cardiochirurgia mini-invasiva: efficacia per il paziente ... · minimally invasive cardiac surgery...

CARDIOCHIRURGIA CARDIOCHIRURGIA MINIMINI--INVASIVA: INVASIVA:

efficacia per il paziente efficacia per il paziente efficienza per la sanitaefficienza per la sanita’’

Dott. Davide Ricci

SC Cardiochirurgia UUniversita’ degli Studi di Torino

Minimally invasive cardiac surgery

Antero-lateral right minithoracotomy Mitral ValveTricuspid ValveASD – VSDMyxoma

MinisternotomyAortic ValveAscending Aorta

Minimally Invasive Surgical approaches

Antero-lateral left minithoracotomy CABG (MIDCABG)LV aneurysmTAVI

Robotic SurgeryCABGMitral ValveTricuspid ValveASD Myxoma

Minimally invasive cardiac surgery

Antero-lateral right mini-thoracotomy

Minimally invasive cardiac surgery

Schwartz DS. Minimally invasive cardiopulmonary bypass with cardioplegic arrest: a closed chest technique with equivalent myocardial protection.

J Thorac Cardiovasc Surg 1996;111(3).

19961996 : : FIRST EXPERIENCEFIRST EXPERIENCE

Reduce surgical traumaMinimize disruption of the chest wallProvide a safe and reproducible approach to CPB and myocardial protection

Be applicable to the majority of patients and proceduresProvide same safety and efficacy as conventional cardiac surgery

Minimally invasive cardiac surgery

Less Invasive Surgery

Patient Comfort

Surg

eon

Com

fort

Conventional Surgery

Minimally invasive cardiac surgery

Minimally invasive cardiac surgery

• Contraindications to the Port-Access Approach

– Moderate to severe aortic or peripheral atherosclerosis

– Small femoral vessels– Ascending aorta aneurysm (≥ 45 mm)– Moderate - severe aortic regurgitation– Chest deformity - adhesions– Oesophageal pathology (TEE assistance)

Minimally invasive cardiac surgery

Short and long-term outcomes after minimally invasive cardiac surgery are equivalent to results achieved with sternotomy by many groups (surgeons) throughout the world

Minimally invasive cardiac surgery

Advantages• Decreased bleeding• Reduced transfusions• Shorter ICU and hospital stay• Shorter ventilation time• Reduced time to return to normal activity• Reduced surgical pain• Better cosmesis

MINI vs ST similar mortality rates30 days 1.2% vs 1.5% - 1 year 0.9% vs 1.3% - 3 years 0.5% vs 0.5% - 9 years 0.2% vs 0.7%

Cheng et al, Innov 2011;6:66-76 – Falk et al, Innov 2011;6:84-103

Disadvantages• Increased risk of stroke• Increased risk of aortic dissection• Increased ECC and aortic clamp time• Groin infections/complications

Minimally invasive cardiac surgery

Svensson et al, JTCS. 2010;139:926-32 Cleveland Clinic

Relatively longer CPB and aortic clamping time

Minimally invasive cardiac surgery

Svensson et al, JTCS. 2010;139:926-32 Cleveland Clinic

Minimally invasive cardiac surgery

Svensson et al, JTCS. 2010;139:926-32 Cleveland Clinic

p<0.001

FEV1

SURVIVAL

PAIN

Minimally invasive cardiac surgery

Goldstone et al, JTCS. 2013;145:748-56

Minimally invasive cardiac surgery

Goldstone et al, JTCS. 2013;145:748-56

Overall MV cohor Degenerative cohor

Minimally invasive cardiac surgery

Iribarne et al, JTCS. 2011;142:1507-14

• 217 MI vs 217 ST pts (2003 – 2008)• Propensity matched showed no difference in morbidity and long term survival

Minimally invasive cardiac surgery

*p<0.05

Iribarne et al, JTCS. 2011;142:1507-14

Median ST 50060 ± 2659 $MINI 41006 ± 1887 $

Difference 9054 ± 3302 $

Hospital Costs

Reduction in:Cardiac imaging p=0.004 Laboratory tests p=0.005Nursing p=0.001Radiology p=0.002

Higher rate of home Higher rate of home discharge with no nursing discharge with no nursing

service in the MI group service in the MI group p=0.01p=0.01

Minimally invasive cardiac surgery

Advantages• Decreased bleeding• Reduced transfusions• Shorter ICU and hospital stay• Shorter ventilation time• Reduced time to return to normal activity• Reduced surgical pain• Better cosmesis

