mini inv surg webinar mihaljevic oct09vacuum assisted venous drainage ... robotically-assisted...
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Minimally Invasive Minimally Invasive
Cardiac Cardiac SurgerySurgery
Tomislav Mihaljevic, M.D.
Minimally Invasive Minimally Invasive
Cardiac SurgeryCardiac Surgery
•• WhyWhy do it?do it?
•• HowHow is it done?is it done?
•• WhatWhat are the results?are the results?
Invasiveness in SurgeryInvasiveness in Surgery
•• InstrumentationInstrumentation
•• VisualizationVisualization
Designers of contemporary Designers of contemporary
surgical instrumentationsurgical instrumentation
Why Do It?Why Do It?
Minimally Invasive Cardiac Minimally Invasive Cardiac
SurgerySurgery
Patient demandPatient demand
•• Less traumaLess trauma
•• Cosmetic appealCosmetic appeal
•• More rapid recoveryMore rapid recovery
Surgeon abilitySurgeon ability
•• Equivalent result with proper selectionEquivalent result with proper selection
•• Build practiceBuild practice
TruthTruth
Patients will always choosePatients will always choose
•• Less invasive therapyLess invasive therapy
•• Even if less effective or Even if less effective or
greater riskgreater risk
ResponsibilityResponsibility
PhysicianPhysician’’s responsibilitys responsibility
•• Optimize less invasive Optimize less invasive
approachesapproaches
•• Inform and guide patientInform and guide patient
How Is It Done?How Is It Done?
Aortic Valve Aortic Valve
ReplacementReplacement
Minimally Invasive AVRMinimally Invasive AVR
•• Indicated for:Indicated for:
•• Isolated aortic Isolated aortic stenosisstenosis
•• Isolated aortic regurgitationIsolated aortic regurgitation
•• Aortic Aortic stenosisstenosis and ascending aortic and ascending aortic aneurysmaneurysm
•• Isolated ascending aortic aneurysmIsolated ascending aortic aneurysm
•• Isolated Isolated reoperativereoperative aortic valve aortic valve replacementreplacement
Vacuum Assisted Vacuum Assisted
Venous DrainageVenous Drainage
•• Small venous Small venous cannulaecannulae
•• Reduced pump primeReduced pump prime
•• Drier fieldDrier field
--5050
--5050
-50
Minimally Invasive AVRMinimally Invasive AVR
100
80
60
40
20
0
100
80
60
40
20
0Aortic
Occlusion
Aortic Occlusion
Mins.Mins.
C-P BypassC-P Bypass
Minimally Invasive AVRMinimally Invasive AVR
Operative TimesOperative Times
Mins.Mins.
P=.001P=.001 CC--P BypassP Bypass
Aortic OcclusionAortic Occlusion
100
80
60
40
20
0
100
80
60
40
20
02003200320022002200120012000200019991999199819981997199719961996
Minimally InvasiveAVR Mortality
Minimally InvasiveMinimally Invasive
AVR MortalityAVR Mortality
0.8 %0.8 %
TransTrans--Apical Aortic Valve Apical Aortic Valve
ImPlantationImPlantation (TAAP) Approach(TAAP) Approach
•• The apex of the heart is The apex of the heart is accessed via a small left accessed via a small left anterior anterior thoracotomythoracotomy
•• Indicated for patients with Indicated for patients with PVD and / or multi valve PVD and / or multi valve diseasedisease
Anterior Anterior ThoracotomyThoracotomy
Valve DeploymentValve Deployment
•• Rapid ventricular Rapid ventricular
pacing initiated to pacing initiated to ↓↓↓↓↓↓↓↓cardiac output to cardiac output to
prevent distal prevent distal
migration of the valvemigration of the valve
•• Valve is then Valve is then
deployed by balloon deployed by balloon
inflation inflation
Final PositionFinal Position
•• The valve sits within The valve sits within native annulus and native annulus and the the stenoticstenotic leaflets, leaflets, below the coronary below the coronary ostiaostia..
