title: Can the learning curve of totally endoscopic robotic mitral valve repair be short-circuited?
abstract: OBJECTIVE
  A concern with the initiation of totally endoscopic robotic mitral valve repair (TERMR) programs has been the risk for the learning curve. To minimize this risk, we initiated a TERMR program with a defined team and structured learning approach before clinical implementation.
  
  
  METHODS
  A dedicated team (two surgeons, one cardiac anesthesiologist, one perfusionist, and two nurses) was trained with clinical scenarios, simulations, wet laboratories, and "expert" observation for 3 months. This team then performed a series of TERMRs of varying complexity.
  
  
  RESULTS
  Thirty-two isolated TERMRs were performed during the first programmatic year. All operations included mitral valve repair, left atrial appendage exclusion, and annuloplasty device implantation. Additional procedures included leaflet resection, neochordae insertion, atrial ablation, and papillary muscle shortening. Longer clamp times were associated with number of neochordae (P < 0.01), papillary muscle procedures (P < 0.01), and leaflet resection (P = 0.06). Sequential case number had no impact on cross-clamp time (P = 0.3). Analysis of nonclamp time demonstrated a 71.3% learning percentage (P < 0.01; ie, 28.7% reduction in nonclamp time with each doubling of case number). There were no hospital deaths or incidences of stroke, myocardial infarction, unplanned reoperation, respiratory failure, or renal failure. Median length of stay was 4 days. All patients were discharged home.
  
  
  CONCLUSIONS
  Totally endoscopic robotic mitral valve repair can be safely performed after a pretraining regimen with emphasis on experts' current practice and team training. After a pretraining regimen, cross-clamp times were not subject to learning curve phenomena but were dependent on procedural complexity. Nonclamp times were associated with a short learning curve.
authors.affiliation: From the Departments of *Cardiothoracic Surgery, †Anesthesiology, and ‡Extracorporeal Services, NYU Langone Medical Center, New York, NY USA.
authors.forename: David W
authors.initials: DW
authors.lastname: Yaffee
authors.forename: Didier F
authors.initials: DF
authors.lastname: Loulmet
authors.forename: Lauren A
authors.initials: LA
authors.lastname: Kelly
authors.forename: Alison F
authors.initials: AF
authors.lastname: Ward
authors.forename: Patricia A
authors.initials: PA
authors.lastname: Ursomanno
authors.forename: Annette E
authors.initials: AE
authors.lastname: Rabinovich
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Neuburger
authors.forename: Sandeep
authors.initials: S
authors.lastname: Krishnan
authors.forename: Frederick T
authors.initials: FT
authors.lastname: Hill
authors.forename: Eugene A
authors.initials: EA
authors.lastname: Grossi
mesh_terms: D000328:Adult; D000368:Aged; D004502:Education, Medical, Continuing / Q000379:methods*; D004724:Endoscopy / Q000193:education* / Q000379:methods; D019918:Heart Valve Prosthesis Implantation / Q000193:education* / Q000379:methods; D006801:Humans; D059032:Learning Curve; D008297:Male; D008875:Middle Aged; D008944:Mitral Valve Insufficiency / Q000601:surgery*; D012371:Robotics / Q000193:education* / Q000379:methods; D013997:Time Factors; D055815:Young Adult