MINI vs ST similar mortality rates30 days 1.2% vs 1.5% - 1 year 0.9% vs 1.3% - 3 years 0.5% vs 0.5% - 9 years 0.2% vs 0.7%

Cheng et al, Innov 2011;6:66-76 – Falk et al, Innov 2011;6:84-103

Disadvantages• Increased risk of stroke• Increased risk of aortic dissection• Increased ECC and aortic clamp time• Groin infections/complications

1.2vs1.9%

Minimally invasive cardiac surgery

Grossi et al, JTCS. 2012;143:S68-70

Need for appropriate patient and technique selection

Minimally invasive cardiac surgery

Iliac Vessels Variations

Pre-operative aorto-iliac-femoral imaging

Minimally invasive cardiac surgery

PortaclampCosgrove

External clamps

Minimally invasive cardiac surgery

EndoClamp Aortic (Endodirect)Femoral (Endoreturn)

Minimally invasive cardiac surgery

EndoClamp (Femoral artery cannulation)-- EndoReturn EndoReturn --

Minimally invasive cardiac surgery

EndoClamp (Direct aortic cannulation)-- EndoDirect EndoDirect --

Minimally invasive cardiac surgery

Turin MIS Port Access global experience

2005 - 2013

Minimally invasive cardiac surgery

July 2005 – May 2013: 629 procedures

Consecutive unselected patients

Minimally invasive cardiac surgery

-Myxomas-VSD

July 2005 – May 2013: 629 procedures

Minimally invasive cardiac surgery

Redo surgery: 185/629 (29.4%)

1st redo 122 (66%) 2nd redo 35 (19%) 3rd redo 24 (13%) 4th redo 4 (2%)

63 (34 %)

Minimally invasive cardiac surgery

Ricci et al, EJCTS. 2010;37:920-7

3,1

7,9

21,1

5,5

11,0

22,2

5,6

0

5

10

15

20

25

1° operation redo overall

ElectiveUrgencyEmergency

12,9

6,78,6

0

5

10

15

20

25

Prior CAB Prior Valve Prior othercardiac

4.9%

Minimally invasive cardiac surgery

MIS is effective and safe and provides as

durable results as traditional surgery…it

should be the technique of choice in

REDOModi et al, JTCS. 2009;137:1481-7

• 1178 pts (1996 – 2008) Mortality: 0.8% isolated MVP3.9% isolated MVR

Minimally invasive cardiac surgery

EndoDirect: 59/618 cases (9.4%)

EndoReturn: 397/618 cases (64.2%)

Transthoracic : 134/618 cases (22.1%)

Beating heart: 28/618 cases (4.3%)

EndoDirect: 59/618 cases (9.4%)

EndoReturn: 397/618 cases (64.2%)

Transthoracic : 134/618 cases (22.1%)

Beating heart: 28/618 cases (4.3%)

Conversion to sternotomy11 cases (1.7%)

Minimally invasive cardiac surgery

Mean ± SD MedianECC (min) 124.5 ± 86.8 117

Aortic clamp (min) 76.1 ± 24.7 84

ICU stay (gg) 2.9 ± 9.2 1

Ventilation (h) 33.5 ± 176.1 9

Reop. for bleeding (%) (n) 5.1 % (28/546)

Drainage blood loss (cc) 439 ± 371 330

Hospital stay (gg) 11.5 ± 13.9 7

Mortality (%) (n) 1.8% 10/546

Operative mortality 0%

Overall MV surgeries: 546/618 (88.3%)

Minimally invasive cardiac surgery

Seeburger et al, EJCTS. 2009;36:532-38

p=NS

p=NS

Minimally invasive cardiac surgery

Overall MV surgeries: 546/618 (88.3%)Degenerative MV: 274/546 (50.1%)

MV repair: 240/260 (92.3%) - MV replacement 34/274 (12.4%)Previous MV repair 14/274

Minimally invasive cardiac surgery

P=NS

94,9%94,9%

97,4%97,4%Actuarial survival rates

P=NS

94,9%94,9%

98,2%98,2%

Requiring additional incision

dehiscience/infection

lymphocele

Retrograde aortic dissection

Femoral/Iliac artery dissection/perforation/thrombosis

Complications of femoral artery cannulation Complications of femoral artery cannulation (Endoreturn+Transthoracic+Peripheral cann)(Endoreturn+Transthoracic+Peripheral cann)

