manejo del paciente operados con técnica de heart port en el postoperatorio inmediato
DESCRIPTION
Manejo del paciente operados con técnica de heart port en el postoperatorio inmediatoTRANSCRIPT
HEART PORT Port-Access® Operative Procedure
UCI - Policlínica Gipuzkoa UCI
UCI
PG: 200 casos
PG: 28 casos
proporciona una plataforma para la realización de procedimientos quirúrgicos cardíacos a través de pequeñas incisiones ("ports"), sin una esternotomía media - al tiempo que permite un acceso completo y con buena visión del corazón no batiente y protegido. Heart Port
UCI
Técnica Heart Port - PG
1º Universidad de Stanford (California) 1995 ‒ Heartport Manual 1997 Europa: Hugo Baron Vanermen (Bélgica)
Port Port: Robot-Assisted
Experience stages
Esternotomía C. Endoscópica
UCI
Técnica Heart Port - PG
Canulación para el by-pass cardiopulmonar:
Lungs
Left Atrium
Right Ventricle
Right Atrium
Left Ventricle
Oxygenator
Left Atrium
Right Ventricle
Right Atrium
Left Ventricle
Lungs
PUMP
Técnica de Perfusión Estándar
UCI
LA RV RA LV
Oxygenator PUMP
Cardioplegia
Técnica de Perfusión Estándar
UCI
Left Atrium
Right Ventricle
Right Atrium
Left Ventricle
IVC Drainage O²
Cardioplegia
SVC Drainage
EndoClamp: Cardioplegia y Clampaje
Clamping
UCI
Técnica By-pass cardiopulmonar
UCI
Canulación para el CEC:
- Vena yugular derecha - Vena femoral derecha
- Arteria femoral derecha: EndoClamp aórtico
- Vena yugular izquierda: PVC ... - Arterias radiales bilaterales
Técnica By-pass cardiopulmonar
UCI
TOT doble luz
Sonda ETE
Cánula en V. Yugular dcha.
PVC en CVC en V. Yugular izda.
Técnica By-pass cardiopulmonar
UCI
Acceso Femoral
UCI
Técnica By-pass cardiopulmonar
Canulación venosa
Aurícula Izquierda
Ventrículo Derecho
Aurícula Derecha
Ventrículo Izquierdo
O²
Cardioplegia
Clampaje
Acceso Femoral Arterial Retorno arterial / EndoClamp aórtico / Cardioplegia
UCI
Acceso Femoral - Arteria: EndoClamp aórtico
UCI
Técnica By-pass cardiopulmonar
Canulación arterial
Clampaje aórtico transtorácico
UCI
Técnica By-pass cardiopulmonar
UCI
Técnica Heart Port - PG
Exposición del campo quirúrgico:
Retractor AI
Toracotomía Puerto para
endoscopio
Puerto para Vent y CO2
Minitoracotomía 4º espacio intercostal / submamario
UCI
Técnica Campo Quirúrgico
Retractor AI
Puerto para endoscopio
Puerto para Vent y CO2
Técnica Campo Quirúrgico
UCI
Técnica Campo Quirúrgico
UCI
Técnica Campo Quirúrgico
UCI
Técnica Campo Quirúrgico
UCI
Técnica Campo Quirúrgico
UCI
TÉCNICA HEART-PORT Port-Access® Operative Procedure
POLICLÍNICA GIPUZKOA
Resultados HEART PORT - PG
UCI
5,5%94,5%
HP
No HP
ü Casos realizados Heart-Port (2003-2009)
192 5,53329 94,53521 100,0
SiNoTotal
FrecuenciaPorcentajeválido
Tabla de contingencia Heart-Port * Año
14 47 32 24 30 16 29 1922,6% 8,5% 6,2% 5,0% 6,2% 3,3% 6,2% 5,5%
Recuento% de Año
Si2003 2004 2005 2006 2007 2008 2009
AñoTotal
