Marc Pelletier, MD, MSc, FRCSC, reviews the pros and cons of minimally invasive surgical procedures for valvular disease.
Good morning. My name is Mark Pelting. I serve as the division chief of cardiac surgery here at university hospitals and over the next few minutes I hope to speak with you about minimally invasive surgical approaches for valvular disease. Our objectives over the next 15 minutes are to review some of the pros and cons of these procedures to gain a better understanding of what these procedures are in order to help educate some of your patients and to discuss appropriate patient selection for minimally invasive surgery. But before we get into that please allow me to introduce our team and cardiac surgery here. Uhh In addition to myself we have a total of 10 cardiac surgeons. We have joseph pick who serves as our department chair and is a master surgeon well recognized internationally. Dr Mark Woods has been a stalwart in the Cleveland area now for several decades he performs many complex operations, especially involving freestyle aortic valve replacements and aortic root replacements and complex might do about surgery. And he also serves as our director at the Hoosier program. Dr chris Bay is um we were able to recruit a couple of years ago from santiago in chile. He serves as our co director of the tavern program and of the aortic program. Dr Yacoub. El Houdin serves as our chief of the via and also the chief of lung transplantation and a master aortic surgeon. Dr Yasser Abu Omar joined us last year from Cambridge University and Papworth Hospital in England. He serves as our director of heart transplantation and a ventricular assist devices. Dr abu walmart is also my colleague and minimally invasive mitral valve surgery and in fact I owe many of the slides and accolades to him today. Dr Pablo rueda vega joined us this year from Buenos Aires in Argentina. Pablo serves as our regional director of cardiac surgery and is our primary off pump surgeon. Dr Omar Hussein serves as our director of the Illyria program. He is also one of our procurement surgeons for heart and lung transplants. In addition recently we've been joined by Dr Kelsey Gray, one of our own graduates who will be working at the V. A. And Greg rushing who was trained at johns Hopkins as join and joins us as the medical director of our Parma program. This heads our team of cardiac surgeons. We perform surgery now at five different locations within the Cleveland area and in fact this year we are on pace for nearly 1600 open heart cardiac surgery cases with over 350 tavern cases. And this puts us is one of the nation's fastest growing cardiac surgery programs. We do this with an area of subspecialty expertise in many areas that we alluded to, including heart transplantation, ventricular assist devices, complex aortic surgery, minimally invasive valve surgery, which we'll talk about today arterial grafting and many other programs. So let's talk about minimally invasive surgery. One of our passions with this is how can we make the patient's experience better. Our goals are for a quicker recovery, equally safe or safer. Less pain, better cosmetics and hopefully an earlier return to normal activities. We do this in different fields including endoscopic vein harvesting, minimally invasive aortic valve, tavern minimally invasive coronary surgery and microsurgery. Let's start with endoscopic vein harvesting and radio are re harvesting. That is now the standard for any of our patients that we need a conduit especially when they're undergoing coronary bypass surgery. The long incisions on the leg and on the arm are really a thing of the past. And nearly all of our conduits are harvested and disk optically and long incisions have been replaced by very small incisions that typically heal quite well and are not very bothersome to the patients with the already valve replacement. We've taken a standard Stern Autumn E. Incision which is the gold standard across most centers and we've replaced that either with a mini thoracotomy in the second intercostal space Or a minister anatomy from the Sternal Notch to the 4th intercostal space. All of these again have better cosmetics, faster healing. A faster return to normal activities and overall less discomfort for the patients. Now the ultra form of our minimally invasive surgery is our Taber program and that's headed by our medical director dr Addison E. And our surgical director dr Baeza as it is across most areas in the country. We are now on pace to do many more taverns than we do standard aortic valve replacements. And that's a good thing. It's a good thing for our patients. And that volume has not just been driven on the fact that it's much more comfortable and safer for many of our older patients. But it's been driven on safety. The overall mortality for Taber across the patients across the country for all comers has now been across the board less than 2% minimally invasive coronary surgery is now something that we are doing on a much more regular basis. And that's been headed by the hybrid revascularization program that is being started by dr Rudy vega and DR paul pulling up on it. And that allows us through a very small left anterior thoracotomy to perform a lima to the lady, which we know is the single best bypass graft that we can give any patient and in fact, is the only form of revascularization that's been associated with improved survival. In nearly every study. This allows our patients to have a lima to the led off pump through a small left thoracotomy. And for those patients who need more grafting, either we can do it surgically or our colleagues in interventional cardiology can go on to step the right or the circum flex. Now