Teaching the next generation of robotic coronary surgeons.

Robotic-assisted coronary bypass is an attractive option in the management of patients with isolated left anterior descending artery (LAD) disease or multi-vessel coronary disease providing the benefits of the left internal mammary artery (LIMA) to the LAD graft while avoiding the morbidity of a sternotomy. Although the learning curve is significant, both cardiothoracic surgery trainees as well as experienced coronary surgeons can learn this technique. As the prevalence of patients requiring these procedures increases, we must be prepared to respond by increasing our training of robotic coronary surgeons.

Developing Proficiency in Robotic Cardiac Surgery.

The purpose of this manuscript is to provide recommendations for cardiac surgeons interested in adopting a robotic platform into their programs. The recommendations are based on the experience of the authors and cover a diverse array of cardiac surgical procedures that are currently being performed with robotic assistance. The focus, as with any innovative surgical approach, is to ensure patient safety, maximize quality and efficacy, and to set realistic expectations about what is required to achieve proficiency in robotic cardiac surgery.

Transthoracic Aortic Clamp Technique for Port-Only Endoscopic Robotic Mitral Surgery.

OBJECTIVE: Many robotic mitral surgeons utilize right thoracotomy with transthoracic clamping of the aorta, while a smaller number employ a port-only endoscopic approach with endoaortic balloon occlusion of the aorta. We present our technique for a port-only endoscopic robotic approach with transthoracic clamping. METHODS: From July 2019 through December 2022, 133 patients underwent port-only endoscopic robotic mitral surgery with transthoracic clamp aortic occlusion and antegrade cardioplegia. Perfusion was through the femoral artery in 101 patients (76%) and axillary in 32 patients (24%). Clamp technique involved placing the clamp at the mid-ascending aorta, dynamic valve testing to 90 mm aortic root pressure, and closure of the cardioplegia cannula site prior to clamp removal. Indications for clamp utilization over balloon occlusion included both balloon supply issues and aortoiliac anatomy. RESULTS: Mitral repair was performed in 122 patients (92.7%) and mitral valve replacement in 11 patients (8.3%). Mean aortic occlusion time was 92 ± 21.4 min. Mean time from left atrial closure to clamp removal was 8.7 (7.2 to 12.8) min. There were no injuries to the aorta or surrounding structures, mortality, strokes, or renal failure. CONCLUSIONS: For robotic teams with endoaortic balloon capability, this technique may be useful in certain patients with aorto-iliac pathology or limited femoral artery access. Alternatively, robotic teams who employ transthoracic aortic clamping through a thoracotomy may find this technique useful to transition to a port-only endoscopic approach.

Mastering the Learning Curve for Robotic-Assisted Coronary Artery Bypass Surgery.

BACKGROUND: Previous studies have evaluated the learning curve to achieve competency in robotic-assisted coronary artery bypass grafting (CABG) but have not identified thresholds for mastery. Robotic-assisted CABG is a minimally invasive alternative to sternotomy CABG. The purpose of this study was to evaluate the short- and long-term outcomes of this procedure and to estimate the threshold for achieving mastery. METHODS: From 2009 to 2020, 1000 robotic-assisted CABG procedures were performed at a single institution. Robotic left internal mammary artery (LIMA) harvest followed by off-pump, LIMA-left anterior descending artery grafting using a 4-cm thoracotomy was performed. Short-term outcomes were obtained from The Society of Thoracic Surgeons database, and long-term follow-up was obtained by telephone questionnaires from dedicated research nurses for all patients more than 1 year from surgery. RESULTS: Mean patient age was 64 ± 11 years, Society of Thoracic Surgeons predicted risk of mortality was 1.1% ± 1.5%, and 76% (758) of patients were men. Thirty-day mortality occurred in 6 patients (0.6%; observed-to-expected ratio, 0.53), 5 patients (0.5%) experienced a postoperative stroke, and postoperative LIMA patency was 97.2% (491/505). Mean procedure time decreased from 195 minutes to 176 minutes, and conversion to sternotomy decreased from 4.4% (22/500) to 1.6% (8/500) after 500 cases. Short-term outcomes suggested expertise was reached between 250 and 500 cases. Long-term follow-up was completed in 97% of patients (873/896) with a median follow-up of 3.9 years (interquartile range, 1.8-5.8), and the overall survival rate was 89% (777). CONCLUSIONS: Robotic-assisted CABG can be performed safely with excellent results even during a surgeon's early experience. However the learning curve to achieve mastery is longer than required to achieve competency, with a threshold of approximately 250 to 500 cases.

Endoscopic Robotic Mitral Valve Surgery in Patients With Previous Sternotomy Cardiac Surgery.

Objective: Mitral surgery is higher risk in patients with a previous median sternotomy. We describe an endoscopic robotic approach in this higher-risk cohort by an experienced robotic team. Methods: From January 2006 through June 2021, 152 consecutive patients with previous sternotomy cardiac surgery underwent mitral surgery using endoscopic robotics. Peripheral perfusion with endoaortic balloon occlusion was used in 148 patients (97.4%) and ventricular fibrillation in 4 patients (2.6%). Results: Mitral repair was performed in 73 patients (48%) including primary repair in 57 patients and re-repair in 16 patients, mitral replacement in 78 patients (51.3%) including primary replacement in 26 patients, conversion of a previous repair to replacement in 28 patients, and re-replacement in 24 patients. A paravalvular leak was primarily repaired in 1 patient (0.7%). Concomitant procedures included tricuspid repair in 28 patients (18.4%) and cryoablation in 8 patients (5.3%). Postoperative echocardiography in the mitral repair patients demonstrated none to mild regurgitation in 72 patients (98.6%). One repair patient (1.4%) had severe regurgitation and required robotic mitral replacement 5 days postoperatively. There were no paravalvular leaks in the mitral replacement patients. Operative mortality occurred in 3 patients (1.97%). Stroke occurred in 1 patient (0.7%), prolonged ventilation in 18 patients (11.8%), renal failure in 2 patients (1.4%), and re-exploration for bleeding in 10 patients (6.6%). Mean length of stay for the entire cohort was 5 ± 5.4 days. Conclusions: Robotic mitral valve surgery can be extended to patients with previous sternotomy with satisfactory efficacy and low operative mortality and morbidity.

Surgical Correction of Tricuspid Regurgitation.

The tricuspid valve is an often forgotten but relevant cause of significant morbidity and mortality. Serious consideration should be given to addressing the valve in patients undergoing left-sided valve surgery who have functional TR, or an enlarged annulus. Tricuspid repair with a ring annuloplasty has shown improved long-term survival and freedom from recurrent TR at as long as 15 years of follow-up compared to suture annuloplasty or other repairs where a prosthetic ring is not used.