UCI
HEART PORT Port-Access® Operative Procedure
INDICACIONES:
" Estenosis mitrales " Insuficiencias mitrales " CIA " Mixomas auriculares. " Ùtil en re-operaciones " Puede ser útil para aortas severamente calcificadas
CADA PACIENTE debe ser analizado de manera INDIVIDUAL y aconsejado sobre sus DIFERENTES OPCIONES
48,4%
51,6%Heart-Port
192 48,4205 51,6397 100,0
SiNoTotal
FrecuenciaPorcentajeválido
Tipo de cirugía
363 91,423 5,8
9 2,32 ,5
397 100,0
ValvularCIAValv-CIAOtros_Heart PortTotal
FrecuenciaPorcentaje
válidon = 3521
UCI
DESCARTAR:
" Problemas vasculares femorales o ilíacos " Estudio de pulsos en EEII " En pacientes añosos / arteriopatía:
- estudio angiográfico de vasos ilíacos y femorales " Insuficiencia Aórtica. " Capacidad pulmonar para tolerar la exclusión del pulmón derecho
HEART PORT Port-Access® Operative Procedure
UCI
CONTRAINDICACIONES:
CONTRAINDICACIONES RELATIVAS: " Toracotomías previas con un pulmón derecho adherido a la caja torácica
" Calcificación severa del anillo mitral " Aorta ascendente dilatada de más de 4.5 cm de diámetro
HEART PORT Port-Access® Operative Procedure
Periodo: ago-03 / jul-10
ü Casos realizados: 200
ü Sexo: mujeres 60%
ü Edad media: 64,9 años (16::86)
ü 2ª Intervención: 7%
ü F.E. Media: 62,6% (min. 31%)
ü P. A. Pulmonar Media: 43 mm Hg. (max. 106)
UCI
Edad corregida (años) Stem-and-Leaf Plot Frequency Stem & Leaf 10,00 Extremes (=<36) 2,00 3 . 77 7,00 4 . 0112244 5,00 4 . 56679 11,00 5 . 00112223444 25,00 5 . 5556777778888889999999999 29,00 6 . 00000111111222222233333344444 29,00 6 . 55566666667777888888889999999 34,00 7 . 0000111111111222222223333344444444 31,00 7 . 5555556666667777777777888888899 16,00 8 . 0001111112223334 1,00 8 . 6 Stem width: 10 Each leaf: 1 case(s)
Resultados HEART PORT - PG
Periodo: ago-03 / jul-10
ü Casos realizados: 200
ü Sexo: mujeres 60%
ü Edad media: 64,9 años (16::86)
ü 2ª Intervención: 7%
ü F.E. Media: 62,6% (min. 31%)
ü P. A. Pulmonar Media: 43 mm Hg. (max. 106)
UCI
Resultados HEART PORT - PG
Alto riesgo (ES >= 10.9%)
164 82,036 18,0200 100,0
NoSiTotal
FrecuenciaPorcentajeválido
Periodo: ago-03 / jul-10
ü Estancia en UCI: 1,8 días / Md:1 día
ü Estancia Hospitalaria: 8,5 días / Md: 7 días
ü Mortalidad en UCI: 2,5%
ü Mortalidad a los 30 días: 4,5% (Media EuroSCORE log.: 6,78%)
UCI
Resultados HEART PORT - PG
Bajo riesgo (ES <= 2.94%)
196 98,04 2,0
200 100,0
NoSiTotal
FrecuenciaPorcentajeválido
UCI
Resultados HEART PORT - PG
Prueba de muestras independientes
39,253 33,868 44,63741,802 35,585 48,019
Tiempo de isquemia (min.)Tiempo de By-pass (min.)
Diferenciade medias Inferior Superior
95% Intervalo deconfianza para la
diferencia
Prueba T para la igualdad de medias
Estadísticos de grupo
192 89,11 30,141 2,175237 49,86 26,552 1,725192 128,47 35,752 2,580240 86,67 28,294 1,826
Heart-PortSiNoSiNo
Tiempo de isquemia (min.)
