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Robotic heart surgery: making repairs without lifting the hood
November 19, 2002

CHICAGO, IL (AHA) For the first time in the United States, open-heart surgery was performed without opening the chest, in more than a dozen patients, researchers reported in preliminary results presented at the American Heart Association's Scientific Sessions 2002.

In this procedure, surgeons remotely maneuver robotic arms from a seat in front of a console away from the patient. Instead of opening the chest and cutting the skin and muscle to view the area, surgeons make four holes (8 to 15 millimeters each) through which robotic arms are inserted. The robotic arms include one with a camera-like device to transmit the image to the console. The other arms are fitted with operating instruments.

Surgeons used this new procedure to successfully repair the hearts of patients with atrial septal defect (ASD) or patent foramen ovale conditions in which people are born with an opening between the heart's two upper chambers. This opening allows some blood from the left atrium to return to the right atrium, instead of flowing through the left ventricle, out the aorta and to the body. It's repaired either by plugging the hole with a patch or suturing the hole closed.

Open-heart surgery traditionally requires that surgeons make a foot-long chest incision to cut patients' breastbones in half.

"We wanted to know if it was possible to operate inside the hearts of these patients without making any incisions," says Mehmet Oz, M.D., director of the Heart Institute at Columbia-Presbyterian Medical Center in New York. "Not only did we show that the operation is feasible, but we demonstrated it in more than a dozen patients."

During 12 months, 15 patients (ages 22 to 68) underwent ASD repair using the robotic technology, called the Da VinciTM system.

"Although the equipment is costly, this is definitely part of the future," says Michael Argenziano, M.D., lead author of the study and director of robotic cardiac surgery at Columbia-Presbyterian. "Patients are going to insist on it despite the expense because it's cosmetically superior and allows for much faster recovery. For certain procedures, like the ASD repair, it's already proving to be a worthy alternative to conventional surgery."

The researchers found that robot-assisted endoscopic heart surgery takes a little longer than the traditional technique, but that might be attributable to the learning curve necessary to use the new approach. The heart was stopped for 34 minutes on average, versus about 20 for traditional surgery. The time needed on a cardiopulmonary bypass machine was also slightly longer.

Patients in the study had no major complications. In 14 cases, imaging tests confirmed that the defect had been successfully closed. One patient required a repair five days later. Surgeons did this through a three-inch incision (a mini-thoracotomy). The average length of stay in the intensive care was 18 hours, which is about the same as for the traditional approach. The average hospital stay was three days two to four days shorter than for a traditional operation.

"The primary advantages of this minimally invasive surgery are faster patient recovery, less pain and dramatically less scarring than traditional open-heart surgery," Argenziano says.

Patients return to work and normal activity about 50 percent faster than those who have the open procedure, he says. Quality of life measures also revealed the robotically treated patients had improved social functioning and less pain compared to patients undergoing traditional surgical approaches.

Doctors are also using the robotic technology to repair mitral valve defects through incisions in the side of the chest.

"What makes the totally endoscopic ASD repair a significant advance is that it is the first closed-chest open-heart procedure," Argenziano says.

Argenziano is also principal investigator of several Food and Drug Administration-sanctioned trials of robotic cardiac surgery including one in which it is used for closed-chest coronary artery bypass surgery (CABG). Earlier this year, the Columbia team performed the first totally endoscopic CABG in the United States.

"We have wonderful surgical cures for heart disease in that they're very effective and long-lasting," Oz says. "However, they're also very traumatic. So, we're evaluating a technology that might provide us with the same wonderful results without the trauma."

Several facilities nationwide offer the Da VinciTM technology, and researchers at about four other centers have been specifically trained to perform ASD closure, the researchers say.

Co-authors are Takushi Kohmoto, M.D.; Mauricio Garrido, M.D.; Jaina Dimitui, R.N.; James Beck, perfusionist; Linda Mongero, perfusionist; Hadar Hermoni, B.S.; and Craig R. Smith Jr., M.D. 

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