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Minimally Invasive Mitral Valve Minimally Invasive Mitral Valve Surgery:Surgery:

Crossing the ChasmCrossing the ChasmRalph J. Damiano, Jr., MD

Evarts A. Graham Professor of SurgeryChief of Cardiothoracic Surgery

Barnes-Jewish HospitalWashington University School of

MedicineSt. Louis, MO USA

14th Annual SymposiumMiami, Florida

February 21, 2016

DISCLOSURE

�� Consultant for Consultant for AtriCureAtriCure�� Speaker for EdwardsSpeaker for Edwards�� Research and educational grants over the Research and educational grants over the

last 2 years:last 2 years:�� AtriCureAtriCure�� EdwardsEdwards

Minimally Invasive Valve Surgery:Minimally Invasive Valve Surgery:DefinitionDefinition

�� Valve repair or replacement performed Valve repair or replacement performed without a full sternotomy. without a full sternotomy.

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Interventional Approaches to Interventional Approaches to Valvular Heart DiseaseValvular Heart Disease

Conventional SurgeryConventional Surgery

�� Median SternotomyMedian Sternotomy

Minimally Invasive SurgeryMinimally Invasive Surgery

�� Partial SternotomyPartial Sternotomy

�� MiniMini--thoracotomythoracotomy

�� ThoracoscopyThoracoscopy

�� TranscatheterTranscatheter

Why minimally invasive valve surgery?

�� Our traditional operative approach is felt to Our traditional operative approach is felt to be too invasive in certain patients both by be too invasive in certain patients both by cardiologists and the patients themselves.cardiologists and the patients themselves.

�� aasymptomatic symptomatic

�� eelderly, high risklderly, high risk

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MITRAL VALVE REPAIRMITRAL VALVE REPAIRClass Class IIaIIa IndicationsIndications

�� MV repair is reasonable in asymptomatic patients MV repair is reasonable in asymptomatic patients with chronic severe primary MR (stage C1) with with chronic severe primary MR (stage C1) with preserved LV function (LVEF > 60% and LVESD preserved LV function (LVEF > 60% and LVESD < 40mm) in whom the likelihood of a successful < 40mm) in whom the likelihood of a successful and durable repair without residual MR is greater and durable repair without residual MR is greater than 95% than 95% with an expected mortality rate of less with an expected mortality rate of less than 1% when performed at a Heart Valve Center than 1% when performed at a Heart Valve Center of Excellence.of Excellence.(Level of Evidence: B)(Level of Evidence: B)

2014 AHA/ACC Guideline for the Management of Patients 2014 AHA/ACC Guideline for the Management of Patients with Valvular Heart Diseasewith Valvular Heart DiseaseCirculationCirculation 2014;129:e5212014;129:e521--e643e643

Median sternotomy for mitral valve surgery

Right Mini-thoracotomy for Mitral Valve Surgery

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Why minimally invasive valve surgery?

�� As long as clinical outcomes are at least As long as clinical outcomes are at least equivalent to traditional surgery, there is a equivalent to traditional surgery, there is a compelling advantage to minimally invasive compelling advantage to minimally invasive approaches.approaches.

Minimally Invasive Mitral Valve SurgeryMinimally Invasive Mitral Valve SurgeryHistoryHistory

1996 Carpentier First video-assisted mitral valve repair

1997 Cosgrove, Cohn Limited sternotomy approaches

1997 Stanford Group Port-access approaches introduced

1997 Chitwood Transthoracic cross-clamp

1998 Mohr First video-assisted mitral valve repair with robotic assistance

1998 Carpentier First completely robotically-assistedmitral valve repair

Minimally Invasive Valve Surgery:Minimally Invasive Valve Surgery:The introduction of two new technologies The introduction of two new technologies

spurred surgical innovationspurred surgical innovation

� HeartportTM system

� Developed by the Stanford group in the mid 1990s

� Surgical robotic systems

� Computer Motion

� Intuitive Surgical

� First clinical cases in 1998

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Minimally Invasive Valve SurgeryLess Invasive Cardiopulmonary Bypass

Robotic Surgical System

Robotically-assisted Cardiac SurgeryMy robotic experience:

�inanimate trainer - 11/96

�cadaver models - 2/97

�live animals - 4/97

�first case in Europe – 10/98

�first clinical robotic case in North America –

12/98

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Minimally Invasive Valve Surgery:Minimally Invasive Valve Surgery:Reasons for slow adoptionReasons for slow adoption

�� Where are we in 2016?Where are we in 2016?

