Robotic Cardiac Surgery Review
Cardiac surgery has traditionally been a technically demanding specialty that often involves treating patients with significant co-morbidities. A sternotomy approach, although regarded as the most versatile incision, has some drawbacks including a longer incision, post-operative sternal precautions, and potentially longer hospitalization and recovery; therefore, the need for minimizing the surgical approach is imperative. Since the introduction of minimally invasive cardiac surgery in 1995, the use of robotic systems has gained popularity. The most common applications for robotics have been single and double vessel coronary artery bypass grafting (CABG), mitral valve (MV) replacement, and, in a much lower frequency, the resection of left atrial tumors and the repair of atrial septal defect (ASD). With excellent MV repair rates, minimal need for coronary reintervention, and a vanishingly low morbidity profile, robotic surgery has been adopted by a growing number of surgeons in their practices. Several studies have shown significantly reduced length of stay, complications, and mortality in patients who underwent robotically assisted cardiac surgery compared with patients who underwent non-robotic cardiac surgery.1,2
Two decades after the first reported robotically assisted MV replacement,3,4 several studies reporting on data of single-center experiences and national databases have established the efficacy and feasibility of this procedure.5,6 Typically, the operative strategy includes femoral cannulation for cardiopulmonary bypass (CPB), deployment of the robotic arms through 8-12 mm incisions in the right thorax, and aortic cross-clamping using the Chitwood clamp (Scanlan International, Inc; St Paul, MN) or endoaortic balloon occlusion. A recent large-volume-center study at the Cleveland Clinic7 reported on short-term outcomes in the first 1,000 patients undergoing robotic primary MV surgery. Almost all patients in the cohort had severe mitral regurgitation (one had mitral stenosis, and one had fibroelastoma). Isolated posterior leaflet prolapse was seen in 80%, isolated anterior leaflet prolapses in 2.5%, and bileaflet prolapse in 17%. After the first 200 cases, both CPB and aortic cross-clamp times stabilized at around 120 minutes and 80 minutes, respectively. Concomitant procedures performed at the time of surgery included ablation for atrial fibrillation in 7.2%, ASD closure in 9% and tricuspid valve repair in 0.2%. MV repair rate was 99.5%. Conversion rate to partial or full sternotomy was 2% with a 2.3% conversion rate to mini-thoracotomy. Operative mortality rate was 0.1%, and the stroke rate was 1.4%. Similar findings were observed in another large cohort study by Murphy et al.8 in Atlanta, with 1,257 consecutive patients undergoing robotic isolated MV procedures using a more advanced lateral endoscopic approach with robotics technique. The patient cohort included those with significantly greater comorbidity than those in the Cleveland Clinic study. However, mean conversion to open sternotomy was still less than 5%, MV repair rate was 93%, and mean CPB and aortic cross-clamp times were 144 minutes and 82 minutes, respectively. The incidence of post-operative atrial fibrillation was comparable to that of open surgery at 12.5%.9,10 The need for re-operation was present in 2.6% of patients and bleeding in 1.7%. All other complications had a rate less than 1%. Moreover, the cumulative survival was greater than that observed in the literature among patients with severe ischemic mitral regurgitation undergoing open MV repair or replacement.11
Since the landmark publication of the first successfully performed totally endoscopic coronary artery bypass,12 the use of minimally invasive techniques for coronary artery revascularization has been increasing with promising results. A study of the Society of Thoracic Surgeons Adult Cardiac Surgery Database from 2006 to 2012 found an increase in the volume of robotically assisted CABG, and no difference in peri-operative mortality was noted when compared with non-robotic CABG.13 In 2013, Bonaros et al. presented results from 500 cases of robotic totally endoscopic coronary artery bypass operations.14 The da Vinci S and Si models (Intuitive Surgical, Inc; Sunnyvale, CA) were used; 3 1-cm ports were introduced into the left chest (or the right chest if the right coronary artery was being grafted) (Figures 1-2). Arrested heart totally endoscopic coronary artery bypass was used in 78%, and beating heart totally endoscopic coronary artery bypass was used in 22%. In the case of arrested heart totally endoscopic coronary artery bypass, femoral CPB was instituted. Single-, double-, triple- and quadruple-vessel totally endoscopic coronary artery bypass was performed in 67%, 30%, 3%, and 0.2% of patients, respectively. The success rate was 80%, and the safety rate was 95%, with conversion to sternotomy in 10% of patients. A recent meta-analysis of 2,947 patients undergoing robotic CABG (1,482 totally endoscopic coronary artery bypass; 1,465 non-totally endoscopic coronary artery bypass) showed a 30-day mortality rate of 0.3% for non-totally endoscopic coronary artery bypass and 0.9% for totally endoscopic coronary artery bypass. However, regarding late mortality, the rate was 3.2% for non-totally endoscopic coronary artery bypass and 2.4% for totally endoscopic coronary artery bypass.15 Additionally, a meta-analysis of 16 studies by Wang et al. concluded that the utilization of robotics in CABG does not lead to an increase in mortality, major adverse cardiac and cerebrovascular events, or need for re-intervention.16 Apart from similar or potentially lower mortality rates compared to open surgery, application of robotic systems in CABG provides certain benefits. Due to its less-invasive nature, robotic CABG is associated with a low rate of wound infection (0.3%), which is important given the fact that patients requiring coronary revascularization typically have body mass indices >25 kg/m2 and diabetes. These two parameters are known to be risk factors for wound infection post-operatively in traditional CABG.17
Figure 2: Robotic Mitral Valve Repair Ports
The application of robotics in cardiac surgery is associated with low mortality and morbidity when compared with traditional sternotomy. Consequently, the utilization of robotic technology in the field of cardiac surgery (CABG, MV replacement, tumor resection, and ASD repair) has continued to grow over time. We anticipate that the many well-documented advantages of a minimally invasive approach will continue to drive adoption of robotic surgery in the future.
