2/7/2012 - Lancaster General Health · 2/7/2012 1 The New Era of ... –Atrial tumor resection...

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The New Era of Minimally Invasive

Cardiac Surgery

Jeffrey T. Cope, MD

Division of Cardiothoracic Surgery

Lancaster General Hospital

February 23, 2012

10:30-11:30 AM

Traditional Approach to Cardiac Surgery

•Full median sternotomy

•Cardiopulmonary bypass

•Arrested heart

Traditional Approach to Cardiac Surgery Advantages of Traditional Approach

Sternotomy:

•Has withstood the test of time

•All surgeons comfortable with it

•Provides full access to:

–Pericardium

–All chambers of the heart and great vessels

–All 4 valves

–All coronary arteries

Advantages of Traditional Approach

On-pump, arrested heart:

•Provides ideal operating conditions

•Allows surgical team full control of circulation

and oxygenation

Disadvantages of Traditional Approach

Sternotomy:

•Pain

•Increased blood loss

•Prolonged healing time (2-3 months)

•Sternal wound complications

•Cosmetically unappealing

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Disadvantages of Traditional Approach Disadvantages of Traditional Approach

On-pump, arrested heart:

•Stroke risk

•Injury to other organs (kidneys, lungs, etc.)

•Ventricular dysfunction

•Bleeding/blood transfusions

Minimally Invasive ApproachesAdvantages of

Minimally Invasive Approach

•Better cosmesis

•Less pain

•Less blood loss

•More rapid healing (2-4 weeks)

•Minimization/avoidance of sternal wound

complications

•Avoid deleterious effects of CPB/arrested

heart

Advantages of


•Reduced postop morbidity

•Shortened postop ICU and total hospital

length of stay

•More cost-effective (?)

Disadvantages of


•Technically very demanding

–Not appropriate for every surgical team

•Expensive technology

•Not appropriate for every patient

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Minimally Invasive Cardiac Surgery

at Lancaster General Hospital

•Via right anterolateral minithoracotomy:

–Mitral valve surgery

–Tricuspid valve surgery

–Atrial septal defect repair

–Atrial tumor resection (e.g. myxoma)

•Aortic valve replacement via upper

ministernotomy

Minimally Invasive Cardiac Surgery

at Lancaster General Hospital

•da Vinci robotic-assisted minimally invasive

direct coronary artery bypass (MIDCAB)

•Hybrid coronary revascularization

•Transcatheter aortic valve implantation

(TAVI)

Minimally Invasive Mitral Valve Surgery

•Approach via 6-8 cm right anterior minithoracotomy

in 4th intercostal space

•Venous cannulation for CPB via right common

femoral vein

•Arterial cannulation via right common femoral

artery or ascending aorta

•Mitral valve repair or replacement performed using

specialized equipment and long-shafted

instruments

Minimally Invasive Mitral Valve Surgery

Contraindications:

•Morbid obesity

•Previous right lung surgery or infection

•Severe LV dysfunction

•Other significant valve or coronary disease

Minimally Invasive Mitral Valve Surgery Minimally Invasive Mitral Valve Surgery

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Minimally Invasive

Aortic Valve Replacement

•Approach via 6-8 cm upper ministernotomy incision

•Standard central aortic and right atrial cannulation

•Provides direct access to ascending aorta and

aortic valve

•AVR performed using standard instrumentation

Minimally Invasive

Aortic Valve Replacement

Contraindications:

•Morbid obesity

•Severe LV dysfunction

•Significant other valve or coronary disease

Minimally Invasive AVR

Partial upper ministernotomy:

Minimally Invasive AVR

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Minimally Invasive AVR Minimally Invasive AVR



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da Vinci Robot-Assisted MIDCAB

Who is a candidate?

•A patient who needs bypass to LAD (not a small,

calcified, or intramyocardial vessel)

•EF > 30%

•No significant lung disease or pulmonary HTN

•No previous left chest surgery

•Not morbidly obese

•Not in the midst of an acute MI


The epitome of minimal invasiveness:

•No sternotomy

•No cardiopulmonary bypass


Disadvantages:

•Not everyone is a candidate

•Steep learning curve

•Anastomosis more difficult than sternotomy

approach

•Operation itself more costly than nonrobotic

approach (but lower LOS and complication rates)


da Vinci Robot-Assisted MIDCAB da Vinci Robot-Assisted MIDCAB

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da Vinci Robot-Assisted MIDCAB Hybrid OR at LGH:

Building for the Future

What is a “Hybrid” Procedure?