�� Twenty years after the introduction of Twenty years after the introduction of minimally invasive valve surgery, these minimally invasive valve surgery, these techniques still remain confined to early techniques still remain confined to early adopters in the US and have not crossed adopters in the US and have not crossed over to the majority of cardiac surgeons.over to the majority of cardiac surgeons.

The Chasm in Technology Adoption

Geoffrey MooreCrossing the Chasm1999

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Minimally Invasive Valve Surgery:Minimally Invasive Valve Surgery:FFactors that impeded widespread adoptionactors that impeded widespread adoption

�� The difficulty and complexity of the new The difficulty and complexity of the new instrumentation and proceduresinstrumentation and procedures

�� The high cost of robotic systemsThe high cost of robotic systems

�� The lack of studies showing any benefit of minimally The lack of studies showing any benefit of minimally invasive approaches and the potential harm caused by invasive approaches and the potential harm caused by the expensive ‘enabling’ technologythe expensive ‘enabling’ technology

�� Port access surgery Port access surgery –– higher incidence of stroke higher incidence of stroke and aortic dissectionand aortic dissection

�� Robotic surgery Robotic surgery –– increased length of surgeryincreased length of surgery

Minimally Invasive Valve Surgery:Minimally Invasive Valve Surgery:Our approach at Washington UniversityOur approach at Washington University

�� Develop a costDevelop a cost--effective, simplified approach that can effective, simplified approach that can be easily adopted by all surgeons and easily taught to be easily adopted by all surgeons and easily taught to our fellows.our fellows.

�� Utilize existing techniques for lessUtilize existing techniques for less--invasive invasive cardiopulmonary bypass that do not require cardiopulmonary bypass that do not require expensive instrumentation and dedicated teams.expensive instrumentation and dedicated teams.

�� Use low cost , Use low cost , reuseablereuseable instrumentation that has instrumentation that has been developed to facilitate MIS, as in other been developed to facilitate MIS, as in other disciplines.disciplines.

�� Take advantage of the superb visualization with high Take advantage of the superb visualization with high definition endoscopes.definition endoscopes.

How to Manage Difficulties in Minimally How to Manage Difficulties in Minimally Invasive Mitral Valve Invasive Mitral Valve Surgery;Surgery;Femoral Femoral CannulationCannulation: Imaging: Imaging

�� All patients over the age of 40 or who have risk All patients over the age of 40 or who have risk factors for atherosclerotic disease undergo factors for atherosclerotic disease undergo preoperative CT angiography of the aorta, iliac preoperative CT angiography of the aorta, iliac and femoral vessels with 3D reconstruction.and femoral vessels with 3D reconstruction.

�� In patients with severe vascular disease or small In patients with severe vascular disease or small femoral vessels (<5mm), we favor a sternotomy femoral vessels (<5mm), we favor a sternotomy approach or direct cannulation of the aorta via a approach or direct cannulation of the aorta via a larger thoracotomy.larger thoracotomy.

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Case Presentation

�� 53 53 y.oy.o. woman with a history of mitral . woman with a history of mitral valve prolapsevalve prolapse

�� Several month history of dyspnea on Several month history of dyspnea on exertion, NYHA class IIexertion, NYHA class II

�� Cardiac catheterization: normal coronariesCardiac catheterization: normal coronaries

Case Presentation:Preoperative Echocardiogram

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Case Presentation:Preoperative 3D Echocardiogram

Minimally Invasive Mitral Valve Repair:Posterior leaflet prolapse

Case Presentation:Postoperative Echocardiogram

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Known advantages of minimally invasive mitral valve surgery

�� Cosmetically superior incisionCosmetically superior incision

�� Quicker recovery Quicker recovery –– return to full return to full activity in 2 weeksactivity in 2 weeks

�� Lower wound infection rateLower wound infection rate

Results: Sternotomy vs. Mini-thoracotomy

�� 356 consecutive patients between January 2002 356 consecutive patients between January 2002 ––February 2014 were examined withFebruary 2014 were examined with ddata were ata were entered prospectively into a longitudinal AF entered prospectively into a longitudinal AF database developed at database developed at our our institution.institution.

�� All patients received a CMIV procedure All patients received a CMIV procedure ±± mitral mitral procedure and/or tricuspid valve procedureprocedure and/or tricuspid valve procedure

�� 104 patients received a mini104 patients received a mini--thoracotomy, 252 thoracotomy, 252 underwent a underwent a sternotomysternotomy

Damiano et al J Thorac Cardiovasc Surg 2014

−No difference in mitral repair rate.−Freedom from AF at 1 and 2 years was

similar with decreased morbidity and length of stay.