•• Radial expansion Radial expansion and friction prevent and friction prevent distal migration of distal migration of the expanded valvethe expanded valve
PercutaneousPercutaneous AVR AVR --
Potential ImpactPotential Impact
•• Indications Indications -- device / procedure specificdevice / procedure specific
•• Definition of high risk populationDefinition of high risk population
•• Size of potential patient populationSize of potential patient population
•• Expansion of indications Expansion of indications
•• Practice of Practice of valvularvalvular interventionsinterventions
•• Physicians education and trainingPhysicians education and training
ConclusionConclusion
•• Minimally invasive AVR represents the Minimally invasive AVR represents the
procedure of choice for majority of procedure of choice for majority of
patients with ASpatients with AS
•• PercutaneousPercutaneous AV implantation is feasible AV implantation is feasible
and potentially life saving for patients who and potentially life saving for patients who
are not surgical candidatesare not surgical candidates
•• Hybrid approaches may enhance the Hybrid approaches may enhance the
safety of catheter based AV implantationsafety of catheter based AV implantation
MitralMitral Valve SurgeryValve Surgery
MitralMitral Repair:Repair:
The Gold StandardThe Gold Standard
The Gold StandardThe Gold Standard
Is ChangingIs Changing
MitralMitral SurgerySurgery
•• Partial Partial sternotomysternotomy
•• Rt. Rt. ThoracotomyThoracotomy
•• Rt. Rt. ThoracotomyThoracotomy/Robotic Assistance/Robotic Assistance
MitralMitral SurgerySurgery
•• Partial Partial sternotomysternotomy
•• Rt. Rt. ThoracotomyThoracotomy
•• Rt. Rt. ThoracotomyThoracotomy/Robotic Assistance/Robotic Assistance
One size does NOT fit all patientsOne size does NOT fit all patients
MitralMitral SurgerySurgery
•• Partial Partial sternotomysternotomy
•• Rt. Rt. ThoracotomyThoracotomy
•• Rt. Rt. ThoracotomyThoracotomy/Robotic Assistance/Robotic Assistance
One size does NOT fit all patientsOne size does NOT fit all patients
One size does NOT fit all surgeonsOne size does NOT fit all surgeons
Partial Partial SternotomySternotomy
Right Right ThoracotomyThoracotomy
RoboticsRobotics
Robotic Surgical Robotic Surgical
InstrumentationInstrumentation
•• StateState--ofof--thethe--art art
robotic technology robotic technology
–– intuitive motion intuitive motion
control of surgical control of surgical
instrumentsinstruments
•• Surgeon in controlSurgeon in control
•• Assistant has direct Assistant has direct
accessaccess
InSiteInSite®® Vision SystemVision System
•• Surgeon Surgeon
immersed in 3D immersed in 3D
image of the image of the
surgical fieldsurgical field
•• 3D image 3D image
produced by produced by
special 2special 2--channel channel
cameracamera
The surgeon directs the The surgeon directs the
instrumentsinstruments
•• Surgeon directs the Surgeon directs the
instrument instrument
movements using movements using
Console controlsConsole controls
•• Motion of the Motion of the
surgeonsurgeon’’s hand s hand
translates in the translates in the
motion of motion of
articulated surgical articulated surgical
instrumentsinstruments
•• Conventional Conventional
minimally invasive minimally invasive
instruments are rigid instruments are rigid
with no wristswith no wrists
•• EndoWristEndoWrist®®
Instrument tips move Instrument tips move
like a human wrist like a human wrist
•• Allows increased Allows increased
dexterity and dexterity and
precisionprecision
Wrist and finger movementWrist and finger movement
RoboticallyRobotically--Assisted Assisted
MitralMitral Valve Repair Valve Repair
RoboticallyRobotically--assisted assisted MitralMitral
Valve RepairValve Repair
•• Patient PreparationPatient Preparation
RoboticallyRobotically--assisted assisted MitralMitral
Valve RepairValve Repair
•• Port PlacementPort Placement
RoboticallyRobotically--assisted assisted MitralMitral
Valve RepairValve Repair
•• CardioCardio--Pulmonary BypassPulmonary Bypass
RoboticallyRobotically--assisted assisted MitralMitral
Valve RepairValve Repair
•• MitralMitral Valve ExposureValve Exposure
RoboticsRobotics
250
200
150
100
50
02005 2006 2007 2008 2004
Distribution of Robotic Operations Distribution of Robotic Operations
2006 2006 -- 20092009
N = 620N = 620
Isolated MV Isolated MV
RepairRepair
64%64%
MV Repair + OtherMV Repair + Other
19%19%
CABG 3%CABG 3%
PFO/ASD/PFO/ASD/
MyxomaMyxoma
14%14%
Robotically-assisted Cardiac Surgery l October 22, 2009 l 60
Isolated MV RepairIsolated MV Repair
360
300
240
180
120
60
0
##
20002000 20042004 2006200620022002
Robotic
2008200820072007
MortalityMortality
0%0%
Repair RateRepair Rate
99%99%99%
Conversion RateConversion Rate
2%2%2%
When?When?
