Dr. Chris Cook describes the types of procedures and benefits to patients when using minimally invasive approach to cardiac surgery.
Good morning. Thank you all for coming. I, um, a couple of weeks ago we gave a, uh an overview of several of the trials and uh such going on um, at the Hart Hospital in cardiovascular medicine and I spent a few minutes touching on minimally invasive cardiac surgery because this is something that, um, we hear a lot about. You, read a lot about. It's something that's, you know, every time you turn on the television or look on the internet for some drug or procedure. Um, there's lots of advertisements and certainly minimally invasive cardiac surgery is something that has been purported over the years with from various institutions, uh individuals and with varying degrees of success. So we are um, embarking on this at Centra uh Heart Hospital. Uh, largely it's gonna be, uh, myself and doctor Scor involved in this. But, uh all of our partners are um, uh gonna be involved with, uh seeing these patients taking care of these patients and involved in the operations as they choose. Um, so it's gonna be something that, uh all of us hopefully are going to be involved with over the next few years. Uh Scor Tino and I are just going to try to get it started for, uh, reasons of having, you know, uh I've had some experience with it and then also, you know, limiting the number of people initially so that our teams, um, uh, are well versed in what we're doing. And that includes probably also, you know, dedicated teams for anesthesia and people, uh, in the operating room. Um, I understand that a few years ago, we had a, a period of time and, and you all know more about this history than I do where minimally invasive surgery uh was attempted. Uh And with varying degrees of success for various procedures that were done. Um some with uh ablation for atrial fibrillation, some with micro valve repair and uh uh and there was uh people that were coming and going over, you know, a period of several years that maybe weren't here for too long. Uh I think uh Chris and I are here to stay for the long haul and hopefully, we can do this uh slowly methodically thoughtfully and um have an approach that uh will have lasting success. I have no disclosures. So I wanna define minimally invasive cardiac surgery because it means a lot of things. OK. When you, when you talk about this, um describe the rationale for it and we will discuss some of the various types of operation that can be done. So what is minimally invasive in general when you think about this. It's usually something that avoids a full sternotomy. So there's all kinds of things that we can do uh to get to the heart that are not a full sternotomy. We can do an upper sternal incision where you divide the upper third and then you can jay that over uh through a transverse sternotomy. Um Either to the right or to the left, you can uh make it to both sides and make an inverted t incision, um a right, an interior throaty at the second or third inner space. This was most often done for minimally invasive aortic valve replacement. Uh generally requires you to uh disarticulated one of the ribs uh at the cost of uh sternal junction. Um And that's usually just been done for uh minimally invasive A VRS uh or a right, an inter lateral thot toy which uh mit valve uh has been the operation that's most been done. But also tricuspid valve can be done this way, maze procedures and uh tumor resection. And now uh there's a few groups that have reported doing uh minimally invasive or robotic A VR through that exact same incision. And at my previous institution, they used the exact same incision that they used for uh minimally invasive uh robotic mits and adapted the same platform to then do uh robotic aortic valve replacement. I think in the era of tar uh robotic A VR doesn't make as much sense to me. Um But it's something that, you know, uh certainly is being done. Uh I think that, um, having seen that operation, I, I, I'm not sure that it's going to gain national or international acceptance as a, uh a procedure that's going to uh supplant open surgery. It's certainly not tar and then left leftward approach, a left, an inter lateral thoro to do a mid cab. Now, mid cab or a minimally invasive direct coronary artery bypass. This is a usually means that you will do some type of left internal memory artery harvest. And the way this was initially done was through a small left anterior thoro atomy. The lemma was taken down with direct vision through that incision. And then there was a small pericardiotomy that was done and you would do a lemma to led uh now more often there's uh it's done robotically to harvest the memory at least. And then the anastomosis is done open under direct vision and that's the most common way that that's done. There are now groups that are doing that operation with a totally endoscopic approach. They now do the anastomosis with an intra coronary shunt and actually sew the anastomosis robotically. And now they've graduated to doing two mammaries through the same incision, putting the RMA on the L AD and then putting the Lima on another left sided target, totally done robotically. These operations take about five hours. Um they're meticulous, they're difficult and there's only a handful of groups in the world that have uh developed the expertise to do that. And it requires a great deal of effort and a dedicated team. So typically, when we talk about doing these operations, we would say that they're non rib spreading. Usually we retract the soft tissue uh of the intercostal muscle but and, and put some pressure on the intercostal space. But by and large, the incisions themselves don't lend themselves to separating the uh ribs more than a couple of centimeters. And so mostly that's just soft tissue retraction and uh minimally invasive operations are almost always done with uh peripheral cannulation. There have been some instances where you can stick a canal through the chest but almost always it's femoral and IJ uh access. So what are the advantages of this? Well, the incision is smaller, uh less trauma and improved cosmesis, which is a secondary outcome. Uh If you look at all of the data that compares and, and um this talk is, is going to be