Analysis Of 628 Consecutive Robotic Mitral Valve Repair: When Are We Out Of The Learning Curve?
Danny Ramzy, Michele De Robertis, James Mirocha, Wen Cheng, Joshua Chung, Alfredo Trento.
Cedars-Sinai Medical Center, Los Angeles, CA, USA.
OBJECTIVE: To compare the surgical outcomes in three eras over 10-years with robotic assisted mitral valve repair(R-MVr).
METHODS: From June 2005 to August 2016, 628 R-MVr were performed. We divided our experience into 3 Eras. Era-1 included first 120 cases using first generation DaVinci system, Era-2 next 180 with newer system and Era-3 latest 328 cases adding a second robotic surgeon. Every patient needing isolated MVr underwent R-MVr and received an annuloplasty band and one or more of the following: leaflet resection, chordal transposition and/or neochordal replacement.
RESULTS: All 628 patients had preoperative severe mitral regurgitation (MR) with no differences between Eras for preoperative characteristics. Anterior prolapse and Barlow syndrome was greater in later eras compared to Era-1(5.8 vs. 27.8 vs. 14.1%). One hospital death(0.33%) occurred in Era-1 and none in Era-2 or Era-3. Overall, 8(1.5%) patients required subsequent MV replacement 6(5.0%) Era-1, 2(1.1%) Era-2 and none Era-3. One patient each in Era-1 and Era-2 had re-repair through right mini-thoracotomy during the original procedure. No re-repair or replacement was required in Era-3. Cross clamp times decreased from Era-1, 116 minutes to 91 and 79 in Era-2 and Era-3 respectively despite training a junior associate doing part of the procedure in Era-2 progressing to 2 surgeons in Era-3. Overall 98.7% had post-pump none-mild MR(86.5% with none-trace). Follow-up echo(1 month to 1 year) showed overall none-trace MR in 73.7%, mild in 19.9% and 0.6% severe MR(Era-3 91.7% had none-trace and no severe MR).
CONCLUSIONS: Complications and reoperations occurred early in our experience. The newer system together with increased experience made R-MVr of all types of degenerative mitral valve pathology reproducible. Training robotic surgeons in high volume centers helps avoid complications during introduction of this technology while not affecting the crossclamp time. The addition of a fully trained surgeon to a robotic program as seen in Era-3 can further reduce OR time and improve outcomes. We demonstrated that after 120 case we pass our learning curve in avoiding complications however cross class time continued to decrease with experience indicating that the learning curve for operative efficiency and time is perpetual.
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