Minimally Invasive Cardiac

Surgery

N John Castro,M.D.

Cardiac Surgeon

Centracare Heart and Vascular Center

Saint Cloud, Minnesota

Disclosures

• Consultant-Surgeon INOVATE HF Trial

Advances in Minimally Invasive Surgery

• Image: intraop TEE guidance placement of

catheters

• CPB: smaller cannulas, negative venous

drainage

• Instruments: long, fine tools

• Endoscope

• Robot

Case One: Minimally Invasive Aortic Valve

Replacement

• A 92-year-old male presents with CHF

symptoms: SOB, fatigue

• PMH: COPD and CRD

• ECHO shows severe aortic stenosis

• He underwent mini AVR with a bovine

pericardial valve. Postop course uneventful.

AVR / CAB

Case Two

• A 75-year-old presents with acute pulmonary

edema.

• PMH: DM, Hormone replacement use, LE

celluitis, HTN

• ECHO: ruptured chordae with severe mitral

regurgitation.

• He underwent mini MV repair. Discharged home

within 5 days.

Case Three

• A 73-year-old presents with chronic congestive

heart failure. Referred to U of M for the 2nd

opinion.

• PMH: DM, HTN, HLD, CRD

• PSH: CABG; AVR; Aortic root replacement.

• ECHO: Severe mitral regurgitation due to

degenerative change.

• He underwent mini MV replacement. Had

uneventful hospital stay.

MV Repair

• MIMVS

– does not refer to a single approach

– a collection of new techniques and operation-

specific technologies

• enhanced visualization and instrumentation

• modified perfusion methods

• all directed toward minimizing surgical trauma by

reducing the incision size

Colvin and Galloway

Colvin and Galloway

Colvin and Galloway

Colvin and Galloway

Colvin and Galloway

Moront

• Reduced trauma and pain

• Statistically decreased blood loss and transfusion requirements

• decreased wound infection

• Statistically reduced recovery time and more rapid return to work

• Better cosmetic results and improved patient satisfaction

• no difference in morbidity and mortality

• Facilitates redo surgery

• avoids sternal wound complications

• Statistically reduced incidence of wound infections

Birdi I

• Excellent cosmetic results for the patient

• Reduced pain

• Early discharge home

• Early return to normal life

• Easily reproducible with a fast learning curve

• Excellent results in high-risk patients

• Excellent mid-term outcomes

• Low cost consumables allowing easy introduction in a

cost-sensitive environment

Lamelas J

• Reduced trauma and pain

• Decreased blood loss

• Decreased wound infection

• Reduced recovery time

• Better cosmetic results and improved

patient satisfaction

• No difference in morbidity and mortality

• Facilitates redo surgery

• Avoids sternal wound complications

Holzhey

• 1,027 elderly patients (>70 years

• August 1999 and July 2009

• analyzed for outcome differences due to surgical approach using propensity score matching

• etiology – degenerative (83%)

– endocarditis (6%)

– rheumatic (10%)

– acute ischemic (<1%)

• Isolated stenosis was rare (3%)

• mitral valve regurgitation (72%)

• combined mitral valve disease (25%)

• longer duration of surgery (186 ± 61 vs

169 ± 59 minutes, p = 0.01)

• cardiopulmonary bypass time (142 ± 54 vs

102 ± 45 minutes, p = 0.0001)

• cross-clamp time (74 ± 44 vs 64 ± 28

minutes, p = 0.015)

• no differences between the matched

groups

– 30-day mortality (7.7% vs 6.3%, p = 0.82)

– combined major adverse cardiac

– cerebrovascular events (11.2% vs 12.6%, p =

0.86)

– other postoperative outcome

• postoperative arrhythmias and pacemaker

implants was higher in the sternotomy

group (65.7% vs 50.3% p = 0.023 and

18.9% vs 10.5%, p = 0.059)

• Long-term survival was 66% ± 5.6% vs 56

± 5.5% at 5 years and 35% ± 12% vs 40%

± 7.9% at 8 years, and did not show

significant differences

Holzey

Modi, Hassan, Chitwood

• 2008

• Meta-analysis

• 10 year investigational data

Mortality

• No difference

• Mihaljevic

– Largest study 474 MIMVS vs 337 MS

– (0.2-0.3%)

– MIMVS lower risk group

• Grossi

– Matched group

– Hospital mortality (3.7 vs 3.4%)

