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MINIMALLY INVASIVE VALVE SURGERY

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... patient demand goals small incision good exposure identical quality to full open procedures identical mitral valve repair rate ... invasive valve surgery ... – PowerPoint PPT presentation

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Title: MINIMALLY INVASIVE VALVE SURGERY


1
  • MINIMALLY INVASIVE VALVE SURGERY

2
HOW FAR WE HAVE COME
  • THE MORTALITY FOR VALVE REPLACEMENT SURGERY IN
    1968 WAS 42

3
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

4
  • PATIENT DEMAND

5
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

6
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7
  • 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.

8
  • 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.

9
APPROACHES
10
PARASTERNAL
11
  • ADVANTAGES
  • GOOD ACCESS TO THE AORTIC VALVE
  • DISADVANTAGES
  • CHEST WALL HERNIA CAN RESULT

12
LOWER STERNAL
13
  • ADVANTAGES
  • GOOD EXPOSURE FOR THE MITRAL VALVE
  • EXCISION CAN BE EXTENDED IF NECESSARY

14
TRANSECTING STERNAL
15
  • ADVANTAGES
  • EXCELLENT EXPOSURE OF THE AORTIC VALVE AND GREAT
    VESSELS
  • DISADVANTAGES
  • BREASTBONE INSTABILITY
  • LOSS OF INTERNAL MAMMARY ARTERIES FOR FUTURE USE

16
PORT ACCESS
17
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18
  • 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

19
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20
  • 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

21
  • 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

22
  • IN THE INITIAL FDA STUDY, 65 OF PATIENTS WERE
    EXCLUDED

23
RIGHT THORACOTOMY
24
  • ADVANTAGES
  • EXCELLENT RESULTS ACHIEVED BY SOME SURGEONS
  • PATIENT PREFERENCE
  • DISADVANTAGES
  • GENERALLY RESTRICTED TO THE MITRAL VALVE
  • LONG INSTRUMENTS REQUIRED
  • CANNOT EXTEND INCISION

25
UPPER STERNOTOMY
26
  • 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

27
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28
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

29
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30
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31
  • AORTA IS OPENED IN THE STANDARD FASHION
  • THE RIGHT ATRIUM IS OPENED TO APPROACH THE MITRAL
    VALVE

32
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35
CONTRAINDICATONS
  • MORBID OBESITY
  • REOPERATIONS
  • PECTUS EXCAVATUM
  • NEED FOR ASSOCIATED PROCEDURES
  • CAN REVASCULARIZE THE RIGHT CORONARY ARTERY

36
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38
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

39
  • 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

40
  • 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
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