Robotic Cardiac Surgery 2018:

What Procedures Can a Dedicated Program Offer?

Husam H Balkhy MD

Professor of Surgery

Director Robotic and Minimally Invasive Cardiac Surgery

University of Chicago Medicine

Winter Workshop 2018

Disclosure

• Proctor Intuitive Surgical

• Proctor: Atricure

• Proctor Liva Nova

• Avid practitioner of robotic cardiac surgery

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We’re in Athens!!

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Objectives

• Understand the value of Robotics in Cardiac Surgery

• Know the scope and depth of a fully committed and multifaceted

robotic cardiac surgical program.

• Understand the indications inclusion and exclusion criteria for various

cardiac robotic procedures

• See live examples of a wide range of robotic cardiac surgical

procedures

Why would we want to use Robotics in Cardiac Surgery?

da VinciTM System Coronary Bypass Post-op Patient

Sternotomy Coronary Bypass Post-op Patient

“Patients don’t like sternotomies”Delos Cosgrove, M.D.

STS 1996

Most Cardiac Surgical procedures require much more dexterity and precision than can be afforded by traditional laparoscopic and thoracoscopic approaches

Why would we want to use Robotics in Cardiac Surgery?

Endoscopic Surgery is Limited

-Unnatural operative feel -2-D vision

-Hands and instruments misaligned-Incisions very small, a few millimeters-Very limited dexterity inside patient -Long instruments -Hands/wrists outside patient -Fixed instrument tips inside patient

Why Robotics?• Completely Endoscopic Surgery

• Least Invasive surgical approach

• 3D visualization and articulating instruments lead to enhanced precision

• Both Epicardial and Endocardial access to the heart

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Why Robotics?

PrecisionAccuracy and Safety

Enhanced Dexterity

Robotic Procedures in 2018

• Intra cardiac procedures (Valves, AS, Myxoma etc..)

• Coronary Bypass (Totally Endoscopic)

• Atrial Fibrillation and other Ablation procedures

• Other:

– Pacer lead Placement/ Removal

– Pericardial Resection

What Intra cardiac procedures can be performed Totally

Endoscopically with the Robot in 2018?

– Mitral valve repair

– Tricuspid valve repair

– Combined MV and TV repair

– ASD repair

– Atrial Myxoma

– Resection Ventricular septum (HOCM)

– Resection Fibroelastoma (Mitral/Aortic valve

– Cryo Maze

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Robotic Intra-cardiac Procedures

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Redo Robotic MV repair, TV, CryoMaze

Robotic Endoscopic ASD Repair

Robotic Endoscopic ASD Repair: Unroofed CS

What procedures do we perform with the robot in 2018?

• Totally Endoscopic CABG (TECAB)

– Single vessel TECAB: (usually LIMA-LAD)

– Multi-vessel TECAB

• Bilateral IMA (LIMA and RIMA)

• Sequential LIMA

– Hybrid Revascularization

• PCI First

• TECAB First

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C-Port Distal anastomotic Device

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TECAB: Operative Setup

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TECAB: Operative Setup

Multivessel Connector TECAB

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Robotic TECAB: Sequential LIMA D1-LAD

-LIMA > Diag - LAD-End to side first: Flex A-Side to side: S18 U clips

Robotic TECAB: Sequential LIMA D1-LAD

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LIMA-LAD Patency: (mid term): 98.2%

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Robotic Endoscopic Release of Myocardial Bridge

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Combined Robotic MV TECAB?

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60 year old male with severe MR and tight prox LAD lesionUnderwent totally endoscopic complex MV repair and LIMA LAD via ports.Home in 3 daysBack to work in 10 days

• “Best of both worlds”: (B)IMA + benefits of minimally invasive

• Expands minimally invasive CABG

• Expands PCI (e.g. protected LM)

• Angiographic confirmation of grafts

Hybrid Coronary Revascularization

What Other procedures can be performed with the

robot in 2018?

Atrial Fibrillation surgery:

– Pulmonary vein isolation with Conduction Block testing

– LAA ligation

– Arrested heart Cryo Maze procedure

Other Epicardial Procedures:

– LV lead placement for Bi Ventricular pacing (intelligent CRT)

– Pericardial drainage and stripping (constrictive pericarditis)

– TMR?

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AF Ablation: Epicardial RF

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Hybrid AF ablation

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VT Ablation: LV Summit exposure

• Epicardial VT Ablation

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Mapping Guided CRT: Smart Resynchronization

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Lead Complications

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Totally Endoscopic BH Pericardiectomy

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How About the Aortic Valve?

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Robotic Assisted Aortic Valve surgery

• Leverages success

with Robotic MV

surgery

• Excellent view of

Aortic valve

• Ports one or two

interspaces higher

• Chitwood clamp

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Robotic AVR 3f

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Sutureless AVR

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Robotic Perceval AVR

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Adult Congenital Cardiac Surgery: Anomalous Left PV Drainage

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Post-operative length of stay

• Robotic TECAB: 2-3 days

• Robotic MV repair/ Port Access AVR: 3 days

• Robotic AF Ablation: 2 days

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Robotic Totally Endoscopic Beating Heart Coronary Bypass

(TECAB)Inclusion Criteria

• CAD involving the LAD, Diagonal, and

high Marginal branches of the

Circumflex coronary artery

• CAD involving the the proximal RCA

• Patients needing one or two IMA grafts

(single, double or triple bypass)

• Patients with 3 vessel coronary disease

as part of a ‘Hybrid Revascularization’

strategy

Exclusion Criteria

• Previous left lung surgery

• Severe COPD/ emphysema

• Severe scarring secondary to previous

sternotomy/ bypass surgery

• Cardiogenic Shock

• Very poor ventricular function

• Need for Emergency CABG surgery

Robotic Mitral and Tricuspid Valve Surgery

Inclusion Criteria

• Myxomatous Mitral valve degeneration

causing severe mitral regurgitation

requiring simple or complex repair

• Patients with severe Mitral regurgitation

requiring Mitral valve replacement

• Patients with severe tricuspid valve

regurgitation

• Patients with Mitral valve disease and

single vessel CAD amenable to PCI

Exclusion Criteria

• Severe scarring from previous right

lung surgery

• Severe COPD/ emphysema

• Associated 3 vessel CAD

• Severe scarring secondary to previous

sternotomy/ bypass surgery

• Very poor ventricular function

• Need for Emergency surgery

Conclusion:

• Adapting robotics can enhance minimally invasive cardiac surgery by

increasing dexterity and visualization to produce a truly MIS approach.

• Multiple intra and epi- cardiac procedures can be performed safely

and effectively enhancing outcomes and shortening recovery time.

• Increasing the number and variety of procedures performed allows the

team to become comfortable and facile with the system.

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The TEAM!

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Thank you