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Sternotomy vs MiniSternotomy vs Mini--Thoracotomy Maze IVThoracotomy Maze IVPerioperative OutcomesPerioperative Outcomes

Variable Mini(n=104)

Sternotomy (n=255)

p-value

Cross clamp time (min) 82 ± 33 69 ± 33 0.001Perfusion time (min) 184 ± 41 156 ± 45 <0.0001

Overall major complications 6 (6%) 33 (13%) 0.044

Median ICU LOS in days (range) 2 (0-21) 3 (1-61) <0.0001

Median hospital LOS in days (range)

7 (4-35) 9 (1-111) <0.0001

30 day mortality (%) 0 10 (4%) 0.039

Minimally Invasive versus Sternotomy Minimally Invasive versus Sternotomy Approach for Mitral Valve RepairApproach for Mitral Valve Repair

�� 201 well matched pairs201 well matched pairs

�� 99% repair rate in all patients, not influenced by 99% repair rate in all patients, not influenced by approachapproach

�� Less transfusion in the minimally invasive group Less transfusion in the minimally invasive group (14 vs 23%, p = 0.03)(14 vs 23%, p = 0.03)

�� No difference in stroke, infection, MI, renal No difference in stroke, infection, MI, renal failure, AF or mortality rates between groupsfailure, AF or mortality rates between groups

Goldstone AB, et al.Goldstone AB, et al.J J ThoracThorac CardiovascCardiovasc SurgSurg 2013;145:7482013;145:748--756756

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Cao C, et al.Cao C, et al.Ann Ann CardiothoracCardiothorac SurgSurg 2013;2(6):6932013;2(6):693--703703

Postoperative Echocardiographic Outcomes

More than 20,000 patients from 45 studies were examined

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Minimally Invasive Versus Conventional Valve Surgery

�� No difference in mortality or stroke ratesNo difference in mortality or stroke rates

�� No difference in rate of No difference in rate of reexplorationreexploration for for bleedingbleeding

�� MI valve surgery had significantly longer MI valve surgery had significantly longer cross clamp and pump timescross clamp and pump times

SündermannSündermann SH, et al.SH, et al.J J ThoracThorac CardiovascCardiovasc SurgSurg 2014;148:19892014;148:1989--1995S1995S

Advantages of Minimally Invasive Mitral Valve Surgery

�� Significantly lessSignificantly less

�� BleedingBleeding

�� TransfusionTransfusion

�� ICU and hospital length of stayICU and hospital length of stay

�� Respirator Respirator dependancedependance

�� Postoperative atrial fibrillationPostoperative atrial fibrillation

�� Total hospital costsTotal hospital costs

SündermannSündermann SH, et al.SH, et al.J J ThoracThorac CardiovascCardiovasc SurgSurg 2014;148:19892014;148:1989--1995S1995S

Minimally Invasive Mitral Valve Repair :Minimally Invasive Mitral Valve Repair :ConclusionsConclusions

�� The field of minimally invasive valve surgery has The field of minimally invasive valve surgery has developed steadily over the last 20 years and is developed steadily over the last 20 years and is now set for crossing the chasm to widespread now set for crossing the chasm to widespread acceptance.acceptance.

�� There is ample evidence that minimally invasive There is ample evidence that minimally invasive have similar results as conventional approaches in have similar results as conventional approaches in terms of mortality and major complications with terms of mortality and major complications with the advantages of less bleeding, shorter LOS and the advantages of less bleeding, shorter LOS and better patient acceptance.better patient acceptance.

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Minimally Invasive Mitral Valve Repair:Minimally Invasive Mitral Valve Repair:ConclusionsConclusions

�� The introduction of transcatheter valve technology The introduction of transcatheter valve technology will necessitate changes in our current surgical will necessitate changes in our current surgical approach if we hope to continue to operate on a approach if we hope to continue to operate on a substantial number of patients.substantial number of patients.

�� There are exciting new developments in minimally There are exciting new developments in minimally invasive techniques and technology that should invasive techniques and technology that should allow for a further evolution of surgical allow for a further evolution of surgical procedures and continue to decrease the morbidity procedures and continue to decrease the morbidity of valve surgeryof valve surgery..

Thank you for your attention