clinical professor, director of cardiovascular surgery ......modern cardiac operations increasingly...

Serdar Gunaydin, MD, PhDClinical Professor,

Director of Cardiovascular Surgery,Numune Training & Research Hospital,

University of Health Sciences,Ankara-Turkey

No Disclosures

✓ Modern cardiac operations increasingly use minimallyinvasive techniques, such as less invasive incisions andapproaches, and extracorporeal support is often reduced oreven avoided

✓ Even so, less than 20% of isolated aortic valve proceduresand about 45% of isolated mitral valve operations in Germany are performed in a minimally invasive fashion

✓ In contrast, approximately 4% of cardiopulmonary supportis minimally invasive in Europe

✓ Innovations in alternative methods for cannulation and cardiopulmonary bypass (CPB), new visualization systems, retractors and stabilizers, and robotic platformshave facilitated the development of minimally invasive cardiac surgery

✓ Complications associated with the endoclamp include balloon migration/ruptureand retrograde aortic dissection

✓ Elevated atherosclerotic plaques greater than 2 mm in height in the descendingthoracic aorta or arch may increase the risk of retrograde cerebral and othersystemic embolization and constitutes a contraindication to femoral artery-perfused minimally invasive mitral valve surgery

✓ Relative contraindications for a mini-right thoracotomy mitral approach includeprevious right thoracotomy with dense pleural adhesions, significant obesity, severe chest deformity (e.g., pectus excavatum), scoliosis, and prior breast implantor reconstruction

✓ Other operations that can be performed through a small right thoracotomy includetricuspid valve surgery, atrial septal defect closure, atrial myxoma resection, andseptal myectomy

✓ Minimally invasive approaches for aortic valve surgery generally consist of limitedsternotomies

➢ May-August 2017

➢ 20 Cases (16 female, Age: 76∓8.2)

➢ 17 AVR, 2 ASD, 1 MVR

➢ J-Sternotomy (5), R.Ant. Thoracotomy (15)

➢ Central Cannulation (8), Femoral (8), Femoral+Jugular (4)

➢ ICU: 1.2 ∓ 0.2 days

➢ Blood Tx : 0.4 ∓ 0.03 U (No Tx in 13 cases)

➢ LOS: 4.2 ∓ 1.3 days

✓ VAVD (-20/-40mmHg)

✓ Single dose Cardioplegia(Del Nido/HTK)

✓ NIRS

✓ RAP

✓ Cell-saver/HemoSep

MiECC Features

MICS• Equivalent early/late clinical

outcome

• Less pain, blood tx, wound infection

• Shorter LOS

• Better cosmetics

• Better results in high-risk patients

• Reoperations

• Easy penetration into a cost-sensitive environment

MiECC▪ A complete physiologically-based

strategy and not just a CPB circuit or a particular product

▪ All types of complicated cardiacsurgery

▪ Destination therapy: Bridge-to-bridge, bridge-to-transplant, orbridge-to-recovery

▪ Postcardiotomy cardiogenic shock, high-risk cardiology interventions, pulmonary embolism, myocarditisand accidental hypothermia

▪ Closed chest temporary mini-CPBusing peripheral cardiopulmonary bypass (salvage approach in patients with cardiogenic shock or cardiopulmonary arrest)

▪ Commercially available device thatcombines portability, rapid and easy deployment, and safe operation, withadaptability to various applications and patient requirements, along withlow cost

• No clear scientific evidnce due tomethodologic concerns: small numberof high-risk patients, surrogate endpoints, confounding factors

• The strong interest might be accountedfor the expected reductions in mortalityin subgroups of patients of highher risk with comorbidities

• New, large randomized controlled trialswill clarify this intriguing aspect