COMMENTARY

Robotic Mitral Valve Repair: Costly or Cost-Effective?

Charanjit (Chet) S. Rihal, MD; Rakesh M. Suri, MD, DPhil

Disclosures

March 24, 2014

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Robotic vs Traditional Mitral Valve Repair

Charanjit S. Rihal, MD: Hi. This is Dr. Chet Rihal. My guest today is Dr. Rakesh Suri, from the Division of Cardiovascular Surgery. Rakesh, welcome.

Rakesh M. Suri, MD, DPhil: Thanks, Chet.

Dr. Rihal: We are here today to talk more about robotic mitral valve repair and some of the implications for practice. Rakesh, you have been involved in leading innovative studies and projects in the area of valvular heart disease. Why is that important?

Dr. Suri: Buzzwords, such as "innovation" and "new technology," are around us almost continuously these days. We want to do things faster, quicker, and better, but the question is, are these in fact better? Are they cheaper? And how does this affect our healthcare system?

Dr. Rihal: You have been particularly interested in robotic mitral valve repair. Can you tell us about robotic mitral valve repair -- what it is, and how it's different from existing repair techniques?

Dr. Suri: Mitral valve repair is the guideline-sanctioned standard of care for those with severe mitral regurgitation. However, patients are often forced to undergo costly and complicated rescue operations because of delayed referral and heart failure symptoms, which in essence increase the healthcare burden.

In addition, some patients and cardiologists defer referral for surgery to avoid the presumed morbidity of traditional surgical intervention performed by open-chest procedures.

So the question, when we consider less invasive approaches, is this: How can we leverage new technology, including high-definition, 3-dimensional imaging, and robotic telemanipulation to perform these life-saving, complex, and judgment-laden operations through small ports in the right side of the chest? That is where robotics has played a crucial role in our practice.

Contraindications to Robotic Repair

Dr. Rihal: How is this actually done, Rakesh?

Dr. Suri: We screen our patients preoperatively with a CT scan of the chest, abdomen, and pelvis, including ECG gating of the coronary arteries, and this allows us to ensure that 1 of 3 contraindications is not present. Two of them can be ruled out on CT. The first is significant coronary disease, necessitating concomitant coronary artery bypass grafting (CABG) through open sternotomy. The second is severe peripheral vascular disease precluding safe cannulation of the peripheral vasculature.

The third contraindication with the currently available robotic technology is redo operations. We don't feel that there is a distinct advantage associated with robotic procedures in this patient population.

Once these contraindications have been ruled out, the patient is placed on cardiopulmonary bypass through a small incision in the groin. Small ports are opened in the right chest. The aorta is cross-clamped and the heart arrested with cold-blood high-potassium antegrade cardioplegia in exactly the same manner as we would through an open sternotomy approach. The mitral valve repair is performed through a left atriotomy incision, which gains us excellent visualization and access to the mitral valve.

Dr. Rihal: As I understand it, the robotic repair that you are performing is actually the exact same repair that you would perform with an open sternotomy; is that not correct?

Dr. Suri: Yes. Not changing the operation is a crucial cornerstone of our program at Mayo Clinic, and we perform exactly the same cutting, sewing, and placement of annuloplasty bands, and quality control, as we would in an open operation.

Dr. Rihal: How long does this repair take in comparison with the standard repair?

Dr. Suri: Any new technology or technique, whether it's a new golf club or a new car or learning a new sport, has a learning curve that must be obeyed and followed. So whether it is the surgeon -- or importantly, in robotics, the team-based approach -- there is a necessary learning curve that must occur.

Initially, when a surgeon and a team begin robotic mitral valve repair practice, as a transcatheter practice, operating times are longer and complications can be slightly higher. However, with persistence, honing, and innovation (which we will speak about in a second) times and costs decrease and patient outcomes improve, such that our times currently for robotic mitral valve repair operation are as low as and, in some cases, lower than those for traditional open operations.

Assessing the Cost of an Innovative Cardiac Surgery Platform

Dr. Rihal: Aren't innovations like this just simply too expensive? I know you have published, or are going to be publishing, some very interesting data about this.[1] What can you tell us about that?

Dr. Suri: The real question is whether novel surgical technology, such as robotics deployed in conjunction with tailored postoperative care pathways, alters cost, and we simply don't know the answer to that. Therefore, we performed an innovative study to examine this exact point. We introduced less invasive mitral valve repair using what is called technical innovation (or what we are calling "technical innovation" in our paper -- eg, robotics) within a concurrent systems innovation initiative, introduced in July 2009.