•A conventional open cardiovascular surgical

procedure which is supported by sophisticated x-

ray imaging

•An interventional procedure which is supported by

conventional surgery

Why Hybrid OR / Hybrid Procedures?

•Combine the benefits of the OR, cath lab, and

interventional radiology suite to optimize and

improve patient care and clinical outcome

•Perform procedures not previously possible due to

infrastructure and logistical constraints

What is a Hybrid OR?

It is both a:

•Cardiovascular operating room

and a:

•Cardiac catheterization laboratory

All in one big room!

Components of a Hybrid OR

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Typical Procedures in Hybrid OR• Cardiothoracic Procedures

• Coronary artery disease:

• Hybrid coronary interventions

• High-risk catheter-based coronary intervention (unprotected left main disease, other complex and high-risk morphology)

• On-table angiography for quality control in coronary artery bypass grafting

• Valve disease:

• Endovascular, catheter-based interventions on the heart valves

• Aortic valve disease

• Mitral valve disease

• Congenital heart disease:

• Pulmonary valve disease

• Integrated surgical and catheter-based procedures for atrial septal defect II, ventricular septal defect repair, and coarctation of the aorta

• Thoracic aortic disease:

• Stenting or stent-graft placement to the thoracic aorta

• Heart failure/cardiac rhythm disturbances:

• Cardiac pacemaker insertion

• Automatic implantable cardiovascular defibrillator insertion

• Insertion of devices for biventricular pacing

• Hybrid procedures for treatment of atrial fibrillation

• Endomyocardial biopsy

Gore

TAG

Cook

Zenith

TX2

Medtronic: Talent and Valiant

Bolton Medical

Relay

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Hybrid Coronary

RevascularizationConcomitant Hybrid Minimally

Invasive AVR/PCI

By 2030, 20% of the U.S. Population Will

Be Over Age 65

Percentage of Populaton By Age Cohort

17%14%11%11%3%2%2%2%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2000 2010 2020 2030

85+

65-84

45-64

20-44

5-19

0-4

Source: U.S. Census Bureau, 2004, "U.S. Interim Projections by Age, Sex, Race, and Hispanic Origin," <http://www.census.gov/ipc/www/usinterimproj/>

Many Patients with Severe AS Are Not

Surgically Treated

40

6859

60

3241

0%

25%

50%

75%

100%

Charlson

2006

Iung 2003 Bouma 1999

Untreated

Surgically Treated

Severe AS*

Percent of Patients Treated

* EuroHeart Survey: Single Valve Disease (AS, MR)

1. Charlson E et al. Decision-making and outcomes in severe symptomatic aortic stenosis. J Heart Valve Dis2006;15:312-321

2. Iung B et al. A prospective survey of patients with valvular heart disease in Europe:

The Euro Heart Survey on Valvular Heart Disease. European Heart Journal 2003;24:1231-1243

3. Bouma B J et al. To operate or not on elderly patients with aortic stenosis:

the decision and its consequences. Heart 1999;82:143-148

EUUS

Rationale For Transcatheter Therapy

• High risk / Inoperable

• Age

• Depressed LVEF

• Stroke

• CRI

• Pulmonary insufficiency

• The frailty concept

• Quality of life

Transfemoral

Transapical

Edwards SapienTM Valve

Transcatheter Aortic Valve Implantation

(TAVI)

Transfemoral

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Other Routes of Access

• Transaortic

• Transsubclavian

Transapical

Exposure

Transapical Deployment Completion Angiogram

How to build a Hybrid OR?

•Planning!

•Planning!

•Planning!

•Design collaboration between LGH administrators,

cardiac surgeons, anesthesiologists, interventional

cardiologists, perfusionists, and OR/cath lab staff.

•Nothing like this has ever been built at LGH

before!

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Potential Impact of Hybrid OR at LGH

•Improve patient outcomes

•Foster sincere multidisciplinary collaboration

•Increase patient volumes

•Regional referral center

Questions?

2/7/2012 - Lancaster General Health · 2/7/2012 1 The New Era of ... –Atrial tumor resection...

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