Minimally Invasive

Cardiac Surgery

Presented by:

Wilson M. Clements M.D.

1

Disclosures

• No financial disclosures

2

McClure RS et al. Early and late outcomes in minimally invasive mitral

valve repair: An eleven year experience in 707 patients. J Thorac

Cardiovasc Surg 2009;137:70-5

• 11 year retrospective analysis

• 707 patients

• Access

– Lower ministernotomy

– Right parasternal incision

– Right thoracotomy

– Upper ministernotomy

• 707 repairs

• 3 (0.4%) operative deaths

• Stroke 1.9%

• Direct aortic clamp

• 4.8% failed repairs necessitating reoperationR. Scott McClure, Lawrence H. Cohn, Esther Wiegerinck, Gregory S. Couper, Sary F. Aranki, R. Morton Bolman III, Michael J. Davidson, Frederick Y.

Chen, Early and late outcomes in minimally invasive mitral valve repair: An eleven-year experience in 707 patients, The Journal of Thoracic and

Cardiovascular Surgery, Volume 137, Issue 1, January 2009, Pages 70-75

Galloway et al 2009 Annals of Thoracic Surgery

• 10 year retrospective analysis single institution

• 1601 patients with degenerative disease

– 1071 minimally invasive

– Right anterior thoracotomy with direct vision

• Mortality 2.2% for all

– 1.3% for isolated minimally invasive

– 1.3% for isolated sternotomy

– 3.6% for valve plus concomitant procedure

• 8 year freedom from reoperation

– 95% for minimally invasive

• Stroke

– 2.3 % MIS

– 1.7% sternotomy

• Ascending aortic perfusion/Direct Cross Clamp

Aubrey C. Galloway, Charles F. Schwartz, Greg H. Ribakove, Gregory A. Crooke, George Gogoladze, Patricia Ursomanno, Margaret Mirabella, Alfred

T. Culliford, Eugene A. Grossi, A Decade of Minimally Invasive Mitral Repair: Long-Term Outcomes, The Annals of Thoracic Surgery, Volume 88,

Issue 4, October 2009, Pages 1180-118

Glower et al. Innovations 2009

• 68 pts retrospective review

• Right mini-thoracotomy with mitral valve repair and edge-to-edge technique

• Direct cross clamping or fibrillatory arrest

• No mortality

• Stroke not recorded

• No reoperations

Grossi et al. JTCVS 2001

• 100 consecutive patients undergoing primary mitral reconstruction via

HeartPort

• 100 patients undergoing primary mitral repair via sternotomy

• 1 year followup

• 1 mortality via sternotomy

• Zero via MIS

• Freedom from operation

– 94.4% vs 96.8% not significant

• Endoaortic occlusion

• Stroke

– 1% sternotomy

– 2% MIS

Eugene A. Grossi, Angelo LaPietra, Greg H. Ribakove, Julie Delianides, Rick Esposito, Alfred T. Culliford, Christopher C. Derivaux, Robert M.

Applebaum, Itzhak Kronzon, Bryan M. Steinberg, F. Gregory Baumann, Aubrey C. Galloway, Stephen B. Colvin, Minimally invasive versus sternotomy

approaches for mitral reconstruction: Comparison of intermediate-term results, Journal of Thoracic and Cardiovascular Surgery, Volume 121, Issue 4,

April 2001, Pages 708-713

Seeburger et al. European Journal of Cardio-thoracic Surgery

2008• Single institution retrospective review

• 1339 valve repairs

• MIS 5-6 cm right lateral mini-thoracotomy

• Direct transthoracic cross clamping

• Hospital mortality

– 2.4%

• Neurological Impairment

– 3.1%

• 2.1% minor

• 1.0% major (editorial aside, these were not defined)

• 5 year freedom from reoperation

– 96.3%

Joerg Seeburger, Michael Andrew Borger, Volkmar Falk, Thomas Kuntze, Markus Czesla, Thomas Walther, Nicolas Doll, Friedrich Wilhelm Mohr, Minimal

invasive mitral valve repair for mitral regurgitation: results of 1339 consecutive patients, European Journal of Cardio-Thoracic Surgery, Volume 34, Issue 4,

October 2008, Pages 760-765.