Tiempo de By-pass (min.)
N MediaDesviación
típ.Error típ. de
la media
CEC:
“PROBLEMAS”
ü Entrenamiento / “curva de aprendizaje”
ü Tiempo y Paciencia Esternotomía Heart -Port
ü Complicaciones accesos vasculares arteriales: 2%
ü Complicaciones canulación venosa: 2%
ü Clampaje transtorácico - Novare: 8%
ü Adherencias pleurales: 2%
UCI
Resultados HEART PORT - PG
COMPLICACIONES - accesos
UCI
Resultados HEART PORT - PG
COMPLICACIONES - globales
Complicaciones Heart-Port 1,5% 0,5% 1,0%
6% ,0%
3,0% 1% ,0% ,0%
ACVA con secuelas IAM peri-IQ Shock Daño renal agudo (RIFLE) FRA con TDE H. Mediatínica SIN re-IQ H. Medistínica CON re-IQ Politrasfusión (> 6 C.H.) Taponamiento
0% conversiones a esternotomía *
ü Pacientes seleccionados
ü DIFICULTAD para realizar comparaciones
Conclusiones HEART PORT - PG
ü HP es una técnica HABITUAL en nuestro centro
Prueba de muestras independientes
,511 -,839 -3,344 1,667,511 -,8387 -3,3442 1,6667,307 1,110 -1,022 3,242,109 -4,146 -9,225 ,933
Edad (años)Edad corregida (años)Fraccion de eyeccion (%)Hipertension pulmonar(mm Hg.)
Sig. (bilateral)Diferenciade medias Inferior Superior
95% Intervalo deconfianza para la
diferencia
Prueba T para la igualdad de medias
Resultados “Comparaciones” NO significativas
HP vs nHP: 2003-2009
65,12 65,9663,01 61,9041,97 46,12
Edad corregida (años)Fraccion de eyeccion (%)Hipertension pulmonar (mm Hg.)
Si NoHeart-Port
Media
Heart-Port
192 48,4205 51,6397 100,0
SiNoTotal
FrecuenciaPorcentajeválido
Resultados
Tabla de contingencia Tipo de prótesis mitral * Heart-Port
109 13356,8% 64,9%
4 212,1% 10,2%
63 2032,8% 9,8%
16 318,3% 15,1%
192 205
Recuento% de Heart-PortRecuento% de Heart-PortRecuento% de Heart-PortRecuento% de Heart-PortRecuento
Mecánica
Biológica
Anuloplastia
No
Tipo deprótesis mitral
Total
Si NoHeart-Port
Tabla de contingencia Reintervenido * Heart-Port
13 556,8% 26,8%
179 15093,2% 73,2%
192 205
Recuento% de Heart-PortRecuento% de Heart-PortRecuento
Si
No
Reintervenido
Total
Si NoHeart-Port
“Comparaciones” NO significativas HP vs nHP: 2003-2009
Resultados
Tabla de contingencia IAM peri-IQ * Heart-Port
190 20399,5% 99,0%
1 2,5% 1,0%191 205
No
Si
IAM peri-IQ
Total
Si NoHeart-Port
Tabla de contingencia Shock * Heart-Port
189 19999,0% 97,1%
2 61,0% 2,9%
191 205
Recuento% de Heart-PortRecuento% de Heart-PortRecuento
No
Si
Shock
Total
Si NoHeart-Port
Tabla de contingencia FRA con TDER * Heart-Port
191 205100,0% 100,0%
191 205
NoFRA con TDER
Total
Si NoHeart-Port
Tabla de contingencia H. Mediatínica sin re-IQ * Heart-Port
185 19796,9% 96,1%
6 83,1% 3,9%
191 205
No
Si
H. Mediatínica sin re-IQ
Total
Si NoHeart-Port
“Comparaciones” NO significativas HP vs nHP: 2003-2009
Port-Access®: tiempos de isquemia y CEC más prolongados
Resultados
Tabla de contingencia H. Medistínica con re-IQ * Heart-Port
189 19599,0% 95,1%
2 101,0% 4,9%
191 205
No
Si
H. Medistínica con re-IQ
Total
Si NoHeart-Port
Tabla de contingencia Politrasfusión (> 6 C.H.)
