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Mitral Valve Surgery - JLT 1306(206) (Page 9)

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Mitral Valve Surgery - JLT 1306(206)
Volume 13, Number 6, 2003
Recently, we published our results of the fi rst 38
mitral repairs with the da VinciTM system.³ Total
robot time represents the exact time of robot deploy-
ment after valve exposure and continues until the end
of annuloplasty band placement. Th
is time decreased
signifi cantly from 1.9 hours in the fi rst group of 19
patients to 1.5 hours in the second group. At the same
time, leafl et repair times fell signifi cantly from 1.0
hour to 0.6 hours, respectively. Also, total operating
times decreased signifi cantly from 5.1 hours to 4.4
hours in the second group of patients. Furthermore,
both cross-clamp and bypass times decreased signifi -
cantly with experience as well. For all patients, the
total length of stay was 3.8 days, with no diff erence
between the two groups. Of all patients in the study,
84% demonstrated a grade 3 or greater reduction in
mitral regurgitation at follow-up. In the entire series
there were no device-related complications or opera-
tive deaths. One valve was replaced at 19 days because
of hemolysis secondary to a leak that was directed
against a prosthetic chord.
In reviewing the Leipzig robotic mitral experi-
ence, Mohr described 17 patients that underwent
robotic mitral valve repair.³ Fourteen of the 17
patients underwent a successful mitral valve re-
pair with the da VinciTM system. In three patients,
conversion to conventional endoscopic instruments
became necessary. Th
e average cross clamp time was
89 ± 18 minutes. Following the repair, intraoperative
TEE demonstrated no regurgitation in 13 patients
and trace regurgitation in three. One patient had a
grade 2 leak requiring immediate endoscopic valve
replacement. Postoperative results were notable for
one failure of a repair requiring emergent valve
replacement on postoperative day 3 secondary to a
disrupted annuloplasty ring.
To date, we have completed over 60 robotic mitral
valve repairs with the da VinciTM system and have
noted certain trends. For example, bypass and cross-
clamp times between the fi rst 25 patients and the
second group of 25 patients continue to signifi cantly
decrease and are currently averaging 2.69 and 2.12
hours, respectively. Suture placement time for annu-
loplasty rings has decreased signifi cantly from 2.15
minutes per suture to 1.46 minutes in the second
group. When P robotic repair times were compared
from the fi rst group of 25 to the second, there was
a signifi cant decrease from 54.19 minutes to 30.79
minutes. A multicenter da VinciTM trial enlisting
112 patients has recently been completed and dem-
onstrates effi
cacy and safety in performing these
operations by multiple surgeons at various centers,
thereby becoming the fi rst robotic telemanipulation
system to become FDA approved for mitral valve
repair surgery.
Similarly, experience with endoscopic coronary
artery bypass surgery has been limited to only a
few centers, and results are highly controlled. Be-
cause the success of coronary surgery depends on
multiple, complex steps culminating in the creation
of a vascular anastomosis, most clinical series have
introduced robotically assisted coronary surgery in
a stepwise fashion. Specifi cally, initial experience is
limited to endoscopic LIMA harvesting, followed by
a robotically assisted anastomosis through a median
sternotomy, and fi nally a total endoscopic procedure
performed on an arrested heart followed by a beating
heart operation.
Currently, the largest published series of TECAB
come from Europe. Wimmer-Grenecker's group in
Frankfurt reported on 45 patients that underwent
TECAB on an arrested heart.³ Most of these (82%)
were single-vessel bypass (either LIMA­LAD or
right internal mammary artery to right coronary
artery). Th
e fi rst 22 patients had angiograms prior
to discharge, revealing a 100% patency rate. Mean
operative time for single-vessel TECAB was 4.2 ±
0.9 hours and 6.3 ± 1.0 hours for double-vessel bypass
procedures. Th
e average cross clamp time for single
bypass was 61 ± 16 minutes and 99 ± 55 minutes
for double bypass. Th
e initial conversion rate of 22%
decreased to 5% in the last 20 patients, refl ecting an
obvious learning curve.
Kappert described TECAB in 37 patients, of
which 29 were performed on a beating heart. Of
these 29 patients, three received double vessel bypass
using bilateral mammary arteries, and the rest were
revascularized with a LIMA­LAD. As experience was

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