a broad overview of what minimally invasive credit surgery is. But as far as reviewing in-depth data, I will make some comments about what the data for comparison are, but I won't go into too much as far as specific studies because there's literally uh hundreds on each one of these topics uh that we're talking about. But um by and large, most of those um show that there's a decreased in incidence of bleeding as you know, if there's decreased transfusion, then there is usually less infection, uh less renal failure. Uh and things that occur with transfusion itself, there's typically less need for narcotics. We have all seen people who've had small incisions have just as much pain as those who have a full sternotomy. Some of that's patient dependent, but by and large pain scores overall would indicate that it is less painful. Hospital stays, uh are often shorter and generally, that's not more than a day. Although recently, uh Sloan guy is a cardiac surgeon who's done a lot more of these uh cases in recent years. Uh had a mit repair, uh go home on postoperative day one. Now he's done literally hundreds of these and he's had one patient go home on post operative day one. Usually these patients go home on postoperative day three or four, which might be the typical four or five. But it's all the usual things that keep someone in the hospital a little bit of fluid overload, pain control. And the thing that always plagues us for any of these operations including minimally invasive is postoperative atrial fibrillation the day you think? Oh, great. I'm gonna send somebody home on postoperative day three and then you go in and they have an irregular heartbeat and their heart rate is 100 and 30. So, um there may be some decreased incidence of atrial fibrillation, but it still happens very commonly, particularly for left sided approaches where you open the left atrium and microvalve, uh, repair most often. And probably the biggest advantage is that if you look at the time to full recovery from the time that somebody gets an operation until they're actually back to full, um, um, activities and doing everything that they want, that is probably shorter by 2 to 4 weeks in the grand scheme of things. What difference does that make? Um, I'm giving a talk on minimally invasive cardiac surgery. But throughout this talk, you're gonna hear me say, you know, a lot of things that would tell you that I'm probably not a great proponent of saying that we should absolutely do this. I'm saying that we should do it, but we should do it with selection. And a lot of the things that I'm gonna say to you are going to maintain some equipoise towards our enthusiasm for jumping on this bandwagon and doing these cases. So, what are the secondary and sort of the long term benefits of doing this? Obviously cosmesis? And I'll show you some pictures faster, return to full, full function. Uh You know, there's, there's these advertisements about the, the downhill skier that gets a minimally invasive microvalve repair. And then he's out in Colorado, you know, tearing up the slopes two weeks later, generally, that person that's out tearing up the slopes two weeks after his minimally invasive mit valve repair is a 50 year old man who is in phenomenal shape and no matter what you've done to him, it could have been a full sternotomy, a laparotomy and a thoracotomy and he would still be close to doing the exact same thing. So it begs the question. If you're going to do this operation or these operations for people that will tolerate that, then why do it to begin with? Um And we'll try to answer that. Um One thing that you have to do when you embark on this is not change the operation for the sake of the incision. And often when I talk to patients and I've only done, you know, three cases here. One's am Eastern Atomy, one's a tumor resection and one was an a SD closure. But every time the discussion has centered around the incision and I get off of that quickly. And I say, you understand that the goal of this operation is to fix the hole in your heart, take out the tumor um or do whoever it is that we're going to do that is the goal of the operation. The goal is not the incision. And if things are not going well, you're gonna get a full sternotomy and you may end up with a thoracotomy and a sternotomy. So you, I think have to, you know, make sure that we understand that the goal is an efficient operation that preserves my cardial function and gets the job done in exactly the same way that we would if we were doing the operation open. Another benefit is that the visualization is excellent when you put a thor scope in there or particularly with the robotics platform and you have multiple screens in the room, everybody can see what's going on. Uh People are involved uh more so in the case, because they actually have a good visualization as to what's happening. And so it's excellent for teaching, for teaching institutions. If you're demonstrating, you know, what is a PT resection and putting in chords, sometimes it's very hard to see from a micro valve repair uh doing astronomy. Uh But it's really excellent for teaching uh for those purposes and probably the most important uh reason. And I, and I'll say this uh unabashedly is that it's program development, quite frankly, the public demands it, I've had people come to my office and say, I appreciate what you're saying. I'm going to go to Cleveland and I know that they do a lot of uh robotic microvalve repairs there. Uh But that's what I'm gonna look into. And there are a significant number of patients that could be taken care of very well. In this hospital, they could get a full sternotomy, get a great operation and go home and do just fine. Um And they choose not to um if we can offer that and we have some benefit to it. Um And we can do it here safely. Is that something that we can replicate for larger institutions that are doing this and having good success at doing it. And I think so, so the rationale for anything that is minimally invasive is to get away from uh larger incisions because of this concept of invasiveness. I mentioned briefly in that talk that I gave a couple of weeks ago. Um I was, I'm old enough to where I, I still remember some of the holdovers uh that were refusing to do