minimally invasive valve surgery. how far we have come the mortality for valve replacement surgery...
TRANSCRIPT
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MINIMALLY INVASIVE VALVE
SURGERY
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HOW FAR WE HAVE COME
THE MORTALITY FOR VALVE REPLACEMENT SURGERY IN 1968 WAS 42%
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WHY MINIMALLY INVASIVE VALVE SURGERY?
SMALLER INCISION/SCAR LESS PAIN EARLIER MOBILIZATION EARLIER RETURN TO
LIFESTYLE/WORK LESS TRAUMATIC LOWER INFECTION RATE LESS BLEEDING SHORTER LENGTH OF STAY SAFER REOPERATION
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PATIENT DEMAND
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GOALS
SMALL INCISION GOOD EXPOSURE IDENTICAL QUALITY TO FULL OPEN
PROCEDURES IDENTICAL MITRAL VALVE REPAIR RATE
SIMILAR COSTS SIMILAR OPERATING/BYPASS TIME ABILITY TO GET OUT OF TROUBLE
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“…cardiologists are strongly encouraged to refer patients who are candidates for complex MV repair to surgical centers experienced in performing MV repair.”
“Surgery for asymptomatic patients with severe MR and normal LV function should only be considered if there is a greater than 90% likelihood of successful valve repair in a center experienced in this procedure.”
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“MV repair should be able to be achieved by experienced surgeons for the majority of patients with degenerative MV disease and ischemic valve disease, and patients should be referred to surgeons expert in repair.”
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APPROACHES
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PARASTERNAL
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ADVANTAGES GOOD ACCESS TO THE AORTIC
VALVE DISADVANTAGES
CHEST WALL HERNIA CAN RESULT
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LOWER STERNAL
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ADVANTAGES GOOD EXPOSURE FOR THE MITRAL
VALVE EXCISION CAN BE EXTENDED IF
NECESSARY
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TRANSECTING STERNAL
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ADVANTAGES EXCELLENT EXPOSURE OF THE
AORTIC VALVE AND GREAT VESSELS
DISADVANTAGES BREASTBONE INSTABILITY LOSS OF INTERNAL MAMMARY
ARTERIES FOR FUTURE USE
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PORT ACCESS
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ADVANTAGES TINY INCISIONS
DISADVANTAGES GREATLY INCREASED OPERATIVE TIME
AND OPERATING ROOM TIME MULTIPLE DEVICE INSERTIONS ENDOVASCULAR AORTIC CLAMP HAS
RESULTED IN TORN AORTAS MORE DIFFICULTY IN ACHIEVING VALVE
REPAIRS SOMEWHAT HIGHER MORTALITY
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ADVANTAGES LOTS OF TINY INCISIONS SOUNDS EXCITING
DISADVANTAGES GREATLY LONGER OPERATIVE TIME
AND OPERATING ROOM TIME MAY USE ENDOVASCULAR AORTIC
CLAMP WITH INCREASED RISK OF TORN AORTA
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GENERALLY RESTRICTED TO THE MITRAL VALVE
LOWER MITRAL VALVE REPAIR RATE
HIGHER REOPERATION RATE FOR VALVE REPAIR FAILURE
HIGHER MORTALITY HIGHER COSTS
REPLACEMENT OF ROBOTIC INSTRUMENTS
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IN THE INITIAL FDA STUDY, 65% OF PATIENTS WERE EXCLUDED
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RIGHT THORACOTOMY
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ADVANTAGES EXCELLENT RESULTS ACHIEVED BY
SOME SURGEONS PATIENT PREFERENCE
DISADVANTAGES GENERALLY RESTRICTED TO THE
MITRAL VALVE LONG INSTRUMENTS REQUIRED CANNOT EXTEND INCISION
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UPPER STERNOTOMY
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ADVANTAGES ALL VALVES CAN BE ACCESSED WITH
EXCELLENT EXPOSURE, AS WELL AS AORTIC PATHOLOGY
STANDARD INSTRUMENTS SHORTER OPERATIVE TIME STANDARD AORTIC CLAMPING EXCELLENT HEALING WITH NO INSTABILITY CAN EXTEND INCISION IF NECESSARY
DISADVANTAGES IRREGULAR HEART RHYTHMS WITH MITRAL
PROCEDURES ?NOT AS EXCITING AS ROBBY THE ROBOT
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HOW WE DO IT
6-8 CM MIDLINE INCISION BEGINNING 6 CM BELOW THE NECK
STERNUM IS DIVIDED FROM THE STERNAL NOTCH INTO THE FOURTH INTERCOSTAL SPACE TO THE RIGHT FOR AORTIC
PROCEDURES TO THE LEFT FOR MITRAL VALVE
AND COMBINED PROCEDURES
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AORTA IS OPENED IN THE STANDARD FASHION
THE RIGHT ATRIUM IS OPENED TO APPROACH THE MITRAL VALVE
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CONTRAINDICATONS
MORBID OBESITY REOPERATIONS PECTUS EXCAVATUM NEED FOR ASSOCIATED
PROCEDURES CAN REVASCULARIZE THE RIGHT
CORONARY ARTERY
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PROCEDURES AT LRMC
AVERAGE AGE 70 (AVERAGE AGE AT CLEVELAND
CLINIC 55) HAVE PERFORMED ALL
COMBINATIONS OF VALVE REPAIRS AND REPLACEMENTS
NOW PERFOMING THE MAZE PROCEDURE FOR ATRIAL FIBRILLATION
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AORTIC VALVE REPLACEMENT MITRAL VALVE REPAIR MITRAL VALVE REPLACEMENT AORTIC VALVE REPLACEMENT/MITRAL
VALVE REPAIR MITRAL VALVE REPAIR/TRICUSPID
VALVE REPAIR AORTIC VALVE REPLACEMENT/MITRAL
VALVE REPAIR/TRICUSPID VALVE REPAIR
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AORTIC VALVE REPLACEMENT/ROOT REPLACEMENT
RESECTION/GRAFTING ASCENDING AORTIC/ARCH ANEURYSMS
AORTIC VALVE REPLACEMENT/CORONARY ARTERY BYPASS GRAFTING
LEFT ATRIAL MYXOMA MITRAL VALVE REPAIR/MAZE
PROCEDURE