let's focus on minimally invasive mitral valve surgery which is what I really want to talk to you about over the next 10 minutes. In fact finish with a video of about four minutes. That will take you into our world into what we're able to do with mitral valve repair and Michael Valve surgery. Now, the traditional stern economy has been very good and reliable and remains the gold standard for any form of complex cardiac surgery provides good access to everything. It's often simpler and shorter, but it does require a bit longer recovery time because of the stern artemis and the healing of the bone. And some complications are a bit higher. Sternal distance and infections, although they're low are certainly higher than they are with many thoracotomy incisions, Minimally invasive. Michael Valve has evolved over the last 20 years and really what that involves is a small right thoracotomy, combined with femoral arterial and venous cannula ation. This is really a basis for minimally invasive cardiac surgery. Instead of going through the sternum, we can relate the groin vessels and go through the chest with this approach. We can do several procedures including mitral valve repair or replacement truck. Is the valve repair or replacement SDS were maze procedures for atrial fibrillation. Now, as it is with every other valve or coronary surgery that we've discussed. The advantages are better cosmetics and that is important to some patients. Less recovery time, faster return to daily activities and workforce, especially for those who have to work and don't want to take much time off of work. There's usually less blood loss and pure transfusions. There are equal, if not better results and in fact, for many complex region cases, this is a better alternative approach. However, as we sit here today, less than 20% of Michael Valve surgeries are done by a minimum base of approach. And why is that? Well it's a different operation that takes a bit longer. There's a long learning curve. Patient selection has to be very careful and some patients simply are not candidates for this and many institutions in the United States have very low volume and because of that there's little room for innovation. So what kind of patients are good candidates? Well first of all there has to be a good reason. There has to be they have to meet H. A. Or a C. C. Criteria to undergo michael balance surgery. They have to have a good body habits. They can't be too obese. They have to have isolated mitral or try custard. They can have one or two but they can also need coronary bypass surgery and aortic valve surgery and they shouldn't have too many. Cool morbidity ease. So why are some patients not candidates? Well some reasons would be that they've had a previous store economy and they have pleural adhesions. Maybe they have severe lung pathology COPD severe lung fibrosis. Some of them if they have peripheral vascular disease or aortic calcification we simply can't safely Kanye late the vessels or clamp the aorta. Those are who are very obese presented a unique problem in terms of access if they have more than mild aortic regurgitation that can be a significant issue for my cardio protection and if they have too much mitral annular calcification, making the operation too risky. Again, that may not be a good candidate. If they have RV failure or severe pulmonary hypertension or severe LV failure. Again, they may not be a great candidate for this procedure. How do we work up these patients? Well, we have to be thinking about it and a referral to minimally invasive surgeon is probably one of those first steps or at least a valve center have to undergo a standard work up, which typically includes an echo and an angiogram. But they also typically undergo a cT scan so that we can assess the chest anatomy, the aorta and the federal vessels. Now can we do standard repairs with minimally invasive surgery? We certainly can. And this involves sometimes neo chords, triangular sections or quadrangular receptions. How is the procedure done is typically done in an operating room, surgeons, scrub nurse, assistant surgeon, anesthesiologist and profusion. This all very stable with with a few differences. The patient is usually put on his or her back with a roll under the right side, which gives us access to the groin and to the right chest. This allows us to do an incision. Typically in the fourth intercostal space that is supplemented with usually two or three ports and different retractors and scopes that allows us to see that area quite well and this is what it actually looks like when you see it in the operating here. You see different ports and the incision that's usually about 4 to 5 centimeter incision that we will work through. This procedure involves calculation of the federal vessels which is really a very important basic but very important step to do very properly. And typically will put a candle in the federal artery and a candle in the federal vein that we will advance all the way to the S. B. C. Under T. E. Guidance. We rely on instruments that are different and have evolved tremendously over the past 10 to 15 years long single shafted instruments that allow us to do complex work From farther away, we have different retractors that allow us to see the mitral valve to open up the left atrium and to allow us to really visualize well which is the most important part of this procedure. These are the types of images and this is how well we can see the valve when we do minimally invasive surgery. This is a picture of the Mitral Valve. You see the anterior leaflet at the top and at the bottom you see a ruptured P2 chord right at the middle of the posterior leaflet. Here you see some annular plastic annual