laparoscopic cholecystectomy. And they were doing these smaller incisions for um the right upper quadrant infiltrating the incision with boatloads of marcaine and putting patients on uh near toxic doses of Demerol and Feagin uh to try to mitigate their nausea and, and pain and to the point of nearly having seizures. And I say this because I, I saw two surgeons, you know, trying to maintain relevance in their practice. And after a while, they just stopped getting referrals and there were no more patients for them to do cholet omy on. And what they very successfully argued for a number of years was that the incidence of common bile duct injury was no doubt higher with laparoscopic cholecystectomy. In the first many years, the first many years that laparoscopic cholecystectomy came on the scene despite how terrible a common bowel duct injury is. And for those of you who took care of those patients as uh general surgeons or, or around those patients, for whatever reason, it's a can be a devastating problem it can be life threatening patients still would not hear of that and wanted laparoscopic cholecystectomy. So it, it really didn't, it really didn't matter. People often will choose less invasiveness for the upfront cost of a larger operation. Almost every time we go through this discussion every day when we talk about PC I versus cabbage, there are certain instances given, you know, all the reasons that, you know, for the number location, distribution of coronary artery blockages that occurring in younger diabetics. Why everyone in this room are listening would favor that person getting cabbage and then you go talk to them and they say, can't you just stent it one more time, can you not just, you know, I've had stints and, and we have to have the discussion about what is best for them. So we already have these discussions all the time uh with patients and, and have to guide them towards what's, what's better. There is a thought amongst many people that, ok, if I've got a bigger incision that I'm gonna take me much longer to heal and I'm not going to do to do well. Um There's no doubt that when we do these operations that the incision yes, is, is bigger for a full sternotomy. But the real detriment, unlike the parallels that we drove for laparoscopic choy, the real detriment to someone getting cardiac surgery most often is their time on cardio pulmonary bypass. And the time that the hearts are arrested. We know that almost invariably, even in expert hands that minimally invasive procedures where we stop the heart, the cross lamp times and cardio pulmonary bypass times are longer. There's no question and that's, and that's undisputed. So when you, we look at these patients and we decide who are we gonna pick for these operations? And you say, well, Mr Jones is 70 years old or he's 80 years old and he's, um not as active as he was and he's got an ef of 35 to 40%. He's obviously higher risk. Can you do something less invasive? The only thing you're doing less invasive in that case is the incision. You're spending more time on cardio pulmonary bypass, more cross plant time. So the real detriment for cardiac surgery, you probably be subjecting a high risk patient for. And it's not uncommon that, you know, referrals would come when and, and I was part of a program where there was, you know, a large uh minimally invasive practice patients would get sent there to have something done less invasively because they were higher risk. But then those patients end up getting a sternotomy because what they need is speed. They need a faster anatomy, a fast cross clamp time, get the operation done and they will survive. Having said that there's obviously a place for minimally invasive and we have to look at these cases and maintain some amount of poise. So there's pros and cons to each, each of these. Um So who's best suited for this? Obviously, those higher functioning patients that want to get back to activity quicker. And as I told you, the iron, ironic thing about that is they're the ones that will tolerate a astronomy. If you look at cases that have been done open about 15 years ago, the Cleveland Clinic reported over 2000 mit valve repairs without a single death. That's an exceedingly high bar 2000 cases, no death for micro valve repair. If you look at these most recent reports, this is from Cleveland Clinic in 2021. This is all their mit cases. This is not very clear, but this is percent. This is 5%. This just goes from 0 to 5% and this is for valve replacement and this is for valve repair. This is the these bars are the sts benchmark for replacement for that year. Just a little over 4% sts mortality and then for repair, sts is less than 1%. Probably around 0.6. Cleveland Clinic reported zero for that particular year for either repair or replacement. Now, many of these were done minimally invasively robotically, but a lot of these were done open. So just a quick snapshot of this, they made no comparison between the two of those. And if you look at their data from 2014 to 2021 for isolated microvalve repair, there was no in hospitals mortality. So everyone survived to discharge over 3400 patients. Most of those were done robotically. Some of those were done with sternotomy. What I would point out about that is that there was no difference. They all survived, ok, whether they got astronomy or whether they got it done robotically. And those are excellent results. But that's, that's the bar that, that we have to hit when people think about open heart surgery. this is what they think about. And then when they come into the office, this is what they ask for. There is the thought that this is horrifically painful, it's higher risk. It's gonna take me much longer to heal. And that if I get this done, then I'm gonna be playing golf next Thursday. And, and that's, and that's the public perception and largely that is born out of experience with many other minimally invasive procedures that are done, particularly with general surgery. And I told the story a couple of weeks ago when I talked about this, that morning, I happened to be here throughout the night. I had done a, a case on a gentleman which was uh not super easy. It was an open uh micro replacement, I think. And at midnight, uh I just happened to walk by his room