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