plastic suitors that around the analysts are in green and a new gortex cord that's being implanted here. You see also an annual plastic ring coming in with the gortex court. So you can see that in some ways we see the valve much better. With this approach, there have been the evolution of many different things that have made this easier. One of those is a corn, a device that allows us to place all these small metallic knots around the mitral valve analysts rather than tying all these futures at the end, we finish with a standard pacemaker, wire and pericardial drains and the incisions typically like that look like this. They're close to the asylum, Typically not far from the areola and after a few weeks you see these incisions healing well and after several weeks they've healed quite nicely. Now allow me over the next 3-4 minutes to take you through a minimally invasive Marshall Valve repair and to take you a little bit into our world. So the procedure typically starts with exposure of the femoral vessels and cancelation of those vessels. Both the femoral artery and the femoral vein. We then approach through a right mini thoracotomy. We open up the pericardium and typically once we put the patient on bypass we can then go on play some futures in the aorta and those futures are going to be used for cardio pleasure which will allow us to stop the heart and open up the left atrium. Once we've done that, we can then place here you see our cardio pledge a cannula going into the ascending aorta and then you see our aorta being moved upwards so that we can clamp the aorta just above there there you see the sending the order being clamped. And through that Canada that you see at the 12:00 position we can give cardio, please Jay. Once the heart is stopped we can open up the left atrium, which typically starts to give us very good exposure to the mitral valve. We then insert a left actual retractor and there you'll see in a second that angel retractor is connected on the outside to something called an iron assist. Here's the react tractor at the top and you can see the anterior mitral valve leaflet and we have beautiful exposure to the mitral valve and now we can start inspecting the valve And here we see what the problem is. This is a prolapse P. Two And this should be in 95% or more of cases, a repairable balle. The majority of our cases start with the annual plastic futures. So we placed all these sutures around the endless of the mitral valve. And that allows us if you will to open up that valve to really kind of get good exposure to all the leaflets. So here you see that posterior leaflet, that P2 segment even better. And you see the ruptured cords that are there, we often will use something called a teleflex retractor that allows us to open up the valve a little bit more and to find the popularity muscle. So here's the popular muscle. And in that popular muscle we will insert often gortex chords that we will use to replace the cords that are broken. So these neo chords have become more and more now the foundation for mitral valve repairs the first futures that you see there. We're in the anterior lateral popular muscle. These are in the posterior medial popular muscle and these gortex chords will serve to anchor the leaflet in place where the chords have previously been ruptured. Now, here you see these gortex futures being passed through the P two segment of the posterior leaflet. These will form a total of four new cords and these cords will replace the ruptured cords that were previously holding posterior leaflet in place. One of the trickiest parts of these repairs is to actually get the chords the right length and we do this by testing the valve repeatedly. And here you see that at this distance there's a very nice tight seal of that valve in very little residual leak. We are now putting in an annual classy ring and more testing of that valve is showing us that that repair looks absolutely beautiful. Will often mark that repair with a marker and some ink just to get a sense of how much opposition there is between the anterior and posterior lethal. And here we see that there's quite a bit of redundancy. So now being happy with those gortex chords will tie those will test the valve one more time in here. You see a highly pressurized left ventricle, virtually no leak at all. And we have a beautiful repair. So once that's done, typically we will finish putting the ring in place, tying all of them with a cornet device. We'll close the left atrium and then we'll get on to allow the heart to restart after taking off the cross clamp and really just giving normal blood to the heart which will allow to restart and to start beating again. We don't typically will close that incision and you end up with a nice small typically four or 56 centimeter decision. That is very cosmetically nice. It doesn't hurt nearly as much in patients recover very very quickly. So the university hospitals, we have a very robust and doing basic cardiac surgery program that is growing as are many of our other programs. The cardiac surgery approaches that we have have evolved tremendously over the past few years. But a common theme is that they are less invasive and they are better tolerated for patients. It's a pleasure to help you evaluate some of your patients, either virtually through a discussion with you or your patients or in person if we can help at all. Here are a few ways that you can reach us either through the cardiac surgery program itself or directly through my email and here's my cell phone number at the bottom if I can ever be of help. Thank you very much. It's been very nice to speak with you this morning, virtually. And I hope you're enjoying the conference. Bye bye.
