviewed the initial 40 consecutive patients who received totally endoscopic mitral valve (MV) repair using a 3D endoscope system between September 2017 and April 2019. The preoperative characteristics, operative data, and immediate postoperative outcomes, including echocardiographic results, were investigated.

Results

In all the patients (n=40, 100%), successful MV repair using the standard repair techniques was achieved regardless of the location of the MV lesion as follows: anterior leaflet (n=8, 20.0%), posterior leaflet (n=15, 37.5%), and both leaflets (n=17, 42.5%). Concomitant tricuspid ring annuloplasty (n=9, 22.5%) and atrial fibrillation ablation (n=7, 17.5%) were performed. There was no mortality. One reoperation for bleeding occurred. One patient had a sternotomy conversion due to aortic dissection immediately after declamping. Postoperative mitral regurgitation (MR) grades were none or trace in 38 patients (95.0%) and mild in 2 patients (5.0%) on predischarge echocardiography.

Conclusions

Totally endoscopic MV repair using a 3D endoscope system is technically feasible and safe on the basis of this initial experience.

A case of abdominal bleeding after mitral valvuloplasty assisted by da Vinci robotic surgery

A 66-year-old female patient was admitted with abdominal bleeding as an unexpected complication of robotic surgery. Assessments included the patient's medical history, physical examination, laboratory data, and abdominal ultrasound scan results. In our case, laparotomy revealed an injury to the diaphragm and liver of the patient caused by the previous robotic surgery. In conclusion, although abdominal bleeding is a rare condition, it should be taken into consideration as a complication of robotic cardiac surgery.

Robotic Mitral Valve Surgey Combined with Left Atrial Reduction and Ablation Procedures

INTRODUCTION

This study aimed to evaluate the feasibility and efficacy of robotically assisted, minimally invasive mitral valve surgery combined with left atrial reduction for mitral valve surgery and elimination of atrial fibrillation (AF).

METHODS

Eleven patients with severe mitral regurgitation, AF, and left atrial enlargement who underwent robotic, minimally invasive surgery between May 2013 and March 2018 were evaluated retrospectively. The da Vinci robotic system was used in all procedures. The patients' demographic data, electrocardiography (ECG) findings, and pre- and postoperative transthoracic echocardiography findings were analyzed. During follow up ECG was performed at postoperative 3, 6, and 12 months additionally at the 3rd month trans thoracic echocardiography was performed and functional capacity was also evaluated for all patients.

RESULTS

All patients underwent robotic-assisted mitral valve surgery with radiofrequency ablation and left atrial reduction. Mean age was 45.76±16.61 years; 7 patients were male and 4 were female. Preoperatively, mean left atrial volume index (LAVI) was 69.55±4.87 mL/m2, ejection fraction (EF) was 54.62±8.27%, and pulmonary artery pressure (PAP) was 45.75±9.42 mmHg. Postoperatively, in hospital evaluation LAVI decreased to 48.01±4.91 mL/m2 (P=0.008), EF to 50.63±10.13% (P>0.05), and PAP to 39.02±3.11 mmHg (P=0.012). AF was eliminated in 8 (72%) of the 11 patients at the 1st postoperative month. There were significant improvements in functional capacity and no mortality during follow-up.

CONCLUSION

Left atrial reduction and radiofrequency ablation concomitant with robotically assisted minimally invasive mitral valve surgery can be performed safely and effectively to eliminate AF and prevent recurrence.