Minimally invasive cardiac surgery

2/59 (3.3%)

Posterior aortic wall perforation 1 Purse-string laceration requiring side-biting aortic clamping

and repair 1

Complications of direct aortic cannulationComplications of direct aortic cannulation(Endodirect)(Endodirect)

Minimally invasive cardiac surgery

Aortic dissection

Minimally invasive cardiac surgery

0.35%

Minimally invasive cardiac surgery

EndoDirect: 59/618 cases (9.4%)

EndoReturn: 397/618 cases (64.2%)

Transthoracic : 134/618 cases (22.1%)

Beating heart: 28/618 cases (4.3%)

EndoDirect: 59/618 cases (9.4%)

EndoReturn: 397/618 cases (64.2%)

Transthoracic : 134/618 cases (22.1%)

Beating heart: 28/618 cases (4.3%)

Conversion to sternotomy11 cases (1.7%)

Minimally invasive cardiac surgery

Minimally invasive cardiac surgery

Minimally invasive cardiac surgery

Minimally invasive cardiac surgery

6464 consecutive unselected ptsconsecutive unselected pts

20052005--20112011

Mean TV annulus diameter 45.7±7.2 mm

Ricci et al, JTCS. 2013 [Epub ahead of print]

Mean log euroscore 11.6±11.7 mm

Minimally invasive cardiac surgery

55--year freedom from year freedom from reoperation 100%reoperation 100%

TV repair 2.8%TV replac. 13.8%

0% Groin wound infections0% Femoral artery

complications

Ricci et al, JTCS. 2013 [Epub ahead of print]

STS database mortality for standard sternotomy

11 – 69%

Minimally invasive cardiac surgery

1414 consecutive unselected pts consecutive unselected pts (1998(1998--2008)2008)

Vistarini et al, ICTS. 2010;10:9-11

Minimally invasive video-assisted surgery for left atrial myxoma resection is a safe, reproducible and cosmetic operation and can be considered an effective oncologic approach as an alternative to standard sternotomy.

Minimally invasive cardiac surgery

MinisternotomyAortic ValveAscending Aorta

Minimally invasive cardiac surgery

Brown et al, JTCS 2009;137:670-9

26 studies (4586 pts; 2054 MINI – 2532 FULL)

Ventilation time Blood loss

Minimally invasive cardiac surgery

Brown et al, JTCS 2009;137:670-9

ICU stay Hospital stay

Minimally invasive cardiac surgery

Brown et al, JTCS 2009;137:670-9

Post-op Pain

30-day Mortality

Minimally invasive cardiac surgery

Glauber et al, JTCS. 2013;145:1222-6

Minimally invasive cardiac surgery

Mini-invasive aortic valve surgeryTurin experience 2007 - 2012

92/325 (28.3%)

Minimally invasive cardiac surgery

Minimally invasive cardiac surgery

PARTNER B TAVI vs medical treat. PARTNER A TAVI vs ST procedure

Minimally invasive cardiac surgery

May 2008 - May 2013

168 TAVI 45 TA123 TF

35 ES 88 CV

Minimally invasive cardiac surgery

PARTNER B TAVI vs medical treat.

Minimally invasive cardiac surgery

PARTNER A TAVI vs ST procedure

Minimally invasive cardiac surgery

Bonatti et al, JTCS 2012;144:1061-6

• 334 SV vs 150 DV (2001 – 2011)

Minimally invasive cardiac surgery

Globally safe and reproducible techniques with good early, mid and long term results …but still few data. Technique not widely diffused…few centers

TECAB• Meet standards of open CABG for SV • Equivalent results respect to MIDCAB in single vessel lesions• Now good results for double vessel lesions (few cases)

NOT superior to mini-thoracotomy

ROBOTIC CARDIAC SURGERY

MV• Consistent data• Repair for all categories of leaflet prolapse• Fast recovery• No difference respect mini-thoracotomy

Minimally invasive cardiac surgery

CONCLUSIONS Same or even better safety and efficacy respect to standard technique

Minimally invasive cardiac surgery

CONCLUSIONS

Need for learning curve with consulting and proctoring Need for Heart team with daily collaboration between Cardiac Surgeons – Cardiologists –Anesthesiologists – Perfusionists and Nurses Need for appropriate patient/technique selection

“We must tailor the operation to the patient and not the patient to the operation”

Denton A. Cooley

“We must tailor the operation to the patient and not the patient to the operation”

Denton A. Cooley

Grazie per l’attenzione…