A propensity matched analysis of robotic, minimally invasive, and conventional mitral valve surgery

Abstract

Objectives: Institutional studies suggest robotic mitral surgery may be associated with superior outcomes. The objective of this study was to compare the outcomes of robotic, minimally invasive (mini), and conventional mitral surgery. Methods: A total of 2,351 patients undergoing non-emergent isolated mitral valve operations from 2011–2016 were extracted from a regional Society of Thoracic Surgeons database. Patients were stratified by approach: robotic(n=372), mini(n=576) and conventional sternotomy(n=1352). To account for preoperative differences, robotic cases were propensity score matched (1:1) to both conventional and mini approaches. Results Robotic cases were well matched to conventional (n=314) and mini (n=295) with no significant baseline differences. Rates of mitral repair were high in the robotic and mini cohorts (91%), but significantly lower with conventional (76%, p<0.0001) despite similar rates of degenerative disease. All procedural times were longest in the robotic cohort, including operative time (224 vs 168 minutes conventional, 222 vs 180 minutes mini; all p<0.0001). Robotic approach had comparable outcomes to conventional except fewer discharges to a facility (7% vs 15%, p=0.001) and 1 less day in the hospital (p<0.0001). However, compared to mini, robotic approach had higher transfusion (15% vs 5%, p<0.0001), atrial fibrillation rates (26% vs 18%, p=0.01) and 1 day longer average hospital stay (p=0.02). Conclusion: Despite longer procedural times, robotic and mini patients had similar complication rates with higher repair rates and shorter length of stay metrics compared to conventional surgery. However, robotic approach is associated with greater atrial fibrillation, transfusion and longer postoperative stays compared to minimally invasive approach.

Comparison of the Surgical Effect and the Long-term Clinical Outcomes Between Robotic and Sternotomy Mitral Valve Replacement

“…The tracheal intubation time, length of ICU stay, and postsurgical hospital stay were signi cantly shorter in TE-MVR than in CS-MVR, which is consistent with the ndings reported by Suri et al [17]. Hawkins reported a shorter ICU stay and postoperative length of hospital stay and obtained similar conclusions when comparing robotic MVR with minimally invasive and conventional MVR [10]. Considering the obvious clinical effects, the main reason for these ndings is that robotic surgery obviates the need to disrupt the sternum and reduces complications associated with sternotomy.…”

“…We have performed more than 150 robotic MV operations, and 30% of them are MVRs. The ratio of replacement is higher than that in centers in developed countries [10,21]. It is believed that the etiological difference between China and developed countries may explain the higher proportion of MVR in MV surgery.…”

“…Carpentier completed the world's rst robot-assisted MV surgery in 1998 [9]. After two decades of development, robotic technology has rapidly evolved and aided in the remarkable advancements witnessed in mitral valve surgery with some apparent advantages which outperform thoracoscopic techniques [10,11]. From our experience with TE-MVR, robotic surgical system can provide a good view of the surgical eld.…”

Seven Habits of Highly Effective Endoscopic Mitral Surgeons

“…There have been anecdotal reports of poor myocardial protection and this needs to be looked at in context of the experience of many centers where there have not been increased reported use of intra-aortic balloon pump or assist devices. 10,12 If this problem is noted by a surgeon or at a center, a root cause analysis may throw light on the specific aspect and hopefully a period of supervision from another center or surgeon will help them overcome this issue.…”

Commentary: How (and why) to make it mini

“…Large series and propensity-matched cohorts confirm safety and suggest satisfactory longer-term durability compared with sternotomy and there appears to be only a modest difference in the length of stay. [5][6][7][8] Further, pain scores are reduced and there may be a faster return to normal activities. 9,10 Nissen and colleagues 11 elegantly describe the establishment of a minimally invasive valve surgery program.…”