51 50100,0% 92,6%
0 4,0% 7,4%51 54
No
Si
Politrasfusión(> 8 C.H.)
Total
Si NoHeart-Port
Tabla de contingencia Taponamiento * Heart-Port
191 201100,0% 98,0%
0 4,0% 2,0%191 205
No
Si
Taponamiento
Total
Si NoHeart-Port
Tabla de contingencia ACVA con secuelas * Heart-Port
188 19498,4% 94,6%
3 111,6% 5,4%
191 205
No
Si
ACVA con secuelas
Total
Si NoHeart-Port
“Comparaciones” NO significativas HP vs nHP: 2003-2009
Resultados
Heart-Port
192 48,4205 51,6397 100,0
SiNoTotal
FrecuenciaPorcentajeválido
Tabla de contingencia Mortalidad a los 30 días * Heart-Port
184 194 37895,8% 94,6% 95,2%
8 11 194,2% 5,4% 4,8%
192 205 39748,4% 51,6% 100,0%
Recuento% de Heart-PortRecuento% de Heart-PortRecuento
No
Si
Mortalidad alos 30 días
Total
Si NoHeart-Port
Total
Prueba de muestras independientes
-3,92828 -5,65610 -2,20045Se han asumidovarianzas iguales
EuroSCORE Log. (%)
Diferenciade medias Inferior Superior
95% Intervalo de confianza para ladiferencia
Prueba T para la igualdad de medias
Estadísticos de grupo
6,5582 8,37325 ,6042910,4865 9,05432 ,63549
Heart-PortSiNo
EuroSCORE Log. (%)Media
Desviacióntíp.
Error típ. dela media
“Comparaciones” NO significativas HP vs nHP: 2003-2009
Tabla de contingencia Alto riesgo (ES >= 10.9) * Heart-Port
159 12182,8% 59,6%
33 8217,2% 40,4%
192 203
No
Si
Alto riesgo (ES >= 10.9)
Total
Si NoHeart-Port
Resultados “Comparaciones” NO significativas
HP vs nHP: 2003-2009
Prueba de muestras independientes
,001 2,048 ,828 3,267Estancia media (días)Sig. (bilateral)
Diferenciade medias Inferior Superior
95% Intervalo deconfianza para la
diferencia
Prueba T para la igualdad de medias205 3,91 8,582 ,599192 1,86 2,147 ,155
Heart-PortNoSi
Estancia Media (días)en UCI
N MediaDesviación
típ.Error típ. de
la media
Pacientes seleccionados
DIFICULTAD para realizar comparaciones
Conclusiones HEART PORT - PG
ü HP es una técnica HABITUAL en nuestro centro
ü HP es una técnica FACTIBLE y SEGURA
Bibliografía
HEART PORT ¿Factible y Seguro?
Ann Thorac Surg 2002;74:660-4
Minimally-Invasive Mitral Valve Surgery: A 6-Year Experience With 714 Patients Eugene A. Grossi, MD, New York University School of Medicine. New York, USA.
Results: Hospital mortality for primary isolated mitral valve repair was 1.1% and 5.8% for isolated mitral valve replacement. Overall hospital mortality was 4.2% (30 of 714). Mean cross-clamp time was 92 minutes and mean cardiopulmonary bypass time was 127 minutes. Postoperatively, median ventilation time was 11 hours, intensive care unit time was 19 hours and total hospital stay was 6 days. Complications for all patients included permanent neurologic deficit (2.9%), aortic dissection (0.3%), no mediastinal infection (0.0%). Follow-up echocardiography demonstrated 89.1% of the repair patients had only trace or no residual mitral insufficiency.