because I was here seeing someone else and um he was laying there with his heart pillow excavated, uh snuggled in with a blanket, snoring on his side. So after sternotomy that had been done about 15 hours before that. So again, for me to improve upon that is a fairly high bar. But there is this concept also of cosmesis. This young woman has a cut that is off center and it's a keloid and it goes up to her neck line and you talk to women even up to their eighties, they will sometimes wonder how long is the incision gonna go? Some people are very vain about that but there is, there is a thought, you know, if I get something smaller, I'm gonna heal up faster and it's gonna look much prettier. What about the standard operation? We know it. Well, the setup is simple. Well, it's simple in the fact that it's familiar. All right. When you look at an open heart operation, there's lines and tubes everywhere, just like when you're in the Cath lab and there's tons of wires and lines. It doesn't look simple. But it's familiar. We have better access and better control. We can get our hands in there, we can see everything. It's not like anything is hidden from us and our, our hands are physically there. We can do more than one procedure at once. We can change the aortic valve, the microvalve, do a maze and put it in a tricuspid ring and do a bypass on the same patient. Um It does hurt a little bit more. Uh but people will say it does hurt much longer people have sternotomy pain when they cough for up to 2 to 3 months. Typically, that's, you know, not the case with minimally invasive. Um, there is the possibility of sternal nonunion or infection that's low and not a reason to avoid surgery. There's the trend towards less invasive procedures throughout everything in cardiovascular medicine on pump. We do cases for many sternotomies, many throaty or robot off pump or catheter based. We can do off pump coronary bypass, which has only slight advantage when it comes to open sternotomy. And it's probably only deep red uh reduced transfusion rate. Graph patency though is not as good. So by and large, we've gotten away from doing off pump cases, but coronary bypass preceded angioplasty even by two decades. If you look at some of the first operations that were done for cabbage back in the fifties were actually off pump operations that were done with uh Lima to actually put into the myocardium, not into the vessel itself. But then in 1967 the largest series of cabbage on pump. Cabbage was reported using aorto saphenous vein bypass. Uh by Doctor Favela. We didn't really doing angioplasty until about 15 years later. Although we were doing cast long before then, then we did bare metal stents several generations of drug utting stents. Now we're even doing chronic total occlusion things that we only did bypass. Four. Even just a few years ago. We do tar for a S we're trialing tar for A I and then all the other technologies like uh Septer for PFO atrial fibrillation, catheter Watchman, um TMVR or MIT clip. 10, all the things that we can do to the micro valve which are less invasive and also for the Tricuspid. Uh every valve now has been replaced with a catheter, uh pulmonary tricuspid, all of them or use of nitro clip, even for off label use for the tricuspid. So these are all less invasive things that can be done with surgery. This is a standard A VR it's one of my favorite operations. A full astronomy. It's straightforward, we can see everything. It's, it's fast, it gives us lots of options. Myocardial protection is easy. We can enlarge the root, although that can be done minimally invasively too. It's much easier with this and patients do exceedingly well, you can see that we're staring right down the barrel of this aortic valve. This view that you see here is what we see during an open operation. And this is simple, straightforward, cut out the calcified valve and sew in a new one. This is not uh technically challenging just from that aspect and it's actually a fun and fast operation. This woman absolutely did not want that. And so I offered her a mini sternotomy. Um and she did fine. She did great. Um Did she go home any faster? Maybe by a day? But it can be done through a four centimeter incision. Really, the incision that you need is just big enough to take out and put in the valve. You can actually do the can through this uh cardio plegia needle, through this cross clamp all that's done through this incision. So it is possible. Um I showed these slides before this was a 63 year old attorney and she was very fit and doing her um cardio on her treadmill. She would notice that she started getting short of breath and she sought care for that. And uh her work up showed this echo which you see this is the aortic root, this is the anti leaflet of the micro valve. Uh And then you see here a prolapsed posterior leaflet in P two and this large posteriorly directed EENT jet consistent with the P two prolapse. So I took her to the operating room. Um This was early in the experience that I was doing and, and the, so this is about a seven centimeter thor economy. This is now can even be cut down smaller than that, but it's still a fairly small incision. Um You can see we got cardio pulmonary bypass lines up on the field. One of these is used for an operating port, but this is uh ends up being a chest tube site. This was her valve. You can see that she has very elongated cords. Um There's some redundancy to the anterior leaflet, but the height of this posterior leaflet, this is very tall. You can see that if you look down into the ventricle, one of the cords is ruptured. So, um I respected P two transferred a cord uh from P two up to a two because there was actually some uh prolapse of this uh redundant anterior leaflet. Um and then put in a 32 millimeter ring. She was a small woman and so it looked like a little bit bigger of a thoracotomy. But this is what her incision ended up looking like that was done probably seven or eight years ago. Um This is an 80 year old gentleman who presented with sepsis, mental status change. This this case was here just about a month ago. He presented with sepsis. Uh and they thought it was secondary to colitis. But in his work up, he ended up uh getting an echo and this showed a 3.5 centimeter mass