What does "systems innovation" mean? Simply, the first thing was the availability of operating rooms, surgical process improvement initiatives, and essentially making the operating room more efficient.

Second, when patients returned to the intensive care unit (ICU), we implemented expedited care pathways which helped them transition quickly through the ICU (a very high-priced area of the hospital) to our postoperative care units, or to our floor-based care.

We sought to determine whether technically innovative cardiac surgical platforms, such as robotics performed in conjunction with surgical process improvement, influences total hospital cost to address the concern that expanding adoption of these high-technology platforms might unnecessarily drive up healthcare expenses.

Robotic Surgery: Lower Length of Stay

Dr. Rihal: What did you find?

Dr. Suri: We studied 185 propensity-matched pairs that were very similar in terms of all preoperative comorbid conditions and risk factors. We considered 2 time points in our analysis. The first was before the implementation of systems innovation (pre-July 2009), and the second was postimplementation.

We found that regardless of the status of utilization of systems innovation (eg, July 2009), the length of hospital stay for robotic surgery patients was always lower. In other words, the mean length of hospital stay after robotic mitral valve repair was on the order of 3-3.5 days, whereas after traditional sternotomy mitral valve repair, the hospital stay was 5-7 days.

Moreover, if we examined total hospital costs, including operating room costs, ICU costs, floor costs, and even amortized costs of the robotic equipment, we found that throughout the course of the study that between groups, the costs were the same.

Now, we spoke about a learning curve. Initially, before implementation of systems innovation, the costs associated with robotic operations were slightly higher than those associated with traditional open sternotomy mitral valve repair procedures. However, with time, and particularly following implementation of systems innovation, robotic costs declined significantly, such that they became statistically indistinguishable -- similar to those of open mitral valve repair operations and, in some instances, even cheaper.

Dr. Rihal: In other words, you were able to introduce a new technology, the team was able to go through the learning curve, you were able to get the same or better results, and you got the patients out of the hospital faster. Is that what you are saying?

Dr. Suri: Those are all correct summaries of what we found. In particular, when people ask what the greatest cost savings was associated with, we found the following diminished ICU stay and quicker extubation (on the operating room table) were both associated with a very rapid reduction in hospital costs. So patients began waking up quicker on the operating room table, and we were able to get the breathing tube out and actually shuttle them through the ICU the same day of surgery and out to the floor. These 2 features, in particular -- which are by-products or offshoots of systems innovation, in our view -- allowed us to reduce cost in a very rapid and reproducible fashion.

Volume Is Critical for Safety

Dr. Rihal: There have been concerns at the national level about safety with some robotically assisted operations. Could you address that? Are these learning curve effects? What is going on with this?

Dr. Suri: Safety is a concern with the implementation or adoption of any new technology, whether it's transcatheter-based technology, port-access approaches, or robotics. This is an age-old trend that needs to be understood to be avoided.

Merely giving a surgeon or a surgical team a $2 million piece of equipment is not going to allow that surgeon to repair mitral valves when previously they were unable to do so or their system wasn't able to support that. In other words, we adhere to the suggestion that a critical volume of mitral valve repair should be performed at an institution with the support of cardiologists, echocardiographic expertise, and postoperative surgical care to deliver high-quality mitral valve repair services.

Once that is in place as an a priori component, we can then introduce more innovative technological solutions in conjunction with systems innovation to help expedite or shorten that learning curve and allow patients to benefit very rapidly from the introduction of these very novel technological platforms.

Dr. Rihal: This has been a most informative conversation. How would you summarize your data for our audience?

Dr. Suri: In summary of our publication, 3 points emerge. The first is that systems innovation -- or in other words, expedited postoperative care pathways -- are useful in reducing hospital costs in general, whether it's a standard approach or a less invasive approach.

Second, high-technology, intensive procedures -- such as transcatheter therapy or robotics, in this case -- can be introduced and be cost-neutral.

Third, these 2 things in concert can have an important effect that we all need to maintain and be mindful of in the current era -- and that is optimizing healthcare value to help sustain our healthcare system into the future.

Dr. Rihal: That is a great summary, Rakesh. I would like to thank you for joining me today, and thank you to our audience for listening.

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