Conclusion: This study demonstrates that the minimally invasive port access approach to mitral valve operations is reproducible with low perioperative morbidity and mortality and with late outcomes that are equivalent to conventional operations.
Objective: To analyze a single-institutional experience with minimally-invasive mitral valve operations of 6 years, reviewing short-term mortality and morbidity and long-term echocardiographic data. Method: Between Nov 1995 and Nov 2001, 714 consecutive patients had minimally invasive mitral valve procedures. 561 patients had isolated mitral valve operations (375 repairs, 186 replacements) . Mean age was 58.3 (30.1% > 70 years) and 15.4% had previous cardiac operations. Arterial cannulation was femoral in 79.0% and central in 21% with the port access balloon endo-occlusion used in 82.3%. Cardioplegia was transjugular retrograde (54.1%) or antegrade (29.4%). Right anterior minithoracotomy was used in 96.6% and left posterior minithoracotomy in 2.2%
HEART PORT ¿Factible y Seguro?
The Journal of Heart Valve Disease 2008;17:48-53
Video-Assisted Mitral Surgery through a Micro-Access: A Safe and Reliable Reality in the Current Era Ernesto Greco MD, Juan M. Zaballos MD, Luis Alvarez MD, Stefano Urso MD, Ivana Pulitani MD,Rafael Sàdaba MD, Arantxa Juaristi MD, Juan J. Goiti MD Policlinica Gipuzkoa, San Sebastian.
Objective: To describe the author´s experience with video-assisted mitral surgery through a micro-access. Method: Between September 2003 and September 2006, 100 patients (mean age 65.7 years; range: 16-84 years; 29 aged >75 years) underwent video-assisted port-access mitral valve surgery through a 4 to 6 cm anterior mini-thoracotomy. Mitral valve repair wascarried out in 36 patients (36%) and mitral valve replacement (MVR) in 64 (64%). Redo procedures were performed in 14 patients.
Results: Endoclamp occlusion of the ascending aorta was used in 94%. The median intensive care unit and hospital stays were 20.0 ± 30.8h and 7.0 ± 5.9 days, respectively. Hospital mortality was 4% (n = 4). No patient required conversion to sternotomy. There were no perioperative myocardial infarctions, permanent strokes, major vascular complications, or peripheral ischemic events. Among the patients, 63% had no complications at all during the postoperative course, and no wound infections were observed.
Conclusion: Video-assisted mitral surgery through a micro-access may be performed safely, at low risk of morbidity and mortality, and with results and quality standards similar to those reported for a sternotomy approach. Of note, older patients may be successfully treated using this technique.
HEART PORT ¿Factible y Seguro?
The Preferable Use of Port Access Surgical Technique for Right and Left Atrial Procedures Gersak B, Sostaric M, Kalisnik JM, Blaumamauer R. Department of Cardiovascular Surgery, University Medical Center Ljubljana, Slovenia.
Results: There were statistically significant differences in cardiopulmonarybypass time (CPB) and aortic cross-clamp time (AXT) between both groups: CPB C versus PA: 98.3 ± 33.5 minutes versus 149.2 ± 44.2 minutes (mean ± sd), AXT C versus PA: 62.9 ± 20.6 minutes versus 88.3 ± 26.8 minutes (mean ± sd). There were no statistically significant differences in mortality and stroke for both the groups There were statistically significant differences in favor of the port access over the classical one for: intensive unit stay postoperative stay in days, blood transfusion, postoperative thoracic bleeding and extubation time in hours. Furthermore, costs analyses showed that the average total patient cost was less for port access. The differences between endo and classical type suggested that the port access type of surgery is 20% cheaper than the classical one.
Conclusion: We may conclude that port access surgery is an acceptable alternative to classical type of surgery, also in complex pathology of the mitral and tricuspid valve.