and you can see this thing prolapsing through the micro valve and he was transferred here. It looked like there might be some uh friability to this mass. Uh It's probably just a microvalve. But when you see them this large, there is this very small incidence of sudden death with these that uh someone becomes dehydrated, whatever get in a certain position. This thing starts to obstruct the mit valve. Usually they're larger than this when that occurs. But uh after this was found, no one felt comfortable sending him home with it. And so he was transferred and we operated on him and did a right mini thoracotomy. You can see here that we're actually taking out the uh endocardium and to completely remove the stock. And then I actually had a hole in the septum because in order to, to completely remove that, you do take out the part of the septum and then just close this up, primarily, you can see that's a four centimeter tumor. So we can do microvalve repair or even replacement mid cab. As I told you about, we do the Lima harvest either directly or robotically and then do an off pump, li led intracardiac masks. As I showed you a SDPFO the Tricuspid valve repairs. Um I did many more of those uh in my prior practice due to endocarditis that we saw and then ended up having to replace a lot of those valves. Um maze procedures or robotic A BR has been done. So, robotics, uh almost all of those have been done robotically as well. Uh And I think for us considering what we might do robotically, microvalve repair or mid cab. These are the things als also could be done, probably not Raver. And this is everybody talks about doing, doing it robotically doing it robotically. The robot does not do anything by itself. It is totally controlled by humans, right? When you look at these instruments, there are long straight shafted instruments that go in through multiple other ports and they are needle drivers, scissors and pickups. The same things that we use to do open operations, needle drivers, scissors and pickups, but they're introduced through other incisions. So there's, there's no magic about the robot. It could be done direct vision through that incision or we can use the robot to bring them in through other ports. Now, there is a platform for the Da Vinci that has just been developed where the instruments are introduced through a single port. And if you look at all of these straight shafted instruments, the chest wall serves as the fulcrum by which these instruments move and these long arms swing about and actually they can move by, you know, 12, 18 inches uh on the outside of the patient in order to make smaller movements inside the patient. But now they've developed flexible instruments like endoscopes and bronchoscopes, which is a bit of a game changer because now we can put the camera in there, move it like an endoscope and actually start moving the instruments. It's not approved for cardiac surgery. It's only for uh prostatectomy and ent surgery. But hopefully as that platform develops this, what I think is very cumbersome setup will become simplified in the next few years. We can do operations with this platform now and doctor Clem is doing a fair number of them uh for thoracic surgery. But I think that if we can go from minimally invasive, using direct instruments to the robotic platform. Then at some point, once the technology continues to improve, we would get even better at this. What about the maze procedure? If you look at all of these lines here, um the red marks are the incisions and uh the blue marks are cry. And this is known as the cox mace four. The cox maze one and two were both open operations that went through different iterations of where the incisions were placed. And then the cox maze three was the full cut. And so maze once all those lesions had been worked out. And then when we got to the cox maze four, it was a combination of incisions plus alternative energy. And the reason that was done was because these used to all be incisions. So it's quite a daunting operation to do. And although there were proponents of this and the results were excellent and people who did this routinely, there were no referrals for standalone atrial fibrillation cases uh to do a sternotomy for a benign but otherwise benign rhythm to take on this in the face of already having to do a microvalve repair or an air drive replacement or a cabbage was too daunting, quite frankly for most surgeons. I liken it to uh these alternative energy sources. And people for a long time said, oh, they're not as good, they're not transmural. They don't get full disruption. We know now that since we have gained experience with those how to use them better that we can get transmural and we can uh do these operations. And now to be able to use alternative energy sources and convert them into the minimally invasive platform, makes it a lot easier. So this is this is a robotic arm but you can see this is this is the micro valve off in the distance here. And this is uh the backside of the left atrium. And you see that we're putting a cryoprobe here across the coronary sinus. And then what we look for when we do this is do we see transmural freezing across the coronary sinus? And you see this mound of ice ball here, we can actually mark that with a with a pin to determine that we have in fact done that. And then we do the mit isthmus uh or actually this is the floor of the atrium um or I'm sorry, the mit isthmus line here and then the floor of the atrium here, the left sided pulmonary veins are here, the right side of pulmonary veins have been isolated because of the incision. And then we do the dome of the left atrium and come across and connect it to that line. And so just to go back over these coronary sinus lesion mitr, uh you mark the ice ball do the mit isthmus lesion, the inferior box that extends from the floor of the atrium over to the left side of pulmonary veins, the dome of the atrium and connects to the left sided, superior pulmonary vein and then we can do the right sided lesions um as well. So um super in and um up to the right a pen and this is the uh over to the tricuspid valve. So all of those lesions can be completed through a right thot. So that's completely done. So how do we work these patients up? Well, in general, we