Neurologic events

• Mohr

– 18% incidence of postoperative confusion

– No CO2

• 10 studies

– no difference in stroke

• 2 studies

– Reduced stroke rate

• 6 studies

– No difference in neurologic events

Bleeding, transfusion, re-exploration

• Chitwood – No difference in blood loss or blood product

transfusion

– MIMVS fewer re-explorations for bleeding

• Glower – No difference in chest tube drainage or transfusion

requirements despite longer CPB time in MIMVS

• Cohn – MIMVS transfused 1.8 units less

• 5 studies – MIMVS showed significant reduction in reoperation

for bleeding

Atrial Fibrillation

• 5/6 studies

– No difference

• Asher

– 100 MICS patients

– 10% incidence of new onset AF with port

access lower than sternotomy

Septic complications

• Grossi

– MIMVS 0.9% vs. sternotomy 5.7%

– Elderly 1.8 vs 7.7

Pain and speed of recovery

• MIMVS (4/4 studies) – Reduction in pain and faster return to normal

activity • Most consistent finding

• Walther – Equivalent pain for 1st 2 days with significant

reduction afterwards with difference widening with time

• Glower – Postop pain resolved more quickly with MIMVS

– Patient returned to normal activity 5 weeks earlier

Pain and speed of recovery

• Cohn

– Less pain in hospital

– Less analgesic usage

– Greater patient satisfaction

– Return to normal activity 4.8 weeks ahead

• Felger and Vleissis

– In Re-do’s, their 2nd procedure (MI) all felt that

their recovery was more rapid and less painful

than their original sternotomy

Hospital stay and costs

• Trend for shorter stay in MIMVS but not

statistically significant

• Chitwood -34%

• Cohn -20%

• Cosgrove -7%

Discharge disposition

• Mihaljevic and Cohn

– fewer requirements for post-hospital

rehabilitation

– significant advantage in terms of healthcare

savings

• 91% being discharged home compared to 67%

with a conventional approach

Intermediate and long term results

• Grossi

– Equivalent 1 year freedom from operation

– Mihaljevic et al.

• significantly better actuarial survival at 5 years for

MI patients (95% vs 86%)

• explained by a lower risk profile

Crude adjusted mortality rate for

entire cohort

• MVRepair 1.1% (STS 1.5%)

• MVReplacement 4.9% (STS 5.5%)

Long Term Survival

• 100% at mean of 2.3 years to 83% at 6.8

years • vs

• Mayo Clinic 5 year survival 86.4%

• Cleveland Clinic 5 year survival 82%

Freedom from Re-operation

• 99.9% at 3.2 years to 91 % at 4 years

• Longest followup was 6.3 years with

96.2% freedom

• vs Mayo clinic data risk of reoperation

– 0.5% per year for isolated posterior leaflet

prolapse

– 1.64% per year for isolated anterior leaflet

prolapse

Special Situations

• Reoperative surgery

– Avoid sternal re-entry

– Limited dissection of adhesions

– Avoid risk of injury to cardiac structures or

patent grafts

– Limit post-op bleeding

– Less blood loss

– Less transfusions

– Faster recovery

Re-operative surgery case

control(Sharony et al)

• Equal mortality at 5%

• Fewer wound complications

• Less blood product

• Decreased hospital stay

• slightly more favorable mid-term outcomes

Bolotin et al.

• 71 reoperative mitral valve operations

– 38 minithoracotomy

– no difference

• Mortality

• CPB

– significantly reduced

• intubation times

• blood transfusion

• hospital stay

MIMVS risks

• vascular risks with femoral cannulation

• Groin seromas can be problematic but are kept to a

minimum by

– dissection only of the anterior surface of the vessels

– clipping lymphatics

• phrenic nerve palsy

– When the pericardium is opened too posteriorly

– place the pericardiotomy at least 3 cm anterior to it.

– Excess tension by pericardial retraction

Conclusions:

• Less invasive procedures are demanded

but at the same time proven safety,

efficacy and durability are expected

• No level one evidence to justify switching

to minimally invasive mitral valve surgery

• All evidence demonstrates that MIMVS is

associated with equal

– mortality

– neurological events

• despite longer cardiopulmonary bypass

and aortic cross-clamp times

• However, MIMVS compared to

conventional sternotomy-based surgery,

there is less morbidity in terms of

– reduced need for reoperation for bleeding

– trend towards shorter hospital stay

– less pain

– faster return to preoperative function levels

• translates into improved utilization of

limited healthcare resources

• long-term outcomes are equivalent to

those of conventional surgery

• Data for MIMVS after previous cardiac surgery is limited

but consistently demonstrates reduced

– blood loss

– fewer transfusions

– faster recovery compared to re-operative sternotomy

• patients who undergo a MIMVS as their second

procedure feel their recovery is more rapid and less

painful than their original sternotomy

Bottomline

• Most patients do not want a sternotomy

• traditional cardiac operations still enjoy

proven long-term success and ever-

decreasing M&M

Case Four: Mini ASD Repair

• 32-year-old male presents with heart murmur.

• ECHO shows a large ASD, not suitable for

percutaneous device closure.

• Underwent mini ASD repair. Had a short hospital

stay.

ASD Repair

Case Five: Hybrid CABG/Stent

• A 86-year-old female presents with angina.

• PMD: Obesity, COPD, DM, HTN, HLD; Bilateral

hip dysfunction; UTI.

