minimally invasive valve surgery. how far we have come the mortality for valve replacement surgery...

MINIMALLY INVASIVE VALVE

SURGERY

HOW FAR WE HAVE COME

THE MORTALITY FOR VALVE REPLACEMENT SURGERY IN 1968 WAS 42%

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

PATIENT DEMAND

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

“…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.”

“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.”

APPROACHES

PARASTERNAL

ADVANTAGES GOOD ACCESS TO THE AORTIC

VALVE DISADVANTAGES

CHEST WALL HERNIA CAN RESULT

LOWER STERNAL

ADVANTAGES GOOD EXPOSURE FOR THE MITRAL

VALVE EXCISION CAN BE EXTENDED IF

NECESSARY

TRANSECTING STERNAL

ADVANTAGES EXCELLENT EXPOSURE OF THE

AORTIC VALVE AND GREAT VESSELS

DISADVANTAGES BREASTBONE INSTABILITY LOSS OF INTERNAL MAMMARY

ARTERIES FOR FUTURE USE

PORT ACCESS

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

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

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

IN THE INITIAL FDA STUDY, 65% OF PATIENTS WERE EXCLUDED

RIGHT THORACOTOMY

ADVANTAGES EXCELLENT RESULTS ACHIEVED BY

SOME SURGEONS PATIENT PREFERENCE

DISADVANTAGES GENERALLY RESTRICTED TO THE

MITRAL VALVE LONG INSTRUMENTS REQUIRED CANNOT EXTEND INCISION

UPPER STERNOTOMY

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

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

AORTA IS OPENED IN THE STANDARD FASHION

THE RIGHT ATRIUM IS OPENED TO APPROACH THE MITRAL VALVE

CONTRAINDICATONS

MORBID OBESITY REOPERATIONS PECTUS EXCAVATUM NEED FOR ASSOCIATED

PROCEDURES CAN REVASCULARIZE THE RIGHT

CORONARY ARTERY

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

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

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