get CT scans on everybody and the CT scan tells you a lot about the ability to prefer a can light. As I told you, most of the time when we do these, it's a peripheral cannulation. So we need to know something about the vasculature. Um Also when we do a right throaty approach, looking at the dome of the liver in relation to the pericardium, gives us some idea about our ability to have good visualization. And we can look for any problems that we may have in the right chest, such as if they've had um any type of infections that might assume that there's some rounded AIS or something that tells us that a right throat economy approach might not be helpful. We do a tee on everybody that we're considering a valve repair on and then the CT A and when we do a calf that generally, we try to avoid the right femoral artery, we like for them to be calf radially uh because uh scar is uh induced even by a calf where there's a small hematoma or plug device that occurs in everyone. We open canula these people. So we like to have that uh done. Um So this paper just came out in the annals of thoracic surgery, the most recent, um the most recent um publication. This is Mike uh from Emory and he's now done uh over 1000 robotic assisted Lehman led. And I, I didn't want to bore people with a lot of data slides because there's a lot of things that I wanted to talk about. But if you look at his study over um this time period, um he had excellent results. The main age was 64. Their predicted rate of mortality was low risk 1.1% 30 day mortality. He had six patients uh which is 0.6% which gave him a favorable um observed versus expected ratio. You would expect it to him uh to have a mortality of one. He only had 0.6. So that's 53 0 to E ratio stroke in five patients, which was very low because Lehman patency for early on was cathing everyone and then caffeine selectively after they gained experience uh was 97%. And that's over the time, the study time period or anyone that got a calf that they knew about main procedure time. If you look at this 100 and 95 minutes, it's over three hours to do a single bypass. So it's not fast, but that decreased by a little bit by about 20 minutes. Uh Conversion from sternotomy in the 1st 500 cases was 22 and decreased down to eight in the last 500 cases. So, um it could be done safely. But the conclusion about this paper was that in order to achieve not just technical success but excellence with this, you had to do 250 to 500 cases. That's a lot, that's a lot of, of, of operations to be done. We can do astronomy in these patients which every surgeon has already done, you know, way over 500 operations and already have that expertise. So now to get past that learning curve to take that on, we have to be very careful about patient selection. So I'll talk a little bit about that. When we were be picking anyone that we might consider for this operation, they would have to have an excellent distal target. Um And that means that the lesion needs to be proximal. It cannot be a diffusely diseased vessel. Uh No prior left sighted chest surgery um whatsoever and um someone that will tolerate single lung ventilation. So there are some caveats to doing this. Um But it may be something that we take on. It's done with a robotic harvest of the Lima. You can see here that uh this is a skeletonized approach. This is uh a electro artery spatula that is peeling the mammary artery off the chest wall. And then we do a small right throaty, we expose or sorry, the left throaty, we enlarge one of those incisions and then do an off pump leant to led. So for these, I told you, we would uh avoid um uh right femoral because for uh corne angy because of the scar tissue, we do a preoperative ct and te on these patients. If the femoral artery is less than seven millimeters, we might consider using a graft or some other alternative cannulation or you just do them open. Um Usually we will incorporate some type of distal perfusion uh into the leg because we have seen cases of limb ischemia. During these cases, we avoid anybody that's got moderate aortic insufficiency. Your ability to protect the heart is not as good. And you should probably do that as an open case. Uh double them an endotracheal tube and it has to be somebody that will at least tolerate single lung ventilation for uh periods of up to 15 to 20 minutes. Uh We usually don't place things in the right arm. We'd use a left radio, left femoral art line, a left eye j central venous catheter because we will put a venous drainage canon in the superior ven cave on the right side. So you have this quote unquote bi cable venus cannulation with one in the neck and then a long dual stage in the femoral vein, we always use vacuum assist. And then typically, uh we, we use moderate hypothermia. I'm not a fan of hypothermia even for big operations. Generally, I don't cool patients. But um probably uh we do uh cooling for this because if you do have an instance where you have to uh convert to astronomy, you might have uh some margin of safety. Usually we use antegrade cardio plegia. I would say that, you know, you could also add retrograde for someone that's got aortic insufficiency. But uh probably in my experience and early in, in our experience here, we're going to avoid anybody that's got any degree of aortic insufficiency for these cases. Usually we'll use a transthoracic cross clamp. The endo balloon is a balloon that you can actually include the aorta with. You can give cardio plegia and you can vent the heart. Um And we may embark on using that. We're gonna get training for that probably the 30th of this month. Uh from Edwards and consider using that for some of the minimum invasive cases. They've made substantial improvements over that old plat old platform and they've actually introduced the ability to use that balloon with one of their commercially available thermal cannula, which makes it a lot nicer. Uh and then we'll do full bilateral ventilation when we wean from cardio pulmonary bypass. Um Traditionally, we've used Aymeric not only for the head but for the lower extremities. I think if you put in a distal fusion catheter, it might obviate the need for that. And um these are not cheap. Anesthesia has to be facile at putting it in a double in the tube, usually