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Minimally Invasive Valvular Surgery

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Minimally Invasive Valvular Surgery Minimally Invasive Valvular Surgery Lisa DeGarmo, MSN, APRN, ACNP-BC Structural Heart APP Department of Cardiothoracic and Vascular Surgery McGovern Medical School The University of Texas Science Center at Houston Memorial Hermann Heart & Vascular Institute DISCLOSURE • I AM NOT A SURGEON. • But I work for one, and he specializes in minimally invasive CV surgery INTRODUCTION TO MINIMALLY INVASIVE VALVULAR SURGERY PRE-OPERATIVE WORK-UP FOR SURGERY OBJECTIVES STEPS OF THE SURGERY POST OPERATIVE CARE MICS MINIMALLY INVASIVE CARDIAC SURGERY MICS Cardiac Surgery Open Dr. Charles P. Theodore Tuffier, Bailey, Mitral and 19070’s – first successful Commissurotomy Mitral Valve valve surgery for mitral stenosis annuloplasty and •Using fingers to reach •Used a hooked knife annuloplasty ring stenotic aortic valve. and finger develops HISTORY OF 1923 1952 VALVE 1912 1948 1960’s SURGERY Elliot Carr Cutler, Dr. John Gibbon, first mitral valve Cardiopulmonary operation bypass •Mitral valvulotomy •first successful open heart surgery on ASD repair Dr. Cohn at Brigham and Dr. Rao and Kumar- Women’s Hospital successful mini AVR • Mini AVR and MVR via right • Right anterior thoracotomy parasternal incision or mini- approach sternotomy HISTORY OF 1996 VALVE 1993 1997 SURGERY Navia and Cosgrove at Cleavland Clinic • Mini MVR MAJOR ADVANCES IN MINIMALLY INVASIVE CARDIAC SURGERY 1. Improvement in arterial and venous cannulas 2. Transjugular coronary sinus catheters for retrograde cardioplegia 3. CO2 in operative field; limits intracardiac air and air embolism 4. Intra-operative transesophageal echo. Schmitto, JACC 2010 PLEASE GIVE ME A STERNOTOMY MICS MINIMALLY INVASIVE CARDIAC SURGERY Mini AVR Robotic Mini MVR MIVS MICS Cardiac Surgery Mini ASD repair TAVR Open Hemisternotomy Minimally Invasive Incisions TF TAVR PAST PRESENT & FUTURE PAST PRESENT & FUTURE Safety CLINICAL Address the Pathology GOALS FOR (without compromise) SURGERY Incision size/ Location WHY MINIMALLY INVASIVE ? Sternotomy Minimally Invasive Case Load 100 150 200 250 300 50 0 N=2571; 3 centers 2011 AVR BY PROCEDURE Procedure Year 2012 2013 2014 SAVR Case Load 100 150 200 250 300 50 0 N=2571; 3 centers 2011 AVR BY PROCEDURE Procedure Year 2012 2013 2014 SAVR TAVR-TF Case Load 100 150 200 250 300 50 0 N=2571; 3 centers 2011 AVR BY PROCEDURE Procedure Year 2012 2013 2014 miniAVR SAVR TAVR-TF RESULTS Surgery Type 30 DAY STROKE AFIB LOS MORTALITY SAVR 1.8% 2.1% 31.7% 8.8 DAYS MINI AVR 0.6% 0.7% 21.5% 7.6 DAYS TF- TAVR 1.9% 2.2% 4.4% 4.3 DAYS Nguyen, T. C. , et al, (2017) • Retrospective study of prospective data • (Jan 2010-Dec 2013) • Compared open AVR (n=211) and minithoractomy AVR (n=311) • Results: • Increase in • Decrease in: • CPB time • Perioperative mortality • Cross-clamp time • Hospital stay • Groin wound infection • ICU stay • Pts who required less • BUT, overall decrease