minimally invasive mitral surgery · mahesh ramchandani md, frcs . mics mv surgery relative...
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MAHESH RAMCHANDANI MD, FRCS
MINIMALLY INVASIVE MITRAL SURGERY
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New Keyhole Heart Surgery Arrived
With Fanfare, but Was It Premature?
Ralph King Jr.
Staff Reporter
Wall Street Journal May 5, 1999
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Dr Cooley’s reaction
• They took something awfully simple
• And made it simply awful!
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Meta-analysis of R mini thoracotomy
vs sternotomy mitral surgery Sundermann et al, JTCVS Nov, 2014
• 20,000 pts, 45 studies
• MICS MVS vs Conventional sternotomy
• No difference in
– All cause mortality – 1.4% vs 1.7%
– Stroke 1.7% vs 1.6%
– AKI 2.1% vs 2.1%
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Meta-analysis of R mini thoracotomy
vs sternotomy mitral surgery Sundermann et al, JTCVS Nov, 2014
• 20,000 patients, 45 studies
• MICS MVS has greater
– Procedure time <.001
– CPB time <.001
– Clamp time <.001
– Aortic dissection <.05
• 4 vs 0
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Meta-analysis of R mini thoracotomy
vs sternotomy mitral surgery Sundermann et al, JTCVS Nov, 2014
• 20,000 patients, 45 studies
• MICS MVS has less
– Blood drainage postop <.001
– Transfusion <.004
– Postop Vent <.001
– Postop AF <.07
– ICU LOS <.001
– Hosp LOS <.001
– Av Cost $7594 less <.07
– Superior cosmetics and patient satisfaction
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Positioning for MICS MVR
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Arterial cannulation
• Femoral artery – open or percutaneous
– Preop CTA to r/o aortoiliac disease
• Axillary artery – direct or with a side conduit
• Central Aortic – More accessible for mini AVR
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Venous Cannulation
• Femoral with TEE guidance
– Percutaneous or cut down
– Beware cannula dislodgement with LA retractor
– Position deeper in SVC than for mini AVR
– Good venous drainage critical
– Can supplement with direct SVC cannula if necc.
• DO NOT proceed further until good venous
drainage established
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Cygnet aortic clamp
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Chitwood clamp
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• IntraClude intra-aortic occlusion device
– Delivers antegrade cardioplegia
– Vents the aortic root
– Monitors aortic root pressure
– Occludes the ascending aorta from within
– Useful in redo’s and porcelain aorta
Intra Aortic Occlusion balloon
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Myocardial preservation
• Antegrade cardioplegia
• Retrograde via Coronary Sinus – if AR
– Direct insertion with TEE guidance
– Percutaneous Coronary Sinus Catheter
• Cardioplegia
– St Thomas’ – every 15-20 min
– Del Nido – every 60 min
– Custodial – every 60-90 min
• Fibrillation strategy
– Used routinely by some
– Visualisation can be compromised
– Possibly higher rate of gaseous emboli
– Not an option if significant AR
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Minimally Invasive Mitral Valve Repair
Mahesh Ramchandani MD, FRCS
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MICS MV Surgery
Relative contraindications
• MAC – more complex surgery – longer clamp time
• Ascending aorta calcification – Intraclude baloon
• Redo chest – Fibrillation startegy
• Aortic regurgitation – retrograde cardioplegia only
• PAD – axillary cannulation
• Pectus excavatum – heart pushed over to left
• Avoid morbid obesity when starting out
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Re Evolution Summit
Hands on teaching of MICS
April 5 and 6, 2018
19
Google ‘ReEvolution Summit for details
Search ‘Debakey Education’ on Youtube for meeting content
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Sternotomy Minimally Invasive
“Less is More” Joseph Lamelas M
D