The Role Of Robotics In Cardiac Surgery: A Systematic Review

Conventional open cardiac surgery carries an increased operation risk and requires a large incision, long hospitalization and recovery time [1]. Minimally invasive approaches applied in cardiac surgery have been shown to significantly merit patients in terms of minimized surgical trauma, reduced need for analgesia and faster recovery [1].

Since its introduction in the late 1990s, robotic cardiac surgery has gained increased acceptance in a number of cardiac surgical procedures including coronary artery bypass grafting (CABG), mitral valve repair/replacement (MVR), cardiac tumor resection and atrial septal defect (ASD) closure [2]. Several studies have aimed to evaluate the safety and efficacy of robotic cardiac surgery. A recently published meta-analysis of 16 studies, which compared totally endoscopic coronary artery bypass (TECAB) and robotically assisted coronary artery bypass (RACAB) with conventional CABG showed that both minimally invasive techniques are safe and feasible [3]. Another systematic review of robotic mitral valve surgery by Seco et al. [4], concluded that the application of robotics is a viable option for every type of mitral valve surgery and that it is associated with acceptable mortality rates (0–3%). Furthermore, a review of the robotic cardiac operations performed in Europe suggested a long-year experience with robotic CABG and a much shorter with robotic MVR, but with low peri-operative complications [2]. Cumulative evidence on the mortality rates associated with robotic cardiac surgery is still inconclusive.

To that end, the objective of our study was to systematically review the existing literature for all types of robotic cardiac surgery and establish a comprehensive overview of the post-operative mortality associated with these novel surgical approaches.

Methods

Search strategy and eligibility of studies

The present systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guidelines and in line with the protocol agreed by all authors. PubMed and Cochrane bibliographic databases were thoroughly searched from January 1986 to February 2018 (last search: March 4th, 2018). Two investigators (I. D and E. S. ) worked independently and executed the search using the following MeSH terms: “robotic”, “cardiac surgery” and “heart surgery”. A manual search of additional articles was conducted using references from relevant articles and review papers. Any discrepancies were resolved by consensus agreement by a third reviewer (MS). Original clinical studies written in English on the applications of robotic surgery in cardiac surgery in more than ten cases and reporting on the associated peri- or post-operative mortality were included in the present study.

Excluded studies met at least one of the following criteria: (1) papers published in a language other than English, (2) studies not showing mortality data explicitly for patients undergone robotic cardiac surgery (3) studies which included patients that solely underwent robotic ablation or resynchronization, (4) case reports, (5) experimental studies in animals, (6) studies in non-adults, (7) studies reporting on data from large-scale databases, (8) reviews and meta-analyses, (9) editorials and letters to the editor and (10) papers irrelevant to our study data, such as epidemiological data, anesthesia techniques, etc. Ethical approvalThis article does not contain any studies with human participants or animals performed by any of the authors.

Data extraction

Data were extracted regarding type of operation, robotic technique and surgical system used, country of origin, Newcastle–Ottawa Scale (NOS), study timeframe, number of patients who underwent cardiac robotic surgery, patient demographics [gender, age, body mass index (BMI)], patient comorbidities (such as known hypertension, diabetes mellitus, dyslipidemia) presence of angina, smoking status, history of myocardial infarction (MI), cerebrovascular disease, peripheral vascular disease, chronic obstructive pulmonary disease (COPD), percutaneous primary coronary intervention (PCI), euroSCORE, presence of single or multi-vessel disease and pre-operative ejection fraction (EF). Peri-operative data such as urgency for operation, total operative time, ventilation time, cardiopulmonary bypass (CPB) time, crossclamp (XC) time, on-pump time, intensive care unit (ICU) stay and length of stay (LoS) were also extracted. Post-operative complications conversion, myocardial infarction (MI), cerebrovascular accident (CVA), atrial fibrillation (AF), bleeding, pneumonia, renal failure, infection, anastomotic stenosis, re-operation, late re-intervention and major adverse cardiac and cerebrovascular events (MACCE) were also noted down. Short-term mortality was defined as the mortality rate in the first 30 days after the operation, whereas long-term mortality referred to a period over 30 days after surgery.

Statistical analysis

The extracted data were incorporated into tables and analyzed regarding the type of operation, namely CABG (TECAB and non-TECAB), MVR and other (ASD repair and atrial myxoma resection). A cumulative analysis of the extracted data was also performed and a descriptive approach was adopted in all parameters. No further statistical analysis was attempted.