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

Clinical Outcomes and Costs of Robotic-assisted vs Conventional Mitral Valve Repair: A National Analysis

BACKGROUND

Robotic approaches have been increasingly utilized for cardiothoracic operations, though concerns regarding costs remain. We evaluated short-term outcomes and costs of robotic-assisted and conventional mitral valve repair (MV-repair), hypothesizing that cost differences would be mitigated at high-volume programs.

METHODS

Adults undergoing elective MV-repair from 2016 to 2020 were identified in the Nationwide Readmissions Database. Patients with rheumatic heart disease, mitral stenosis, and those undergoing concomitant operations were excluded. Generalized linear models were utilized to evaluate the association between approach and in-hospital mortality, complications, length of stay, costs, and 90-day readmissions. Annual institutional MV-repair volume was modeled using restricted cubic splines, and cost differences subsequently evaluated by volume tertile.

RESULTS

Of 40,738 patients, 9.8% underwent robotic-assisted MV-repair. Risk-adjusted outcomes including mortality, stroke, reoperation, respiratory complications, postoperative infection, and readmission were comparable between the 2 groups, while those undergoing robotic-assisted MV-repair had lower rates of nonhome discharge. The median cost of robotic-assisted MV-repair was greater than conventional surgery ($46,800 vs $38,500, P < .001). Despite a 1.3-day decrement (95% CI, 1.1-1.6) in length of stay, robotic-assisted MV-repair was associated with greater risk-adjusted costs by $10,500 (95% CI, $5800-$15,200). Programs in the highest volume tertile exhibited comparable costs for robotic-assisted and conventional MV-repair (cost difference, $5900; 95% CI, -$1200 to $12,200; P > .05).

CONCLUSIONS

Robotic-assisted MV-repair had comparable short-term outcomes relative to conventional surgery. Despite increased costs of robotic-assisted MV-repair overall, high-volume programs had similar risk-adjusted costs by approach. These findings support the designation and performance of robotic MV-repair at centers of excellence in the United States.

Improved robotic-assisted cardiac surgery outcomes with greater hospital volume: a national representative cohort analysis of 10,543 cardiac surgery surgeries

Robot-assisted surgical techniques have enhanced surgical precision, control, stability, and vision, particularly in cardiac interventions. However, the relationship between hospital volume and the clinical and readmission outcomes of robot-assisted cardiac surgery remains undefined. This retrospective cohort study analyzed Nationwide Readmissions Database (NRD) data from 2010 to 2020. Patients who underwent various cardiac procedures were categorized into three groups based on hospital volume of robot-assisted cardiac surgery: low-volume centers (LVCs), medium-volume centers (MVCs), and high-volume centers (HVCs). Our primary outcome variables of interest were the incidence of perioperative complications, 30-day readmission, and in-hospital mortality. 10,543 patients were included in the analysis. Compared with those treated in LVCs, the adjusted OR of 30-day readmission [OR, 0.70; (95% CI 0.53-0.92), P = 0.014] was lower in HVCs. However, higher perioperative bleeding rates were observed in MVCs (OR, 1.38; (95% CI 1.14-1.66), P = 0.001) and HVCs (OR, 1.84; (95% CI 1.52-2.21), P = 0.001). No significant differences were found in in-hospital mortality. Our research demonstrated that higher hospital surgical volume was associated with better outcomes in robot-assisted cardiac surgery, despite higher perioperative bleeding rates.

Endoscopic micro-invasive cardiac surgery: State-of-the-art

The advancement of micro-invasive cardiac surgery techniques has introduced a viable alternative to conventional full-sternotomy operations. These approaches are designed to reduce tissue trauma, shorten recovery time, and meet the increasing demand for less invasive treatment options. In this review, we discuss current progresses in endoscopic micro-invasive cardiac surgery, which utilizes refined tools and advanced imaging technologies to perform complex heart procedures, including valve surgery, coronary artery bypass grafting, and congenital defect corrections. By reviewing our experience with these techniques, we provide practical insights for surgeons interested in adopting micro-invasive cardiac surgery. The highlighted innovations in planning and execution of micro-invasive cardiac surgery reflect the growing trend toward safer and more efficient cardiac surgeries.

Five historical innovations that have shaped modern cardiothoracic surgery

Throughout history, many innovations have contributed to the development of modern cardiothoracic surgery, improving patient outcomes and expanding the range of treatment options available to patients. This article explores five key historical innovations that have shaped modern cardiothoracic surgery: cardiopulmonary bypass, surgical pacemakers, video assisted thoracic surgery, robotic surgery and mechanical circulatory support. We will review the development, impact and significance of each innovation, highlighting their contributions to the field of cardiothoracic surgery and their ongoing relevance in contemporary and perioperative practice.

