title: Three hundred robotic-assisted mitral valve repairs: the Cedars-Sinai experience.
abstract: OBJECTIVE
  The study objective was to review our first 300 consecutive robotic-assisted mitral repairs performed from June 2005 to October 2012 and to compare the surgical outcomes of our previously reported initial 120 cases with the subsequent 180 procedures.
  
  
  METHODS
  Our initial 120 robotic-assisted mitral repairs were previously reported, and we now compare our early experience with the recent 180 consecutive procedures for a total of 300 robotic-assisted mitral repairs. There was no patient selection. Every patient in need of isolated mitral valve repair underwent this procedure. All patients received an annuloplasty band and 1 or more of the following: leaflet resection, secondary chordal transposition, or polytetrafluoroethylene neochordal replacement and edge-to-edge repair.
  
  
  RESULTS
  All 300 patients had preoperative echocardiographic findings of severe mitral regurgitation. There were no differences (P = not significant) between the initial and the recent cohorts for preoperative characteristics, including age (58.4 ± 10.5 years vs 59.9 years), female gender (35.8% vs 36.1%), ejection fraction (61.9% vs 60.6%), congestive heart failure (35.0% vs 36.7%), creatinine (0.94 mg/dL vs 0.98 mg/dL), and New York Heart Association class. The incidence of anterior and posterior leaflet prolapse was similar in both groups, whereas Barlow syndrome was higher in group 2 (5.8% vs 27.8%). There was 1 (0.33%) hospital mortality and no deaths in the last 180 cases. Overall, 8 patients (2.7%) required subsequent mitral valve replacement via a median sternotomy, 6 (5.0%) in the first group and 2 (1.1%) in the second group (P = .06). One patient in each group had mitral valve re-repair through a right mini-thoracotomy, and 1 patient in the first group required a mitral valve replacement via a mini-thoracotomy during the original procedure. Two of the 180 patients had documented cerebrovascular accident, but both fully recovered clinically. There was no cerebrovascular accident in the last 120 patients. Crossclamp times decreased from 116 minutes to 91 minutes in the second group despite starting a training program with a junior associate performing part of the procedure at the console in the last 100 cases. Post-pump echocardiograms showed no/trace mitral regurgitation in 86.1% of the last 180 patients and mild mitral regurgitation in 11.1%. Follow-up echocardiography for the last 180 patients from 1 month to more than 1 year showed no/trace mitral regurgitation in 64.6% of patients and mild mitral regurgitation in 23.1% of patients. Seven patients (10.8%) had moderate mitral regurgitation, and 1 patient (1.5%) had severe mitral regurgitation.
  
  
  CONCLUSIONS
  The majority of complications and reoperations occurred early in our experience, especially using the first-generation da Vinci robot (Intuitive Surgical Inc, Sunnyvale, Calif). The newer da Vinci Si HD system with the addition of an adjustable left atrial roof retractor together with increased experience has made robotic-assisted mitral repair of all types of degenerative mitral valve pathology reproducible. The training of young surgeons in a stepwise fashion in high-volume centers will help to avoid the complications encountered during the introduction of this technology.
authors.affiliation: Division of Cardiothoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, Calif. Electronic address: dannyramzy@yahoo.ca.
authors.forename: Danny
authors.initials: D
authors.lastname: Ramzy
authors.affiliation: Division of Cardiothoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, Calif.
authors.forename: Alfredo
authors.initials: A
authors.lastname: Trento
authors.affiliation: Division of Cardiothoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, Calif.
authors.forename: Wen
authors.initials: W
authors.lastname: Cheng
authors.affiliation: Division of Cardiothoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, Calif.
authors.forename: Michele A
authors.initials: MA
authors.lastname: De Robertis
authors.affiliation: Division of Cardiothoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, Calif.
authors.forename: James
authors.initials: J
authors.lastname: Mirocha
authors.affiliation: Division of Cardiothoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, Calif.
authors.forename: Andrea
authors.initials: A
authors.lastname: Ruzza
authors.affiliation: Division of Cardiothoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, Calif.
authors.forename: Robert M
authors.initials: RM
authors.lastname: Kass
mesh_terms: D000368:Aged; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods* / Q000401:mortality; D002983:Clinical Competence; D004867:Equipment Design; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D059032:Learning Curve; D015141:Los Angeles; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000000981:diagnostic imaging / Q000601:surgery*; D058386:Mitral Valve Annuloplasty / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods* / Q000401:mortality; D008944:Mitral Valve Insufficiency / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D011183:Postoperative Complications / Q000401:mortality / Q000601:surgery; D012086:Reoperation; D012189:Retrospective Studies; D012371:Robotics / Q000295:instrumentation; D012720:Severity of Illness Index; D025321:Surgery, Computer-Assisted / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D013997:Time Factors; D016896:Treatment Outcome; D014463:Ultrasonography
keywords: 28; 35; MR; MV; TEE; mitral regurgitation; mitral valve; transesophageal echocardiography