Chitwood et al. JCTVS 2008

• Single institution retrospective review

• 300 patients undergoing robotic mitral valve repair

• 3-4 cm right inframammary incision

• Transthoracic aortic clamping

• Hospital mortality-0.7% early

• Later mortality 2.0%

– 6 patients

• Four non cardiac

• 2 died after MV reoperations

• 0.7% stroke—2 patients

• 0.7% TIA—3 patients

• 16 pts required reoperation (5.3%)

W. Randolph Chitwood Jr., Evelio Rodriguez, Michael W.A. Chu, Ansar Hassan, T. Bruce Ferguson, Paul W. Vos, L. Wiley Nifong, Robotic mitral valve

repairs in 300 patients: A single-center experience, The Journal of Thoracic and Cardiovascular Surgery, Volume 136, Issue 2, August 2008, Pages 436-

441

Murphy et al. JTCVS 2006

• Single institution retrospective review

• 127 patients undergoing endoscopic robotic mitral surgery

• 121 patients completed operation endoscopically

– Repair 114

– Replace 7

– 2 pts required reoperation

– 1 hospital death (0.8%)

– 1 late death

• Stroke 2 pts (1.6%)

Douglas A. Murphy, Jeffrey S. Miller, David A. Langford, Averel B. Snyder, Endoscopic robotic mitral valve surgery, The Journal of Thoracic and

Cardiovascular Surgery, Volume 132, Issue 4, October 2006, Pages 776-78

Modi et al. 2009 JCTVS

• 2 institution 12 year retrospective analysis

• 4 cm right mini thoracotomy with video assist

• 1178 patients

– 941 repair

– 237 replace

• Isolated mortality

– 0.8% repair

– 3.9% replace

• Stroke 2%

• Clamp

– 48% transthoracic

– 40.7% endoaortic balloon occlusion

– 10.1 % hypothermic fibrillation

• Reoperation for failure 1.9% @ 2 yearsPaul Modi, Evelio Rodriguez, W. Clark Hargrove III, Ansar Hassan, Wilson Y. Szeto, W. Randolph Chitwood Jr., Minimally invasive video-assisted mitral

valve surgery: A 12-year, 2-center experience in 1178 patients, The Journal of Thoracic and Cardiovascular Surgery, Volume 137, Issue 6, June 2009,

Pages 1481-1487

Gammie et al. Annals of Surgery 2009

• 5 year single institution retrospective review

• 187 patients with right chest small incisions allowing direct vision

• Direct aortic clamping

• 180 repair

• 7 replace

• Zero mortality

• Zero stroke

• Freedom from MR> mild was 92% @ one year

• 3 patients required reoperation

Gammie, James S. MD; Bartlett, Stephen T. MD; Griffith, Bartley P. MD> Small-Incision Mitral Valve Repair: Safe, Durable, and Approaching Perfection.

Annals of Surgery. 250(3): 409-415. September 2009

VanErman et al. 2003 Circulation

• Single institution retrospective review

• 306 pts

– 226 repair

– 80 replacement

• Video assist 4 cm worrking port right chest

• Endoaortic occlusion

• Thirty day mortality was 1%

• Stoke 0.3%

• Freedom from reoperation

– 99.7% @ 30 days

– 97,7% @ 1 year

– 91% @ 4 years

Filip P. Casselman, Sam VanSlycke, Francis Wellens, Rapheal De Geest, Ivan Degrieck, Frank Van Praet, Yette Vermeulen, and Hugo Vanermen.

Mitral Valve Surgery Can Now Routinely Be Performed Endoscopically. Circulation 108: II-48-54.

Byrne et al. 2004 Annals of Surgery

• 1000 pts. 474 mitral valve operations

• 7 year retrospective review from a single institution

• Incisions

– Lower sternal

– Right parasternal

– Right thoracotomy

• Repair 416

• Replace 58

• Mortality 0.2%

• Freedom from reoperation was 95% @ 6 years

• Direct crossclamp

• Stroke 1%

• Survival 95% @ 5 years

Mihaljevic T, Cohn LH, Unic D, Aranki SF, Couper GS, Byrne JG. One thousand minimally invasive valve operations: early and late results. Ann Surg

2004 Sep;240(3): 529-34.

Dogan et al. Annals of Thoracic Surgery 2005

• Prospective randomized study

• 40 pts randomized to sternotomy or mini right thoracotomy

• 14 pts in each arm underwent repair

• 6 in each arm underwent replace

• Endoclamp with 6 conversions to transthoracic

• Zero mortality

• Zero stroke

Selami Dogan, Tayfun Aybek, Petar S. Risteski, Farooq Detho, Andrea Rapp, Gerhard Wimmer-Greinecker, Anton Moritz, Minimally Invasive Port

Access Versus Conventional Mitral Valve Surgery: Prospective Randomized Study, The Annals of Thoracic Surgery, Volume 79, Issue 2, February