Historical landmarks in the development of robotic coronary bypass grafting

Robotic technology was first used in history for the minimally invasive surgical treatment of coronary artery disease. In 1998, the first operations were carried out at the Hôpital Broussais in Paris. Thereafter, several European and United States (US) centers developed surgical concepts for robotically assisted internal mammary artery harvesting and the construction of the anastomoses, either through minithoracotomy or in a totally endoscopic fashion. Initial experiences were documented in a number of single and multicenter series published in the early and mid-2000s. Key steps in further procedure development included the introduction of a robotic endostabilizer for beating heart completely endoscopic operations, the combination with percutaneous coronary intervention in hybrid approaches, the introduction of second, third, and fourth generations of surgical robots with improvements in each iteration, the availability of anastomotic devices, and most recently, the emergence of new robotic technology companies producing interesting alternatives to the existing machines. The larger clinical series included 500 to over 1,000 patients, with clinical results that well justified the continued application of robotics. Development of robotic coronary bypass grafting has generally been slow, but at committed centers, the procedures are routine, reproducible, safe, and effective. Over 25 years of development, robotic surgical coronary revascularization has become an important component in the armamentarium of minimally invasive heart surgery.

Beyond Conventional Operations: Embracing the Era of Contemporary Minimally Invasive Cardiac Surgery

Over the past two decades, minimally invasive cardiac surgery (MICS) has gained a significant place due to the emergence of innovative tools and improvements in surgical techniques, offering comparable efficacy and safety to traditional surgical methods. This review provides an overview of the history of MICS, its current state, and its prospects and highlights its advantages and limitations. Additionally, we highlight the growing trends and potential pathways for the expansion of MICS, underscoring the crucial role of technological advancements in shaping the future of this field. Recognizing the challenges, we strive to pave the way for further breakthroughs in minimally invasive cardiac procedures.

Minimally-invasive approach via percutaneous femoral cannulation for the resection of intra-cardiac masses: a single center experience in the Middle-East

BACKGROUND

Intra-cardiac masses are rare and challenging lesions with an overall incidence ranging of 0.02-0.2%. Minimally invasive approaches have been recently introduced for surgical resection of these lesions. Here, we evaluated our early experience using minimally invasive techniques in addressing intra-cardiac lesions.

METHODOLOGY

This is a retrospective descriptive study conducted between April 2018 to December 2020. All patients were diagnosed with cardiac tumors and treated via a right mini-thoracotomy with cardiopulmonary bypass through femoral cannulation at King Faisal Specialist Hospital and Research Centre, Jeddah.

RESULTS

Myxoma was the most common pathology representing 46% of cases followed by thrombus (27%), leiomyoma (9%), lipoma (9%) and angiosarcoma (9%). All tumors were resected with negative margins. One patient was converted to open sternotomy. Tumor locations were in the right atrium, left atrium, and left ventricle in 5, 3, and 3 patients, respectively. The median ICU stay was 1.33 days. The median length of hospitalization was 5.7 days. There was no 30-days hospital mortality recorded in this cohort.

CONCLUSION

Our early experience shows that minimally invasive resection can be performed safely and effectively for intra-cardiac masses. The minimally invasive approach using a mini-thoracotomy with percutaneous femoral cannulation can be an effective alternative in resecting intra-cardiac masses that achieves clear margin resection, quick post-operative recovery, and low rates of recurrence for benign lesions.

Artificial Intelligence-Oriented Heart Surgery: A Complex Bioethical Concept

Artificial intelligence (AI) has come to the frontline, paving the way toward a future of operational efficiency. Following the current, cardiac surgery has evolved as well. We live in a world where AI has brought immense progress in almost every aspect of the field, but still, the question remains; will there be a time when robots will replace cardiac surgeons? The currently used operating systems necessitate constant supervision. Upgrading the algorithms from visual augmentation and post-operative prognosis to completely operating software is not something to be taken lightly. However, if we manage to succeed, would you be receptive to a fully autonomous robot as your surgeon? Significant barriers concerning bioethics emerge; the potential for misuse, risk assessment, supervision, referrals, the need to respect and protect patient autonomy and transparency while using the algorithms, and above all the understanding of the dynamics of illness and the human condition. So, can we provide a simple response to such a prime issue? The truth is, we cannot provide an answer for the future where an answer cannot be delivered effortlessly.