Robotic mitral repair compares favorably to surgery—but some concerns remain
Robotic-assisted mitral valve repair is associated with short-term outcomes comparable to conventional surgery, according to a recent study published in The Annals of Thoracic Surgery.[1] Robotic treatment also helps patients spend less time in the hospital, but the costs are considerably higher.
“Robotic-assisted techniques offer 3D visualization, wristed instruments and avoidance of sternotomy, which may be valuable in younger patients or those anticipated to require reoperation,” wrote corresponding author Peyman Benharash, MD, a cardiac surgeon with UCLA Health and director of the UCLA Cardiovascular Outcomes Research Laboratories, and colleagues. “Given the relevance of value-based healthcare delivery, costs of new technologies are weighted against their incremental clinical benefit. In the case of robotic surgery, costs stem from acquisition/maintenance of robotic platforms, disposable instruments and increased operative times. Some have argued that enhanced recovery and reduced hospitalization time counterbalance the excess costs associated with robotic approaches.”
Hoping to learn more about how robotic mitral repair compares with surgery, Benharash et al. examined data from more than 40,000 patients who underwent treatment from 2016 to 2020. Nearly 10% of those patients underwent robotic mitral repair. The median ages for the two groups were nearly identical—approximately 61 years old—but robotic mitral repair patients were more likely to be men, have private insurance coverage and belong to the highest income quartile. These patients were also less likely to present with certain comorbidities, including chronic lung disease, end-stage renal disease, peripheral vascular disease and pulmonary hypertension.
Overall, robotic mitral repair and surgery resulted in comparable rates of in-hospital mortality, stroke, blood transfusion, reoperation and hospital readmission. In addition, robotic treatment was associated with lower rates of pulmonary complications (6.1% vs. 8.1%), postoperative infection (1.7% vs. 3.4%) and acute kidney injury (AKI) (5.7% vs. 8.5%) as well as significantly shorter lengths of stay and a reduced chance of being discharged to another type of healthcare facility.
As one may expect, however, mean healthcare costs were considerably higher for robotic mitral repair ($53,600 vs. $45,200).
Researchers then performed another analysis after adjusting for certain risks. Many of the same trends remained, including the comparable mortality, stroke and reoperation rates. However, robotic mitral repair was no longer associated with a reduced risk of pulmonary complications, infection or AKI.
After risk adjustment, some key differences between the two approaches did remain. Robotic mitral repair was still associated with significantly higher healthcare costs, for example, and patients were able to get out of the hospital more than a day faster than with conventional surgery.
Yet another key takeaway from the team’s research was the fact that facilities performing the most robotic mitral valve repairs saw the smallest difference in healthcare costs. This suggests that costs may be higher at first for any new facilities starting to offer robotic mitral repair, but those costs can decrease over time.
“In conclusion, robotic-assisted surgery is comparable to conventional approaches for mitral valve repair in regard to short-term outcomes,” the authors wrote. “While robotic-assisted mitral valve repair was associated with greater inpatient costs, LOS and discharge to facility were significantly reduced.”
‘We have a lot more work to do’
A team of specialists with Cedars-Sinai in Los Angeles, including veteran cardiac surgeon Alfredo Trento, MD, shared their perspective about this research in a separate editorial.[2] The group congratulated the authors for their work, highlighting the importance of learning more about this topic, but they also wrote shared some concerns about the study’s findings. The fact that robotic treatment was more commonly used to treat patients who earn a higher income, for example, suggests that the increased costs of robotic mitral repair could not necessarily be as beneficial for all patients.
“A health intervention that can only be performed at a handful of hospitals by a select group of individuals is not necessarily a good intervention as it is not generalizable and not applicable to most of the population,” the group wrote. “For cardiac surgery to remain relevant in the mitral realm, we must be able to offer safe, durable repairs in a noninvasive manner to as much of the population as possible.”
The group also wrote that more long-term outcomes data is needed to gain a better perspective on the true cost difference between robotic mitral repair and conventional surgery.
The authors concluded their editorial by saying this research is “a step in the right direction” and shows that “we have a lot more work to do to ensure equitable adoption of robotic mitral repair in the United States.”
Michael has more than 18 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.