W. Randolph Chitwood, Jr., M.D.

Greenville, North Carolina

In the last three years, a new wave of interest in less-invasive cardiac surgery has arisen almost as a "tsunami". The potential benefits of minimally invasive heart surgery include less intensive care stay requirements, less patient discomfort, earlier hospital discharge, more rapid recovery and less cost. Critics of minimally invasive valve surgery have stressed operative adequacy and safety, as well as the continued need for a pump/oxygenator. A truly endoscopic mitral and coronary operation may seem ideal, but it will require many technological advancements before being employed widely. Thus, an evolutionary quality must accompany the development of these more complex operations to ensure safety and excellence.

Video assistance, or "secondary vision" appears to offer advantages over direct vision through tiny incisions. However, acquisition of video dexterity becomes a next challenge. This becomes an even greater challenge to those who plan complex repairs using these techniques. Videoscopic valve surgery is a reality. In February of 1996, Carpentier successfully performed the first video-assisted mitral valve repair through a mini-thoracotomy using cold ventricular fibrillation. In May of 1996, our group performed the first video-assisted minimally invasive mitral valve operation in North America, using a percutaneous cross clamp and cardioplegia. Other surgeons recently pioneering video-assisted valve surgery include Mohr, Vannermin and Reichenspurner in Europe. These surgeons have collectively done more than 300 operations using assisted vision. As of October 1999, we had performed 85 "micro-mitral" either video-assisted or video-directed mitral repair/replacement operations successfully at our center and five in Europe. Repairs were done in nearly 65% of patients. Operative results have been excellent with a mortality of 1.2% at our institution and few major perioperative complications. Perfusion and cardiac arrest times were long initially; however, patients were discharged significantly earlier (four vs eight days - sternotomy) and with less postoperative pain. It is clear to us that patients recover faster than with conventional sternotomies. Transfusion requirements and hospital costs have been significantly less when compared with a cohort of conventional mitral surgery patients. Thus, the addition of video assistance is beneficial and does not add cost. This is the first step toward a truly endoscopic operation.

Robotic devices are now being employed to enable cardiac surgery. We have used the Aesop 3000™ voice-activated robotically controlled camera to endoscopically repair or replace over 40 mitral valves. Visualization was easier, and these devices helped reduce operative and perfusion times. The next step is robotic instrument-tip manipulation at the intracardiac operative site. Totally robotic mitral operations have and continue to be done Europe by Carpentier and Mohr using the da Vinci™ (Intuitive) system. The author was present for several early coronary and mitral robotic operations and became convinced that intracardiac suturing and tissue reconstruction can be done totally robotically. Since mid-1998, nearly 50 mitral operations have been done in Europe using the da Vinci™ (Intuitive) device. The author was the first American to perform a mitral repair using this robot, while working in Leipzig last March with Professor Mohr.

These systems work on the concept of telepresence surgery, in which the surgeon no longer manipulates the tissue directly, but through robotic instruments controlled electronically by the surgeon. Last summer, Reichenspurner and Damiano reported using the Zeus™ system (Computer Motion, Inc.) to affect excellent coronary anastomoses. These latter procedures approximated an endoscopic coronary operation; however, a very small thoracic incision still was required. Loulmet and Carpentier reported the first totally endoscopic coronary operation in July of 1999. In this case the internal thoracic artery was harvested and anastomosed to the left anterior descending coronary completely robotically with da Vinci™. This month (October 1999) Boyd and Menkis in Canada completed a beating heart coronary anastomosis using Zeus™. Contemporaneously, Wolfe and Michler harvested internal mammary arteries using the da Vinci™ system at Ohio State University under an FDA protocol. Next month, East Carolina University/Pitt Memorial Hospital will obtain the second da Vinci™ system in the United States, and, to open the new millennium in cardiac surgery, we are planning the first mitral repairs here in early 2000.

Our micromitral video-assisted/video-directed method appears to have promise for the future as it is safe and employs modifications of conventional cardiac surgical technology while moving surgeons forward. This method represents sort of a "halfway house" to a totally endoscopic mitral operation. Surgeons can learn video dexterity and operation using a totally new concept as a bridge to the future, which will be heavily influenced by electronic robotic manipulation. Technical familiarity and cost benefits are important for surgeons first experiencing the challenging nuances of operating through tiny incisions. Newer three-dimensional visioning devices may help immensely in operating through even smaller incisions. We believe that various forms of developing robotic devices will lead us to true "telemicro access " for both valve and coronary surgery. A new era has arrived for cardiac surgeons. We believe that our patients will benefit from these new operations if we proceed cautiously, question our results and maintain databases that can help us critically review our progress. Yes, these devices are expensive, but be assured they are not toys and will surely evolve to become true enabling devices for many cardiac operations. However, these devices mirror our motions and expertise. Colleagues, a robot will never make a mediocre surgeon a "whizz-bang".

(In Order of Publication)