title: Robotically assisted totally endoscopic atrial septal defect repair: insights from operative times, learning curves, and clinical outcome.
abstract: BACKGROUND
  Remote access perfusion and robotics have enabled totally endoscopic closure of atrial septal defect and patent foramen ovale. The aim of this study was to address learning curve issues of totally endoscopic atrial septal defect repair on the basis of a single-center experience and to investigate whether long cardiopulmonary bypass and aortic occlusion times influence intraoperative and postoperative outcomes.
  
  
  METHODS
  Seventeen patients (median age, 35 years; range, 16 to 55 years) underwent totally endoscopic atrial septal defect repair using remote access perfusion and robotic technology (da Vinci telemanipulation system). Learning curves were assessed by means of regression analysis with logarithmic curve fit. The effect of operative variables on clinical outcome was analyzed by linear regression using the Spearman's rho coefficient.
  
  
  RESULTS
  No operative mortality or serious surgical complications were observed. No residual shunt was detected at intraoperative or postoperative echocardiography. Significant learning curves were noted for total operative time: y(min) = 406 - 49 ln(x) (r2 = 0.725; p = 0.002); cardiopulmonary bypass time: y(min) = 225 - 42 ln(x) (r2 = 0.699; p = 0.003); and aortic occlusion time: y(min) = 117 - 25 ln(x) (r2 = 0.517; p = 0.04), x = number of procedures. Median ventilation time, intensive care unit stay, and hospital length of stay were 7 hours (range, 2 to 19 hours), 26 hours (range, 15 to 120 hours), and 8 days (range, 5 to 14 days), respectively. No correlation was detected between cardiopulmonary bypass time and intubation time (r2 = 0.283; p = 0.326), intensive care unit stay (r2 = -0.138; p = 0.639), or total length of stay (r2 = 0.013; p = 0.962).
  
  
  CONCLUSIONS
  Totally endoscopic atrial septal defect repair can be performed safely, and learning curves for operative times are steep. Longer cardiopulmonary bypass times had no negative impact on intraoperative and postoperative outcome.
authors.affiliation: Department of Cardiac Surgery, Innsbruck Medical University, Innsbruck, Austria. nikolaos.bonaros@uibk.ac.at
authors.forename: Nikolaos
authors.initials: N
authors.lastname: Bonaros
authors.forename: Thomas
authors.initials: T
authors.lastname: Schachner
authors.forename: Armin
authors.initials: A
authors.lastname: Oehlinger
authors.forename: Elisabeth
authors.initials: E
authors.lastname: Ruetzler
authors.forename: Christian
authors.initials: C
authors.lastname: Kolbitsch
authors.forename: Wolfgang
authors.initials: W
authors.lastname: Dichtl
authors.forename: Silvana
authors.initials: S
authors.lastname: Mueller
authors.forename: Guenther
authors.initials: G
authors.lastname: Laufer
authors.forename: Johannes
authors.initials: J
authors.lastname: Bonatti
mesh_terms: D000293:Adolescent; D000328:Adult; D006348:Cardiac Surgical Procedures; D002315:Cardiopulmonary Bypass; D004724:Endoscopy; D005260:Female; D006344:Heart Septal Defects, Atrial / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D012371:Robotics; D013997:Time Factors