•• ValveValve
�� RepairRepair
�� Replacement Replacement
(simple)(simple)
•• PatientPatient
�� Relatively healthyRelatively healthy
•• ValveValve
�� MACMAC
�� Very complexVery complex
•• PatientPatient
�� LV dysfunctionLV dysfunction
�� AIAI
�� PADPAD
�� Small Small femoralsfemorals
Indications and Contraindications
Indications and Indications and
ContraindicationsContraindications
YESYES NONO
Results?Results?
Results Results
Minimally Invasive Minimally Invasive
vs. Conventionalvs. Conventional
Transfusion: PRBCTransfusion: PRBC
NoneNone 11 22 3 +3 +
P<.0001
MiniFull
%%
100100
8080
6060
4040
2020
00
Hospital DeathHospital Death
P<.0001 P=.2
UnadjustedUnadjusted
%%
55
44
33
22
11
00
MiniFull
MatchedMatched
0.2
1.6
0.5
1.1
75
80
85
90
95
100
0 1 2 3 4 5 6 7 8
%%
YearsYears
Mini
Full
Matched SurvivalMatched Survival
Minimally Invasive Minimally Invasive
MitralMitral Valve SurgeryValve Surgery
Fewer transfusionsFewer transfusions
Shorter ICU stayShorter ICU stay
Shorter LOSShorter LOS
Better early survivalBetter early survival
ResultsResults
SuperiorSuperior
•• CosmesisCosmesis
•• Patient Patient
satisfactionsatisfaction
EquivalentEquivalent
•• SafetySafety
•• Repair rateRepair rate
CostCost
CostCost
NonNon--robotic approachesrobotic approaches
•• Small capital investmentSmall capital investment
•• Decreased length of stayDecreased length of stay
•• OverallOverall--equal or less expensiveequal or less expensive
CostCost
Robotic approachRobotic approach
•• Initial capital investmentInitial capital investment
•• More disposablesMore disposables
•• Decreased length of stayDecreased length of stay
Mitral Valve Repair Mitral Valve Repair
Length of StayLength of Stay
•• If you can do the same operation withIf you can do the same operation with
•• Equal repair rateEqual repair rate
•• Equivalent safetyEquivalent safety
•• Smaller incisionSmaller incision
•• Superior Superior cosmesiscosmesis
QuestionQuestion
•• If you can do the same operation withIf you can do the same operation with
•• Equal repair rateEqual repair rate
•• Equivalent safetyEquivalent safety
•• Smaller incisionSmaller incision
•• Superior Superior cosmesiscosmesis
•• Why not?Why not?
AnswerAnswer
The SurgeonThe Surgeon’’s s
ResponsibilityResponsibility
OptimizeOptimize
•• SafetySafety
•• Repair rateRepair rate
MinimizeMinimize•• Incision/traumaIncision/trauma
EnhanceEnhance
•• OutcomeOutcome
•• Patient satisfactionPatient satisfaction
Thank YouThank You
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Market and Network Services Access LineA new, one-stop, easy to use service dedicated for Case Managers, Medical
Directors and Corporate Leaders who need assistance in referring patients to
Cleveland Clinic, Main Campus. This line is open from 7am – 11pm, seven
days a week.
216-738-5439