mics cabg in-service presentation - medtronic of mics cabg procedure/ instrumentation recommended...
TRANSCRIPT
MICS CABG In-service Presentation
This presentation is based on a compilation of the
surgical techniques and protocols of:
Dr. Joseph McGinn - Staten Island, New York
Dr. Marc Ruel - Ottawa, Canada
Dr. Steven Hoff - Nashville, TN
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• What is a MICS CABG Procedure?
– Off-Pump CABG in which the anastomoses are performed
under direct vision through a lateral thoracotomy
– LIMA harvested– under direct vision, robotically or with
video assistance
– Additionally, in order to achieve complete revascularization,
a pump-assisted beating heart approach or hybrid approach
can be employed
MICS CABG: Overview
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• Complete revascularization can be achieved
• 5 – 7 cm posterior-lateral thoracotomy providing improved patient
and referring physician satisfaction1
• Shortened intubation time1
• Reduced hospital length of stay1
• Quicker return to normal activities and less restrictions post
surgery2
1 Poston RS, Tran R, Collins M, Reynolds M, Connerney I, Reicher B, Zimrin D, Griffith BP, Bartlett ST. Comparison of economic and patient outcomes with minimally invasive versus traditional off-pump coronary
artery bypass grafting techniques. Ann Surg 2008;248:638-646.
2 Lapierre H, Chan V, Sohmer B, Mesana TG, Ruel M. Minimally invasive coronary artery bypass grafting via small thoracotomy versus off-pump: A case-matched study. Eur J Cardiothorac Surg. 2011;40:804-810.
Potential Benefits of MICS CABG
MICS CABG vs. MIDCAB
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• Coronary Anatomy
– Left main coronary artery disease (CAD) with normal right
coronary artery (RCA)
– Triple vessel disease with medium to large posterior
descending artery (PDA)
– Complex proximal left sided lesions with or without large branch
involvement
– Previous unsuccessful stenting
Patient Selection/Inclusion Criteria
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• Co-Morbidities:
Includes patients who are at a high risk for problems with
median sternotomy
– Long-term steroid use
– Severe chronic obstructive pulmonary disease (COPD)
– Advanced age
– Need for other major operative procedures
– Severe deconditioning
– Patients with arthritic or orthopedic problems
– Patients who want the procedure and seek out less invasive
surgical options
Patient Selection/Inclusion Criteria
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• Contraindications
– Emergency cases
– Patients with hemodynamic instability
• Potential Contraindications
– Previous CABG surgery
– Morbid obesity
– Patients with posterolateral branch disease
– EF < 20%
– Patients with peripheral vascular disease (PVD)
– Patients with dilated cardiomyopathy
Contraindications
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Anesthesia
• Double lumen or bronchial blocker for single lung ventilation
• Defibrillator pads placed over right lateral chest wall and left scapula
• Positive ionotropic agents
• Continuous monitoring of hemodynamics
• Fluid for volume control and blood pressure support
• Maintain body temperature
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Patient Positioning
• Lumbar region at break of bed
• Patient pulled towards left side
of bed
• Vertical roll between spine and
left scapula
• Left arm slightly flexed and
tucked
Photo courtesy of Dr. Ramchandani, Houston, TX
MICS CABG Set-up
Rultract ® Rultract® with
optional
Swivel (Preferred)
Surgeon
Position
1st
Assistant Pump 4th ICS
ThoraTrak®
MICS
Retractor
System
Mounting Rail
Mounting Rail
Sub-xyphoid incision
(Starfish® NS and
Octopus Nuvo placement) 6th ICS
Octopus® Nuvo
Rultract® is a registered trademark of Rultract, Inc.
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Trademarks may be registered and are the property of their respective owners.
MICS CABG Incisions
4th or 5th ICS –
1/3 Medial, 2/3
Lateral to
Nipple
5-7 cm
6th ICS at Mid
Axillary Line
1-2 cm
Sub-
Xyphoid
1-2 cm
Window Incision
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Octopus®
Nuvo Starfish® NS
MICS CABG - The Tools and Technology
ThoraTrak®
MICS Retractor
System
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ThoraTrak® MICS Retractor Positioning
Position Rultract®
post at patient's
neck
Swivel towards
feet to provide
access to
mammary
Swivel towards
head to access
aorta
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Positioning and Stabilization
6th ICS
Sub-xyphoid
Octopus® Nuvo
Tissue Stabilizer
Starfish® NS Heart Positioner
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Pump-Assisted Beating Heart
Bio-Medicus® Arterial cannula
Bio-Medicus® Venous cannula
Reduced Prime Pump Set-Up
Pump flow rate 2-3 Liters
Order of MICS CABG Procedure/
Instrumentation Recommended
• Thoracotomy/Incisions
• IMA Harvest – Rultract® is required with ThoraTrak® #1 or #2 blades to provide access
– Small and medium endoscopic clip appliers
– Bovie with extended blade
– Minimally invasive Debakey Forceps
– Soft-tissue retractor
• Proximal Attachment – Rultract is required with ThoraTrak #1 or #2 blades
– Vaginal packing (if utilizing a technique to go behind the aorta)
– C-Clamp
– Partial occlusion clamp
– Knot pusher
• Distal Attachment – ThoraTrak MICS Retractor System, Octopus® Nuvo Tissue Stabilizer,
and Starfish® NS Heart Positioner are needed to complete distal attachments
– LIMA-LAD is the last anastomosis performed
• Pain Management – Recommend pain pump
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Trademarks may be registered and are the property of their respective owners.
MICS CABG Product Overview
• ThoraTrak® MICS Retractor System
• Octopus® Nuvo Tissue Stabilizer
• Starfish® NS Heart Positioner
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• Modular retractor system with
interchangeable blades to
accommodate various
procedures and patient
anatomies
• Reusable, stainless steel
retractor designed specifically
for minimally invasive procedures
• Low-profile design
ThoraTrak® MICS Retractor System
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Octopus® Nuvo Tissue Stabilizer
• Incorporation of the Octopus® Evolution headlink for minimally invasive
– Malleable pods
– Increased headlink flexibility
and range of motion
– Flexible suction tubing
• Three pod design
– Smaller headlink for MICS CABG procedure
• Quick connect, detachable headlink
• New whale tail
• Improved flex arm
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• Enables multi-vessel therapy
through a thoracotomy
• Presents coronary artery for direct vision
anastomosis
• Remote shaft insertion eliminates clutter at
the incision site
• Dependable positioning technology that you
are already using in your OPCAB patients
• No additional suction tube
Starfish® NS Heart Positioner
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• Starfish® NS Heart Positioner through a sub-xyphoid incision
• Octopus® Nuvo Tissue Stabilizer through the 6th ICS
• Positioning and stabilization of several vessels directly under the
mini-thoracotomy is possible
• Active pain management with pain pump
MICS CABG Technology Overview
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UC 200903819 EN
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UC201105477a EN