as opposed to our right AJ central line, we'll do a left side. And then we will actually use one of our arterial cannulas and put that in the right internal jugular vein and use that as a Venus drainage cannula to give us this quote unquote bi cable Venus drainage. And then I've outlined all the steps and put all this here for uh any of us or for our uh anesthesia colleagues that would be interested. Uh Actually one of our anesthesiologists uh has done these cases uh with me, um two of them and he's actually put in the can. Um And so, um and done a nice job of that and we haven't even had that in the field. So I added some of the tips because I know that we do have a broad audience. We also have perfusion here and we also have um our or staff that are watching this. So I wanted to talk a little bit about some of the setup. Uh As far as this goes, typically, we will put external defibrillation pads on this posteriorly near the spine and then uh the left pad will go in the interior chest uh near the mid COVID line. We can't use internal defibrillation paddles for these patients, we put the patients far over to the right side of the bed and basically, uh, bump them up with what we call a football or some type of pad to bump up the right chest and bring the arm off the side of the bed. Some programs will put the arm uh, over the head. I think that's a little bit more cumbersome, but that's possible. And then we'll circumferentially pad that arm. And what we're really trying to do is expose that right chest and prevent any injuries to the brachial plexus that can come from overextension or traction of the right arm. Uh And then we'll pad the left arm and tuck it with a draw sheet like we would. So if you can see from the top, this red line marks the edge of the bed, the arm is actually off the bed, which is usually a no, no. Um But in this case, we do it purposefully and we pad the shoulder up so that the shoulder doesn't fall back. And this allows us access to the uh to the chest and then usually we'll just take a draw sheet, roll it up and then put a couple of or towels under it to create this, you know, football looking thing that you put under here, we do uh open cannulation in the groin um because the canals can be large, you know, up to 18 French. So uh per closing those is not always easy. A lot of programs have do it gone to percutaneous and then they've almost all of them have reverted back to doing this open. Uh because it's easier to put in this distal perfusion cannula as well. And they can just open this and repair and literally, this can be done through a two centimeter incision. You can see that these incisions are just big enough to put the canilles in. Um And really, we uh just expose, we don't do a circumferential dissection of the femoral vessels where uh we were taught when we were doing vascular bypasses where we encircled them with vessel loops and put clamps on them. You really just expose the interior surface of the artery and put a purse string in and you tie it down and generally that works well and it's safe and uh our need to then convert and do something uh open is so rare that we don't gain full access and control to those vessels. Um We can certainly practice uh on dummies, but this is in general, the field set up the cardio pulmonary bypass lines are brought up at the hip as they typically are. And then for this is for a robotic setup. Typically, the uh the robot is on the patient's right side for Lima to take down whatever side you're operating on the robot is brought in from the other side. So this would be for a right throaty approach. Here's the primary surgeon that's gonna do the thoro this might be, you know, the surgeon or assistant who's exposing the groin. The scrub uh tech can be here and generally, we will have the scrub on this side to pass instruments, side to side, just like we do our set up after the growing cumulation has been done. Uh then the robotic consult so is down here and you may have a second um uh had to be able for someone else to see or to take over and assist uh particularly during learning and then perfusion is here like always um behind us. And you can see that this is the, this is the typical setup. These are the lines that are coming in. This is the super ava line that's passed up through the drape and goes to the neck line and the right edge IJ. And you can see that the camera is introduced here and that could be put directly through the incision or through a separate port like this. Um And then you can see the left side of instrument which is typically a pickup of some kind an or a tractor and then the operating uh port here which is either a needle driver or scissors. So, you know, people are obviously nervous about doing, you know, robotic cases, uh you know, again for, but you know what's new and what's not new and the robot is a new thing, but we're doing robotics here. And we're, you know, Doctor Klin is doing a nice job of that with lung surgery as far as the minimally invasive instruments. These are just instruments. There's nothing magic about them. They are single shafted instruments much the same as, um, we all had in, uh, training with doing thos cop procedures or even laparscopic procedures. So they're really just different needle drivers. There's nothing magic about them as far as the incision. Well, thoro is done all the time. For lung surgery, we can do it for access to the heart and it's not that great of a leap. What about the valve repair? Well, there's nothing that changes and nothing should change about our ability to do the repair. And if we change the operation to fit the incision, that's the wrong thing. So we need to be able to replicate the operation exactly as we would do it open or we shouldn't do it at all. And the results um perfusion, we do profanation here every single day. So for dissections for redo cases, for ECMO S, we do it all the time. And this is, this was a cannulation that I did here in the IC U. This was two percutaneous cannula and then we did a dis S fa so this was an ECMO cannulation and we can do this with this level of um sophistication, having a bedside ultrasound accumulate somebody like this in our IC U. There's absolutely no reason why we can't do this. Well, so I outlined