Keyhole surgery for heart valve repair may trump robotic surgery

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Keyhole surgery for heart valve repair may trump robotic surgery, because it is associated with lower rates of subsequent heart flutter and blood transfusions, and a shorter hospital stay, reveal researchers at the University of Virginia, Charlottesville, East Carolina University, Greenville, North Carolina, Medical University of South Carolina, Charleston, Virginia Commonwealth University, Richmond and INOVA Heart and Vascular Institute, Falls Church on the pros and cons of different surgical approaches.

But as keyhole, robotic, and conventional surgery are all very safe and effective, the choice of which to perform should be governed by patient preference and the experience of the operating surgeon, suggest the researchers.

Despite the steep learning curves and additional cost involved, mitral valve repair is the most common heart operation performed using robot assisted surgery. But to date few studies have compared it with keyhole and conventional surgical techniques.

The researchers therefore drew on a comparison of 2,300 patients who needed planned mitral valve repair surgery between 2011 and 2016, and who were allocated to either robotic surgery (372), keyhole surgery (576), or conventional (1,352) sternotomy – where the sternum is cut open and divided.

Rates of successful repair were high in those undergoing robotic and keyhole surgery: 91%. But they were significantly lower in those who had conventional surgery: 76%. This was despite similar rates of degenerative disease across all the cases.

The robotic procedure took the most time to perform – 224 minutes compared with 180 minutes for keyhole and 168 minutes for conventional surgery.

The robotic approach had similar outcomes to the conventional approach except that there were half the number of onward discharges to further care – 7% vs 15% – and one day less spent in hospital.

But compared with keyhole surgery, robotic surgery required more blood transfusions (15% vs 5%), was associated with higher rates of heart flutter (atrial fibrillation) of 26% vs 18%, and one day longer in hospital, on average.

Because the cases were all reviewed after surgery had taken place, the findings can’t establish cause, caution the authors, and the patients may not be representative of all those who require mitral valve repair.

There are pros and cons to each of the techniques, prompting the authors to conclude: “From a patient perspective, all three approaches provide excellent outcomes, thus patient preference and surgeon experience should dictate the approach for 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 2300 patients undergoing non-emergent isolated mitral valve operations from 2011 to 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: The robotic cases were well matched to the conventional (n=314) and mini (n=295) cases 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 min conventional, 222 vs 180 min mini; all P<0.0001). The robotic approach had comparable outcomes to the conventional approach except there were fewer discharges to a facility (7% vs 15%, P=0.001) and 1 less day in the hospital (P<0.0001). However, compared with the mini approach, the robotic approach had more transfusions (15% vs 5%, P<0.0001), higher 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 with conventional surgery. However, the robotic approach was associated with higher atrial fibrillation rates, more transfusions and longer postoperative stays compared with minimally invasive approach.

Authors
Robert B Hawkins, J Hunter Mehaffey, Matthew M Mullen, Wiley L Nifong, W Randolph Chitwood, Marc R Katz, Mohammed A Quader, Andy C Kiser, Alan M Speir, Gorav Ailawadi

BMJ material
Heart abstract


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