in transfusions • ICU days and LOS • Stroke • Atrial Fibrillation MINIMALLY INVASIVE AORTIC SURGERY • RIGHT ANTERIOR THORACOTOMY • Between 2nd and 3rd rib space • AVOID STERNOTOMY- post discharge rehab, faster recovery • PERIPHERAL CARDIOPULMONARY BYPASS Permission granted by patient Two surgeons work simultaneously to open and close ICU MONITOR FIRST 24 HRS EVERYDAY- ASSESS YOUR IS THERE STILL A MURMUR? PATIENT! USUALLY SMALLER BLAKE 24 FR CHEST TUBE x 2 CHEST TUBE MONITORING OFTEN PACING WIRES THROUGH THE POST OP PLEURAL CHEST TUBE SITE ASA AND AC STARTED POD (TISSUE VS MECHANICAL) CARE 1 OR WHEN APPROPRIATE PT UP OUT OF BED AND AMBULATING MONITOR GROIN SITE MINIMALLY INVASIVE MITRAL VALVE SURGERY • Results similar • Stroke rate and mortality at • Decrease in: 30 day were similar • Perioperative mortality • Hospital stay • Increase in • ICU stay • CPB time • Pts who required less • Cross-clamp time transfusions • Stroke • Atrial Fibrillation ROBOTIC ASSISTED VALVULAR SURGERY WHO IS A CANDIDATE? THE WORK UP…. • Qualifying Echo (TTE or TEE) • Is the patient symptomatic? • May need LHC • May need CT Chest/abdomen/ pelvis • Free of infection (check labs, UA, good history and PE, check dentation) WHEN MIGHT OPEN STERNOTOMY BE APPROPRIATE? • Previous minimally invasive surgery • Previous trauma or chest radiation • Unable to cannulate femoral artery • Tortuous abdominal aorta or dissection • Severe Aortic insufficiency (d/t difficulty with cardioplegia) • Valve + CABG required • AVR + MVR WHERE ARE WE HEADED TMVR TRANSCATHETER MITRAL VALVE REPLACEMENT TRANSCATHETER TRICUSPID VALVE REPLACEMENT • NaviGate stent valve WHERE ARE WE HEADED “ALEXA….. FIX MY HEART!” THANK YOU! LISA DEGARMO REFERENCES Nguyen, T.C., Terwelp, M.D., Thourani, V.H., Zhao, Y., Ganim, N., Hoffmann,C., et al. 2017). Clinical trends in surgical, minimally invasive and transcatheter aortic valve replacement†, European Journal of Cardio-Thoracic Surgery, June 2017, Volume 51, (6,) pg 1086-1092. Retrieved from: https://doi.org/10.1093/ejcts/ezx008 Schmitto, J.D., Mokashi, S.A., Cohn, L.H. (2010). Minimally invasive valve surgery. Journal of the American College of Cardiology Aug 2010, 56 (6) 455- 462; DOI:10.1016/j.jacc.2010.03.053 Stolinksi, J., Plicner, D., Grudzien, G., Wasowicz, M., Musial, R., Andres, J. and Kapelak, B. (2016). A comparison of minimally invasive and standard aortic valve replacement. Journal of Thoracic and Cardiovascular Surgery, Oct 2016, Volume 152 (4), pg. 1030- 1039. Retrieved from: https://doi.org/10.1016/j.jtcvs.2016.06.012 REFERENCES Sundermann, S.H., Sromicki, J., Cetina-Biefer, H.R., Seifert, B., Holubec, T., Falk, V., et al (2014). Mitral valve surgery: Right lateral minithoracotomy or sternotomy? A systematic review and meta-analysis. The Journal of Thoracic and Cardiovascular Surgery, Nov 2014, vol. 148 (5), pg. 1989- 1995. Retrieved from: https://doi.org/10.1016/j.jtcvs.2014.01.046 THANK YOU UTCVSurgery [email protected] https://med.uth.edu/cvs/.
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