2005, Pages 492-49

Murphy et al. Innovations 2007

• 201 patients scheduled for robotic endoscopic mitral valve surgery

– 186 repair

– 15 replace

• 8 conversions

• 2 deaths

• 2 reoperations for valvular issues

• No comment on neurological injuries

• Endoaortic occlusion

Nifong et al. JTCVS 2005

• Phase II FDA trail

• Robotic mitral valve repair with da Vinci telemanipulation

• 4-5 cm mini right thoracotomy

• 112 patients in 10 institutions

• End point

• Grade 0 or I mitral regurgitation @ 1 month

• Zero deaths

• Zero strokes

• @ 1 month followup

• 9 (8.0%) pts had grade 2 mitral regurgitation

• 6 (5.4%)had reoperations

L. Wiley Nifong, W.R. Chitwood, P.S. Pappas, C.R. Smith, M. Argenziano, V.A. Starnes, P.M. Shah and Multi-center Robotic Mitral Repair Group, Robotic

mitral valve surgery: A United States multicenter trial, The Journal of Thoracic and Cardiovascular Surgery, Volume 129, Issue 6, June 2005, Pages 1395-

1404

Gammie et al. Ann Thorac Surg 2010

• Outcomes data from STS database

• 2004-2008 28143 patients undergoing isolated MV operations

• 23,821 conventional

• 4,322 less invasive mitral valve (LIMV)

• Less invasive defined by cannulation site

• Combination of transthoracic clamp, endoaortic balloon occlusion, and

fibrillatory arrest

• Mortality was similar between the groups (less than 2% in all studied

groups!)

• Adjusted OR 1.13

• Stroke was higher in the LIMV group in unadjusted, adjusted, and

propensity analyses.

• Adjusted OR 1.96 for less invasive

• Three-fold higher risk of stroke for LIMV performed without aortic occlusion

• Femoral cannulation was not an independent predictor of stroke

Svensson et al. JTCVS 2009

• Single institution propensity matched analysis

• 2124 MIS patients and 1047 conventional approach

• 590 matched pairs

• MIS approach

• Paramedian

• J incision

• Partial lower sternotomy

• Central cannulation and direct cross clamping

• Mortality similar

• 0.17% MIS

• 0.85% Conventional

• Stroke similar

• 1.2% MIS

• 1.0% Conventional

• Survival similar at 1,5,and 8 years

• 98%, 91%, and 86% MIS

• 96%, 89%, and 84% Conventional

• No right thoracotomy or robotic assist patients in this study

Seeburger et al. EJCTS 2009

• Single institution review encompassing 8 years and 1708 patients

• 1230 diagnosed with predominant prolapse of

• Anterior mitral leaflet n=156

• Posterior mitral leaflet n=672

• Bileaflet disease n=402

• Transthoracic clamp and right mini thoracotomy

• 94% successful repair overall

• 90.3% bileaflet, 91% anterior leaflet, and 96.9% posterior leaflet

• 6% replacement

• 30 day mortality 1.8%

• Stroke 2.4 % n=30

• Reoperation 4.1% n=51

Joerg Seeburger, Michael A. Borger, Nicolas Doll, Thomas Walther, Jurgen Passage, Volkmar Falk, Friedrich W. Mohr, Comparison of outcomes of

minimally invasive mitral valve surgery for posterior, anterior and bileaflet prolapse, European Journal of Cardio-Thoracic Surgery, Volume 36, Issue 3,

September 2009, Pages 532-538

Introduction

• Until 1995, cardiac surgery lagged behind

other fields

• Reduced incision sizes first for aortic and

mitral valve

• Port access with endoaortic occluders

• Skepticism abounded

Ideal Cardiac Valve Operation

• Small incisions

• Antegrade perfusion

• Tactile feedback

• Clear visualization

• Easy secure valve

attachment

• Intracardiac access

• No instrument

conflicts

• Same or better quality

as open procedures

– Repair in 60-80%

– Few reops

– Low mortality

Types of Incisions

Hemisternotomy Right MiniThoractomy

Levels Of Minimal Access

• 1: direct vision-mini 10-12cm incisions

• 2: video assisted: micro incisions 4-8cm

• 3: video directed and robot assisted-1cm

ports and micro incisions

• 4: robotic telemanipulation: ports and

micro incisions

Suitable Candidates

• Patients with primary mitral valve disease

• Reoperative mitral valve patients

• Bileaflet and/or anterior leaflet disease

• Combined tricuspid and mitral operations

• Mild annular calcification

• Obese or large patients

• Elderly patients

Unsuitable Candidates

• Highly calcified mitral annulus

• Severe pulmonary hypertension,

especially with a small right coronary

artery

• Significant untreated coronary disease

• Severe peripheral atherosclerosis

• Prior right chest surgery

Da Vinci System

• Stereoscopic vision

• Small yet fine instrumentation

DaVinci

dVMVR Patient Markings

dVMVR Port Placement

AAL

PAL

Arm #2

Arm #3

Camera Port

Pericardial Retraction Stitches

Arm #1

Cross-clamp

dVMVR Patient Positioning

dVMVR Ports in Place

Incisions after case

Triangular Resection

• P2 resection

• Posterior

annuloplasty band

PreProcedure TEE

PreProcedure TEE

PreProcedure TEE

Post Repair

PreProcedure TEE

TEE

POST REPAIR

PREOP

PREOP

POST REPAIR

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