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Is Robotic Mitral Valve Repair a Reproducible Approach?
*Alfredo Trento, *Wen Cheng, Michele A De Robertis, James Mirocha, *Robert M Kass, *Gregory P Fontana
Cedars-Sinai Medical Center, Los Angeles, CA
BACKGROUND: Dr. W. Randolph Chitwood’s experience with Robotic Mitral Valve repair (R-MVr) and convincing enthusiasm as well as extraordinary results motivated our team to initiate a similar program in June of 2005. At the time there were 4 centers in the United States performing R-MVr surgery. We present our initial evaluation of the first 100 R-MVr procedures performed at our center.
METHODS: We reviewed the overall surgical outcome of our first 100 R-MVr consecutive procedures (daVinci Surgical System; Intuitive Surgical, Inc. Sunnyvale, Ca) performed between June 2005 and November 2008. The repairs were also grouped by predominant leaflet pathology; posterior leaflet (n=75), anterior leaflet with or without posterior leaflet involvement (n=21), functional (n=4). All patients received an annuloplasty ring that may have included one or more of the following: leaflet resection (triangular or quadrangular) sliding plasty, chordal transposition and or chordal replacement and edge-to-edge approximations. Pre, perioperative and postoperative patient characteristics including follow-up and early and late echocardiographic (echo) findings were obtained from a hospital quality assurance database.
RESULTS: Overall mean age was 58.9±10.8 years, 66 males and 34 females. There was 1 hospital mortality. Five patients required mitral valve replacement, two patients <24 hrs, and 3, 6 and 41 days post R-MVr. Postoperative complications: 2 strokes, 1 transient ischemic attack, 1 liver laceration, 1 phrenic nerve paralysis and 6 reoperation for bleeding. Post-pump mitral regurgitation (MR) grades: none/trivial 80; mild 17; moderate 2 and severe 0. Greater than 30day follow-up (F-U) echo was obtained in 74 patients, median 411 days. Echocardiographic measurements included: MR grade, left ventricular end diastolic dimension, cm (LVEDD), left atrial diameter, cm (LA diam) and ejection fraction, % (EF). There was a clinically significant decrease in LVEDD and LA diam at F-U. There was a trend for shorter pump time in the last 30 patients (158±30 min.) compared with the first 70 patients (173±61 min.), p=0.11.
CONCLUSIONS: We found that the learning curve is steep and long. Training of the surgeon and surgical team provided by the manufacture of the robotic system is less than optimal due to time constraints that prove short and incomplete. Some complications such as liver puncture, phrenic paralysis and endo-balloon complications are nearly exclusive to this approach. With time the team becomes very comfortable with the technology and the results tend to improve. In particular the operating room time and CPB time tend to decrease. From carefully selecting patients with appropriate pathology we have progressed to include nearly any form of degenerative mitral valve disease, including Barlow syndrome with results comparable to the standard approach.
Overall Echocardiographic Findings (n=100) | Preop | F-U | Change | p value | | MR grade | 4.0 | 1.3 | 2.7 | <0.0001 | | Mod. or Sev. MR | 100% | 10.8% | -89.2% | | | LVEDD | 5.8 | 5.0 | -0.8 | <0.0001 | | LA diam | 4.7 | 4.0 | -0.7 | <0.0001 | | EF | 62.6 | 59.1 | -3.6 | 0.003 |
Echo results; Posterior leaflet (n=75) | Preop | F-U | Change | p value | | MR grade | 4.0 | 1.1 | 2.9 | <0.0001 | | Mod. or Sev. MR | 100% | 9.1% | -90.9% | | | LVEDD | 5.9 | 5.1 | -0.8 | <0.0001 | | LA diam | 4.7 | 4.0 | -0.7 | <0.0001 | | EF | 62.8 | 59.8 | -3.1 | 0.03 |
Echo results; Anterior leaflet with or w/out Posterior leaflet (n=21) | Preop | F-U | Change | p value | | MR grade | 4.0 | 1.6 | 2.4 | <0.0001 | | Mod. or Sev. MR | 100% | 12.5% | -87.5% | | | LVEDD | 5.7 | 4.8 | -0.9 | <0.001 | | LA diam | 4.8 | 4.3 | -0.5 | 0.02 | | EF | 63.1 | 57.1 | -6.1 | 0.01 |
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