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Original Investigation |

Value of Robotically Assisted Surgery for Mitral Valve Disease

Tomislav Mihaljevic, MD1,2; Marijan Koprivanac, MD1; Marta Kelava, MD1; Avi Goodman, BS3; Craig Jarrett, MD, MBA1; Sarah J. Williams, MS4; A. Marc Gillinov, MD1; Gurjyot Bajwa, MD1; Stephanie L. Mick, MD1; Johannes Bonatti, MD1; Eugene H. Blackstone, MD1,4
[+] Author Affiliations
1Heart and Vascular Institute, Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
2Heart and Vascular Institute, Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Abu Dhabi, United Arab Emirates
3Case Western Reserve University School of Medicine, Cleveland, Ohio
4Research Institute, Department of Quantitative Health Sciences, Cleveland, Ohio
JAMA Surg. 2014;149(7):679-686. doi:10.1001/jamasurg.2013.5680.
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Importance  The value of robotically assisted surgery for mitral valve disease is questioned because the high cost of care associated with robotic technology may outweigh its clinical benefits.

Objective  To investigate conditions under which benefits of robotically assisted surgery mitigate high technology costs.

Design, Setting, and Participants  Clinical cohort study at a large multispecialty academic medical center comparing costs of robotically assisted surgery with 3 contemporaneous conventional surgical approaches for degenerative mitral valve disease. From January 1, 2006, through December 31, 2010, a total of 1290 patients with a mean (SD) age of 57 (11) years underwent mitral valve repair for regurgitation from posterior leaflet prolapse. Robotically assisted surgery was performed in 473 patients, complete sternotomy in 227, partial sternotomy in 349, and anterolateral thoracotomy in 241. Comparisons were based on intent to treat, with 3 propensity-matched groups formed based on demographics, symptoms, cardiac and noncardiac comorbidities, valve pathophysiologic disorders, and echocardiographic measurements: robotic vs sternotomy (198 pairs) vs partial sternotomy (293 pairs) vs thoracotomy (224 pairs).

Interventions  Mitral valve repair.

Main Outcomes and Measures  Cost of care (expressed as robotic capital investment, maintenance of equipment, and direct technical hospital costs) and benefit of care (based on differences in recovery time).

Results  Cost of care (median [15th and 85th percentiles]) for robotically assisted surgery exceeded that of alternative approaches by 26.8% (–5.3% and 67.9%), 32.1% (–6.1% and 69.6%), and 20.7% (–2.4% and 48.4%) for complete sternotomy, partial sternotomy, and anterolateral thoracotomy, respectively. Higher operative costs were partially offset by lower postoperative costs and earlier return to work: a median (15th and 85th percentiles) of 35 (19 and 63) days for robotically assisted surgery, 49 (21 and 109) days for complete sternotomy, 56 (30 and 119) days for partial sternotomy, and 42 (18 and 90) days for anterolateral thoracotomy. Resulting net differences (median [15th and 85th percentiles]) in the cost of robotic surgery vs the 3 alternatives were 15.6% (–14.7% and 55.1%), 15.7% (–19.4% and 51.2%), and 14.8% (–7.4% and 43.6%), respectively. Beyond a volume threshold of 55 to 100 robotically assisted operations per year, distribution of the cost of this technology broadly overlapped those of conventional approaches.

Conclusions and Relevance  In exchange for higher procedural costs, robotically assisted surgery for mitral valve repair offers the clinical benefit of least-invasive surgery, lowest postoperative cost, and fastest return to work. The value of robotically assisted surgery that is similar to that of conventional approaches can be realized only in high-volume centers.

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Figure 1.
CONSORT Diagram Showing Patient Groups by Approach

Ninety-one percent of patients matched (87.2% of complete sternotomy, 83.9% of partial sternotomy, 92.9% of anterolateral thoracotomy, and 96.8% of robotic groups). MV indicates mitral valve.

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Figure 2.
Forest Plot of Cost Ratios

All cost ratios are presented as robotic to nonrobotic. Each symbol denotes median cost ratio, with lines extending from the 15th to 85th percentiles. Note that the horizontal axis is logarithmic.

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Figure 3.
Case Volume–Cost Relationship

The horizontal line represents a cost ratio of 1 (meaning costs are equal), and the solid curved line represents a net cost ratio, including amortization for robotic capital investment and maintenance, direct technical hospital costs, and benefit of care translated into income difference, depending on the annual number of patients for whom robotic procedures were performed. Dashed lines enclose the 15th through 85th percentiles of the ratio. A, Robotically assisted surgery (ROB) vs complete sternotomy (CST). B, ROB vs partial sternotomy (PST). C, ROB vs anterolateral thoracotomy (ANT).

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