The Heart Surgery Forum # 2004-1143 8(5), 2005
Objective: To analyze the results of mitral valve operations, either alone or in combination with the tricuspid valve surgeries. Method: From January 2001 till June 2004. The period was divided into two parts, classical sternotomy part (C) (110 patients) and minimally invasive port access part (PA) (105 patients), later being used from December 2002 till now. Also, what we were interested in was the total hospital cost of both types of the procedures and if there are any advantages of port access over the classical sternotomy. The mean age was 61.2 ± 10.2 and 60.3 ± 12.4 (C versus PA) and mean additive Euroscore was 6.5 versus 4.8 (C versus PA).
HEART PORT ¿Factible y Seguro?
J Thorac Cardiovasc Surg. 2009
Quality of mitral valve repair: Median sternotomy versus port-access approach. Raanani E, Spiegelstein D, Sternik L, Preisman S, Moshkovitz Y, Smolinsky AK, Shinfeld A. Department of Cardiac Surgery, Chaim Sheba Med. Center, Tel Hashomer, affiliated with the Sackler School of Medicine, Tel-Aviv University, Israel.
Objectives: We sought to compare early and late clinical and echocardiographic outcomes of patients undergoing minimally invasive mitral valve repair by means of the port-access and median sternotomy approaches. Methods: Between 2000 and 2009, 503 patients had mitral valve repair, of whom 143 underwent surgical intervention for isolated posterior leaflet pathology: 61 through port access and 82 through median sternotomy. The port-access group had better preoperative New York Heart Association functional class (P = .007) and a higher rate of elective cases (97% vs 87%, P = .037). Other preoperative characteristics were similar between the groups, including mitral valve pathology and repair techniques.
Results: Operative, bypass, and clamp times were significantly longer in the port-access group. Mean hospital stay was 5.3 +/- 2.5 days in the port-access group versus 5.7 +/- 2.5 days in the median sternotomy group (P = .4). Early postoperative echocardiographic analysis showed that most patients in both groups had none or trivial mitral regurgitation and none of the patients had greater than grade 2 mitral regurgitation. Follow-up extended for up to 100 months (mean, 34 +/- 24 months). New York Heart Association class improved in both groups (P = .394). Freedom from reoperation was 97% and 95% in the port-access and median sternotomy groups, respectively. Late echocardiographic analysis revealed that 82% (49/60) in the port-access group and 91% (73/80) in the median sternotomy group were free from moderate or severe mitral regurgitation (P = .11).
Conclusion: In isolated posterior mitral valve pathology, quality of mitral valve repair with the port-access approach can compare with that with the conventional median sternotomy approach.
HEART PORT: dolor y calidad de vida
Pain and Quality of Life After Minimally Invasive Versus Conventional Cardiac Surgery Thomas Walther, MD, Herzzentrum Leipzig
Ann Thorac Surg 1999;67:1643-7
Objective: To evaluate pain and quality of life after minimally invasive cardiac operations in comparison with conventional cardiac operations. Method: From Oct 1996 to May 1997, a total of 338 patients were interviewed daily using standard scoring systems (myocardial revascularization n = 160; mitral valve reconstruction or replacement n = 58; aortic valve replacement n = 120).
Results: There was no significant difference regarding ventricular function and intensive care and hospital stay. Pain decreased until the seventh postoperative day in all patients. Patients with a lateral minithoracotomy had lower pain levels from the third postoperative day onward. There were no differences in quality of life, postoperative wound healing or stability of the bony thorax.
Conclusion: After minimally invasive procedures with lateral minithoracotomy, earlier mobilization is possible because of a better stability of the bony thorax, resulting in lower pain levels.
Pacientes seleccionados
DIFICULTAD para realizar comparaciones
ü HP es una técnica FACTIBLE y SEGURA
ü Paso previo a la CIRUGÍA ROBÓTICA
Conclusiones HEART PORT - PG
ü HP es una técnica HABITUAL en nuestro centro
Gracias
Técnica By-pass cardiopulmonar
UCI
Canulación arterial femoral EndoClamp