Robotic heart surgery – What you should know and what you should ask

Hello, my name is Joseph Dearani, and I’m the Chair of Cardiovascular Surgery at the Mayo Clinic. And we’re going to talk about robotic heart surgery. What you should know, and what questions you should ask. So robotics is really the ultimate in minimally invasive surgery. There is no bone breaking, and there’s no significant muscle cutting. And the robot is really three arms that are an extension of the surgeon’s hands. So actually we’re not able to touch the heart. And success in robotic heart surgery really requires the cohesive team with a high volume of cases, in order to optimize results. So the Mayo team includes a careful selection of cardiologists for the preoperative phase, and then a polished operating room team that consists of surgeons and technicians and anesthesia, and then critical care, and allied health in the post-operative phase. And then after the patient leaves the hospital, we have communication with the home physician, so continuity is maintained. Now importantly, in our program, we utilize two staff surgeons–one at the bedside and one at the console, and we feel that this is very, very important in terms of minimizing operating time, particularly on the heart-lung machine. The OR team, beyond the surgeons, consists of a cardiologist who is doing the echocardiogram, and an anesthesiologist who is well versed with the minimally invasive techniques in the passage of catheters. Postoperatively, the anesthesia team does a hand-off to the critical care team. We have protocols that minimize time in the ICU, determines when lines and tubes are removed. Patients are cared for with competence and compassion. And having a high volume of cases allows us to do this so that it becomes routine, which is very important for you.

Now the indications for robotic heart surgery generally revolve around mitral valve disease, although there are many other indications where it could be considered– tricuspid valve problems, small cardiac tumors, although they are not very common, selected congenital heart defects, septal defects, like atrial septal defect, and other structural problems that fall into the congenital arena. In addition, aspects of coronary bypass surgery can be done robotically or minimally invasively, and then selected arrhythmia procedures can also be done robotically.

Now there are some patients that are not able to have robotic heart surgery. If they need multiple procedures, particularly multiple valve procedures, or a combination of valve and coronary bypass surgery, it just may be too much to do with the robot. Patients that have had previous cardiac surgery, or they’ve had a previous operation that involves an incision in the right chest, they are also not eligible for the robot at the current time. Patients who are very large, or morbidly obese, may also not be a candidate because of the limitations with the technology at the present time with the length of arms and such, related to the robot. Also, patients must not have significant peripheral vascular disease because in order to do this minimally invasively, we rely on attachment to the heart-lung machine utilizing vessels in the groin and in the neck.

Now with regard to mitral valve disease, generally speaking, the indications for surgery have historically revolved around the presence of symptoms–shortness of breath, decreased exercise tolerance, or simple fatigue. And when the ventricular function has been going down, or the size of the heart has been enlarging, these have been traditional indications to transfer somebody for a surgical consultation. Importantly now, we have learned that mitral valve disease is one of the structural heart defects where the asymptomatic patient, in fact, should be referred for surgery. And this requires the presence of severe mitral regurgitation with some notice of heart enlargement, and/or the onset of arrhythmias. And importantly, the probability of valve repair must be very high.

Now, some may ask, are there any technical compromises with doing this robotically? Importantly in our practice, we apply the gold standard open approach robotically and this is important for you as a patient to understand that we have not compromised on the operation that we are doing robotically. In fact, if we were to do it in an open manner, with a full incision, it would be the same exact operation. That is the gold standard for what we do. Some patients may ask, is it risky, or is it safe? And, in fact, now we are approaching 600 robotic heart repairs, most of which have been mitral valve repair. Our repair rate fortunately, to date, has been 100%. And the mortality is exceedingly low, less than 1/2 of a percent. We’ve not had any conversions to an open procedure, which is something that we always mention to patients in advance. But fortunately, with a cohesive team, we have not had to do this to date. Robotic times we have found are shorter from an overall length of stay in the hospital. The time on the ventilator is shorter. The time in the ICU is shorter. The time on the floor is shorter. And the total hospital stay is roughly about three days. We have good solid five-year follow-up, now in almost 100% of the patients, and the results have been very encouraging.

There are real advantages for you as a patient. First, you get the same operation whether it’s done open or whether it’s done robotically, and the repair rate here exceeds 99%. There is less pain, there’s less bleeding, there’s less infection, and you’re also less likely to have transient arrhythmias after surgery, which can be quite common with valvular heart disease. The length of hospital stay is short and the recovery is generally easier. The quality of life, we have learned, is better with the robotic approach. It’s excellent with the open approach, but you have an advantage having it done robotically in terms of all of these other favorable aspects. And there is earlier return to work. And many patients, depending upon the type of work they do, are able to return to work within two to three weeks of surgery. So the most important points for you to remember is that the outcome is similar to the open repair with the robotic approach. The technique of operation should be identical to the open operation. But it does require the presence of an elite, experienced team that includes cardiovascular surgery, cardiology, anesthesia, critical care, and all of the many essential allied health care members. The length of stay is shorter, and the recovery year is easier, and the quality of life, in general, is improved, with an earlier time returning to work.

So what questions should you ask your surgeon or cardiologist if you’re being considered for a robotic approach? First is, you should ask what the experience of the team is. And importantly, I think it’s helpful to know what their experience is with the open operation, because programs that have extensive experience with the open operation generally have incredibly good results with the robotic approach because of all of the experience that they have accrued. What is the nature of the team, and who is doing what? It has been our practice to have two staff surgeons involved with each and every patient–one at the bedside and one at the console. Now while this is not mandatory, we do find it helpful. And at the very, very least, the team at the bedside needs to be very, very experienced in this niche area of cardiac surgery. All of this is important because outcome is generally related to the length of time in the operating room, and most importantly the length of time on the heart-lung machine. So having experience reduces these time intervals which generally result in improved outcome. How many have been done totally in the program? And how many is the team doing each week? There needs to be some regularity with cases going on every week so that everybody stays versatile and experienced and comfortable with all of the nuance that surround this technology. How many have needed to be converted to an open procedure, and what has been the success rate, both early and late?

I’m proud to work at Mayo Clinic and be part of this robotic heart team, and proud to be part of the whole cardiovascular surgery enterprise, in general. Thank you very much for listening.

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