title: Systematic review of robotic minimally invasive mitral valve surgery.
abstract: BACKGROUND
  Robotic telemanipulators have evolved to assist the challenges of minimally invasive mitral valve surgery (MVS). A systematic review was performed to provide a synopsis of the literature, focusing on clinical outcomes and cost-effectiveness.
  
  
  METHODS
  Structured searches of MEDLINE, Embase, and Cochrane databases were performed in August 2013. All original studies except case-reports were included in qualitative review. Studies with ≥50 patients were presented quantitatively.
  
  
  RESULTS
  After applying inclusion and exclusion criteria to the search results, 27 studies were included in qualitative review, 16 of which had ≥50 patients. All studies were observational in nature, and thus the quality of evidence was rated low to medium. Patients generally had good left ventricular performance, were relatively asymptomatic, and mean patient age ranged from 52.6-58.4 years. Rates of intraoperative outcomes ranged from: 0.0-9.1% for conversion to non-robotic surgery, 106±22 to 188.5±53.8 min for cardiopulmonary bypass (CPB) time and 79±16 to 140±40 min for cross-clamp (XC) time. Rates of short-term postoperative outcomes ranged from: 0.0-3.0% for mortality, 0.0-3.2% for myocardial infarction (MI), 0.0-3.0% for permanent stroke, 1.6-15% for pleural effusion, 0.0-5.0% for reoperations for bleeding, 0.0-0.3% for infection, and 1.1-6% for prolonged ventilation (>48 hours), 1.5-5.4% for early repair failure, 12.3±6.7 to 36.6±24.7 hours for intensive care length of stay, 3.1±0.3 to 6.3±3.9 days for hospital length of stay (HLOS) and 81.7-97.6% had no or trivial mitral regurgitation (MR) before discharge.
  
  
  CONCLUSIONS
  All subtypes of mitral valve prolapse are repairable with robotic techniques. CPB and XC times are long, and novel techniques such as the Cor-Knot, Nitinol clips or running sutures may reduce the time required. The overall rates of early postoperative mortality and morbidity are low. Improvements in postoperative quality of life (QoL) and expeditious return to work offset the increase in equipment and intraoperative cost. Evidence for long-term outcomes is as yet limited.
authors.affiliation: Sydney Medical School, The University of Sydney, Sydney, Australia; ; The Baird Institute of Applied Heart & Lung Surgical Research, Sydney, Australia;
authors.forename: Michael
authors.initials: M
authors.lastname: Seco
authors.affiliation: The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia;
authors.forename: Christopher
authors.initials: C
authors.lastname: Cao
authors.affiliation: Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK;
authors.forename: Paul
authors.initials: P
authors.lastname: Modi
authors.affiliation: The Baird Institute of Applied Heart & Lung Surgical Research, Sydney, Australia; ; The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia; ; Department of Cardiothoracic Surgery, University of Sydney, Royal Prince Alfred Hospital, Sydney, Australia;
authors.forename: Paul G
authors.initials: PG
authors.lastname: Bannon
authors.affiliation: Department of Cardiothoracic Surgery, University of Sydney, Royal Prince Alfred Hospital, Sydney, Australia; ; Australian School of Advanced Medicine, Macquarie University, Sydney, Australia;
authors.forename: Michael K
authors.initials: MK
authors.lastname: Wilson
authors.affiliation: The Baird Institute of Applied Heart & Lung Surgical Research, Sydney, Australia; ; Department of Cardiothoracic Surgery, University of Sydney, Royal Prince Alfred Hospital, Sydney, Australia; ; Australian School of Advanced Medicine, Macquarie University, Sydney, Australia;
authors.forename: Michael P
authors.initials: MP
authors.lastname: Vallely
authors.affiliation: The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia; ; Department of Cardiothoracic Surgery, University of Sydney, Royal Prince Alfred Hospital, Sydney, Australia;
authors.forename: Kevin
authors.initials: K
authors.lastname: Phan
authors.affiliation: Department of Cardiac Surgery, Heart Centre Leipzig, University of Leipzig, Leipzig, Germany.
authors.forename: Martin
authors.initials: M
authors.lastname: Misfeld
authors.affiliation: Department of Cardiac Surgery, Heart Centre Leipzig, University of Leipzig, Leipzig, Germany.
authors.forename: Friedrich
authors.initials: F
authors.lastname: Mohr
authors.affiliation: The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia; ; Department of Cardiothoracic Surgery, University of Sydney, Royal Prince Alfred Hospital, Sydney, Australia; ; Australian School of Advanced Medicine, Macquarie University, Sydney, Australia;
authors.forename: Tristan D
authors.initials: TD
authors.lastname: Yan
keywords: Robot; minimally invasive; mitral valve; repair; replacement; telemanipulator