- Yanagawa F, Perez M, Bell T, Grim R, Martin J, Ahuja V. Critical Outcomes in Nonrobotic vs Robotic-Assisted Cardiac Surgery. JAMA Surg 2015;150:771-7.
- Deeba S, Aggarwal R, Sains P, et al. Cardiac robotics: a review and St. Mary's experience. Int J Med Robot 2006;2:16-20.
- Carpentier A, Loulmet D, Carpentier A, et al. Open heart operation under videosurgery and minithoracotomy. First case (mitral valvuloplasty) operated with success. C R Acad Sci III 1996;319:219-23.
- Falk V, Walther T, Autschbach R, Diegeler A, Battellini R, Mohr FW. Robot-assisted minimally invasive solo mitral valve operation. J Thorac Cardiovasc Surg 1998;115:470-1.
- Paul S, Isaacs AJ, Jalbert J, et al. A population-based analysis of robotic-assisted mitral valve repair. Ann Thorac Surg 2015;99:1546-53.
- Mihaljevic T, Jarrett CM, Gillinov AM, et al. Robotic repair of posterior mitral valve prolapse versus conventional approaches: potential realized. J Thorac Cardiovasc Surg 2011;141:72-80.
- Gillinov AM, Mihaljevic T, Javadikasgari H, et al. Early results of robotically assisted mitral valve surgery: Analysis of the first 1000 cases. J Thorac Cardiovasc Surg 2018;155:82-91.e2.
- Murphy DA, Moss E, Binongo J, et al. The Expanding Role of Endoscopic Robotics in Mitral Valve Surgery: 1,257 Consecutive Procedures. Ann Thorac Surg 2015;100:1675-81.
- Magruder JT, Collica S, Belmustakov S, et al. Predictors of Late-Onset Atrial Fibrillation Following Isolated Mitral Valve Repairs in Patients With Preserved Ejection Fraction. J Card Surg 2016;31:486-92.
- Gregers E, Ahlberg G, Christensen T, et al. Deep sequencing of atrial fibrillation patients with mitral valve regurgitation shows no evidence of mosaicism but reveals novel rare germline variants. Heart Rhythm 2017;14:1531-8.
- Goldstein D, Moskowitz AJ, Gelijns AC, et al. Two-Year Outcomes of Surgical Treatment of Severe Ischemic Mitral Regurgitation. N Engl J Med 2016;374:344-53.
- Loulmet D, Carpentier A, d'Attellis N, et al. Endoscopic coronary artery bypass grafting with the aid of robotic assisted instruments. J Thorac Cardiovasc Surg 1999;118:4-10.
- Whellan DJ, McCarey MM, Taylor BS, et al. Trends in Robotic-Assisted Coronary Artery Bypass Grafts: A Study of The Society of Thoracic Surgeons Adult Cardiac Surgery Database, 2006 to 2012. Ann Thorac Surg 2016;102:140-6.
- Bonaros N, Schachner T, Lehr E, et al. Five hundred cases of robotic totally endoscopic coronary artery bypass grafting: predictors of success and safety. Ann Thorac Surg 2013;95:803-12.
- Doulamis IP, Spartalis E, Machairas N, et al. The role of robotics in cardiac surgery: a systematic review. J Robot Surg 2019;13:41-52.
- Wang S, Zhou J, Cai JF. Traditional coronary artery bypass graft versus totally endoscopic coronary artery bypass graft or robot-assisted coronary artery bypass graft--meta-analysis of 16 studies. Eur Rev Med Pharmacol Sci 2014;18:790-7.
- Hällberg V, Palomäki A, Lahtela J, et al. Associations of metabolic syndrome and diabetes mellitus with 16-year survival after CABG. Cardiovasc Diabetol 2014;13:25.
Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and VHD, Interventions and Structural Heart Disease, Mitral Regurgitation
Keywords: Cardiac Surgical Procedures, Atrial Fibrillation, Mitral Valve Insufficiency, Sternotomy, Thoracotomy, Coronary Vessels, Mitral Valve Stenosis, Risk Factors, Cardiopulmonary Bypass, Incidence, Cohort Studies, Length of Stay, Feasibility Studies, Constriction, Mitral Valve, Robotics
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