this case before I did it uh and went through uh with everyone. And I think it's helpful when we embark on anything new that we have a playbook and we outline the case with the team beforehand. So we went through what our prep, what our position was. Uh We marked the incisions and the port sites and the patient, we do a groin dissection, uh put the purse strings in, then we'll deflate the right lung, do a mini thoracotomy and we'll put in the wound retractor, we'll do a parac cardiotomy and then we'll put in some parac cardial traction sutures and we'll create port incisions at that point. Uh bring up the cardio pulmonary bypass lines and then we'll hyper the patient. So we do all this thing without all these things, without heparin. We expose the vessels. We do the thot we do the parac cardiotomy. We, and we expose the heart and we heper uh and can then right, coming from my vein, right, coming from our artery and then a distal perfusion catheter. The right IJ catheter is a Canon is already in place. Typically, I'll do that or anesthesia can do that and flush it with heparin, but we don't get full heparin for that. We'll put an antegrade needle in the ay and aorta for cardio plegia. Although if we use the in uh endo balloon or now the interclude balloon, you can actually deliver cardio plegia through the tip of that or vent through that. We'll go on bypass. If we anticipate putting in an LV vent, we can put it in right then and there just like we would for an open case, cross clamp arrest the heart with antegrade, cardio plegia open with the right atrium or the left atrium. If you're doing a microvalve repair, put in a retractor, do whatever operation you need to do, close the right atrium, remove the cross clamp ventilate and wean from cardio pulmonary bypass and close just like you would. And this is the in interclude, this is just a an Edwards can that now has the side limb off of it. Um You, cardiology is familiar with working with a uh diaphragm uh occlusion device called a. Um this has a similar thing on that we can introduce this cannula or this catheter through here. This has an aortic balloon clutter on the end of it. And we have the ability to monitor pressure but also to infuse cardio plegia and then vent the heart through that. And so, uh that's all a single setup. So I said that we probably shouldn't be using this for people that are older and sicker. This was a um uh large meta analysis talking about could you use minimally invasive surgery as an alternative in high risk patients? Um And so this was not a high-end journal. This was interactive cardiovascular and thas surgery, but they looked over several papers and, and, and basically concluded that it was associated with a longer cardio bypass and cross claim time. But in fact, their morbidity mortality uh was the same as well full annoy even in high risk patients. Now, obviously, this was a myriad of patients when they say high risk um lower ef patients, um patients who were older sicker and had a higher sts. So our plan I think should be to continue to increase the volume uh of minimally invasive cases but very selectively. Um we reserve these for acceptable risk patients early on in the program and then maybe future, we will stretch the limits of what we might be able to do. But for now and I think for the first couple of years, we need to be very careful about this, especially given the history and that we're embarking on something new, lots of staff turnover, lots of things that are new. And then maybe we can eventually, you know, start looking at robotic mid cab trans transition to a robotic platform. And I hope that over the next few years, if you look at the region, we can establish ourselves as uh a dominant minimally invasive program. We know that there are lots of other programs that are fairly close to us that are doing cardiac surgery. Some of them are doing minimally invasive cases, not to a large degree, but it is being done. Um And so hopefully, we can do that. Uh We can do that here. We know that other programs in the region are coming online even though, you know, uh Chesapeake is not as large a hospital as us. Certainly. Uh I did minimally invasive cases in a hospital of that size. Uh It makes us, uh I, I think continue to be relevant. Um We'll decide to do these minimally invasive or robotic. I think we can embark on minimally invasive mitr repair. Uh eventually probably replacement, uh mid cab intracardiac masses uh would be easy. Uh A SDPFO uh easy cases to do minimally invasive tricuspid valve repair replacement, not difficult to do minimally invasive and then maybe right through coy maze. Um A VR likely, uh you know, I did one minier anatomy here. We don't do as many isolated A VRS here period, largely because we do have a very good structural program. But I mean, for the reasonable risk patient, uh I think you can do just as well with a minier anatomy uh robotic A VR probably unlikely. Uh I think that's gonna be reserved for one or two centers who have enthusiasm for it. I personally don't. So the ideal candidates probably younger and healthier, close to our ideal body weight. Well, gee wouldn't we all love that every day? I mean, just you could just do anything to those people and it would be easy and they would all do well if they have a single cardiac lesion, uh normal ventricular function RV, and LV. And they obviously don't have peripheral vascular disease. So as we embark on this, I think that those would be the patients that we would, you know, um take on. Um there's a lot that can be said about each one of these topics, robotic, mid cab versus cabbage, micro repair versus sternotomy. And there are literally hundreds of papers that we can look at. And I think that as we go along next year and we start having more talks that we will isolate and focus on some of those things. But I really just wanted to give you a broad overview of what, what does it mean when we say minimally invasive, how do we go about it? What is possible where we think we're going to be with this and how we should go about this and also to make this a two way street to get some input from you as to what you might say, I'm close to the end of the hour. So I'm gonna stop there.
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