• Angiogram shows severe CAD

• She underwent Robotic CABG and stenting

during the same hospital stay.

What is the da Vinci® Surgical System?

• Powered by state-of-

the-art robotic

technology

• Surgeon is in control

and operates at the

console

• Assistant surgeon is

next to the patient

• 4 robotic arms enable Solo Surgery™

• Fingertip control

• 7º of freedom 90º of articulation

• Motion scaling and tremor reduction

da Vinci Surgical System

da Vinci Surgical System

• 3-channel vision system

• High resolution 3-D image

• Panoramic view of the surgical field

• EndoWrist®

Instruments fit

through dime-

sized incisions

• A wide range of

instruments are

available

Indications for Minimally Invasive Surgery

• 1. Aortic valve replacement

• 2. Mitral valve repair and replacement

• 3. CABG

• 4. LV pacing lead for biventricular pacing

treatment of CHF

• 5. Complex ASD

Indications for Minimally Invasive Surgery

• 6. High risk patients: elderly, immobile, DM,

respiratory compromise, osteoporosis

• 7. In some complex redo cardiac surgery

patients

• 8. Hybrid surgery:

– 1).Robotic CABG + stents for CAD

– 2). Mini AVR + stent

– 3). Mini MV repair/replacement + stent

– 4). Robotic CABG + mini valve

References:

• Colvin SB, Galloway AC, A Revolutionary Approach to Mitral Valve Repair, webcast, NYU Medical

Center, NY, 2005

• Petracek M, Minimally Invasive Mitral Valve Replacement and Surgical Ablation, Webcast, St Thomas

Heart Institute, Nashville TN' 2005

• Modi P, Hassan A, Chitwood WR, Minimally invasive mitral valve surgery: a systematic review and

meta-analysisEur J Cardiothorac Surg 2008;34:943-952

• Holzhey DM, Shi W, Minimally Invasive Versus Sternotomy Approach for Mitral Valve Surgery in

Patients Greater Than 70 Years Old: A Propensity-Matched Comparison, Annals of Thoracic Surgery,

Aug 2010

• Glauber M, Karimov JH, Minimally Invasive mitral valve surgery via right minithoracotomy, MMCTS,

Jan 2009.

• Cohn LH, Adams DH, Couper GS, Bichell DP, Rosborough DM, Sears SP, Aranki SF. Minimally

invasive cardiac valve surgery improves patient satisfaction while reducing costs of cardiac valve

replacement and repair. Ann Surg 1997;226(October (4)):421-426

• Grossi EA, LaPietra A, Ribakove GH, Delianides J, Esposito R, Culliford AT, Derivaux CC, Applebaum

RM, Kronzon I, Steinberg BM, Baumann FG, Galloway AC, Colvin SB. Minimally invasive versus

sternotomy approaches for mitral reconstruction: comparison of intermediate-term results. J Thorac

Cardiovasc Surg 2001;121(April (4)):708-713

References

• Grossi EA, Galloway AC, Ribakove GH, Buttenheim PM, Esposito R, Baumann FG, Colvin SB.

Minimally invasive port access surgery reduces operative morbidity for valve replacement in the

elderly. Heart Surg Forum 1999;2(3):212-215 • Mihaljevic T, Cohn LH, Unic D, Aranki SF, Couper GS, Byrne JG. One thousand minimally invasive

valve operations: early and late results. Ann Surg 2004;240(September (3)):529-534 • Walther T, Falk V, Metz S, Diegeler A, Battellini R, Autschbach R, Mohr FW. Pain and quality of life

after minimally invasive versus conventional cardiac surgery. Ann Thorac Surg 1999;67(June

(6)):1643-1647 • Glower DD, Landolfo KP, Clements F, Debruijn NP, Stafford-Smith M, Smith PK, Duhaylongsod F.

Mitral valve operation via port-access versus median sternotomy. Eur J Cardiothorac Surg

1998;14(October (Suppl. 1)):S143-S147 • Vleissis AA, Bolling SF. Mini-reoperative mitral valve surgery. J Cardiac Surg 1998;13(November–

December (6)):468-470 • Felger JE, Chitwood Jr. WR, Nifong LW, Holbert D. Evolution of mitral valve surgery: toward a totally

endoscopic approach. Ann Thorac Surg 2001;72(October (4)):1203-1208 • Sharony R, Grossi EA, Saunders PC, Schwartz CF, Ursomanno P, Ribakove GH, Galloway AC, Colvin

SB. Minimally invasive reoperative isolated valve surgery: early and mid-term results. J Card Surg

2006 May-Jun;21(3):240-244 • Bolotin G, Kypson AP, Reade CC, Chu VF, Freund Jr. WL, Nifong LW, Chitwood Jr. WR. Should a

video-assisted mini-thoracotomy be the approach of choice for reoperative mitral valve surgery?. J

Heart Valve Dis 2004;13(March (2)):155-158 • Liao K, Personal Communication, April 18, 2011

Thank You!