12. Advances in Minimally Invasive Surgery
• Image: intraop TEE guidance placement of
catheters
• CPB: smaller cannulas, negative venous
drainage
• Instruments: long, fine tools
• Endoscope
• Robot
13.
14. Case One: Minimally Invasive Aortic Valve
Replacement
• A 92-year-old male presents with CHF
symptoms: SOB, fatigue
• PMH: COPD and CRD
• ECHO shows severe aortic stenosis
• He underwent mini AVR with a bovine
pericardial valve. Postop course uneventful.
27. Case Two
• A 75-year-old presents with acute pulmonary
edema.
• PMH: DM, Hormone replacement use, LE
celluitis, HTN
• ECHO: ruptured chordae with severe mitral
regurgitation.
• He underwent mini MV repair. Discharged home
within 5 days.
28. Case Three
• A 73-year-old presents with chronic congestive
heart failure. Referred to U of M for the 2nd
opinion.
• PMH: DM, HTN, HLD, CRD
• PSH: CABG; AVR; Aortic root replacement.
• ECHO: Severe mitral regurgitation due to
degenerative change.
• He underwent mini MV replacement. Had
uneventful hospital stay.
42. • MIMVS
– does not refer to a single approach
– a collection of new techniques and operation-
specific technologies
• enhanced visualization and instrumentation
• modified perfusion methods
• all directed toward minimizing surgical trauma by
reducing the incision size
48. Moront
• Reduced trauma and pain
• Statistically decreased blood loss and transfusion
requirements
• decreased wound infection
• Statistically reduced recovery time and more rapid
return to work
• Better cosmetic results and improved patient
satisfaction
• no difference in morbidity and mortality
• Facilitates redo surgery
• avoids sternal wound complications
• Statistically reduced incidence of wound infections
49. Birdi I
• Excellent cosmetic results for the patient
• Reduced pain
• Early discharge home
• Early return to normal life
• Easily reproducible with a fast learning curve
• Excellent results in high-risk patients
• Excellent mid-term outcomes
• Low cost consumables allowing easy introduction in a
cost-sensitive environment
50. Lamelas J
• Reduced trauma and pain
• Decreased blood loss
• Decreased wound infection
• Reduced recovery time
• Better cosmetic results and improved
patient satisfaction
• No difference in morbidity and mortality
• Facilitates redo surgery
• Avoids sternal wound complications
51. Holzhey
• 1,027 elderly patients (>70 years
• August 1999 and July 2009
• analyzed for outcome differences due to surgical
approach using propensity score matching
• etiology
– degenerative (83%)
– endocarditis (6%)
– rheumatic (10%)
– acute ischemic (<1%)
• Isolated stenosis was rare (3%)
• mitral valve regurgitation (72%)
• combined mitral valve disease (25%)
52. • longer duration of surgery (186 ± 61 vs
169 ± 59 minutes, p = 0.01)
• cardiopulmonary bypass time (142 ± 54 vs
102 ± 45 minutes, p = 0.0001)
• cross-clamp time (74 ± 44 vs 64 ± 28
minutes, p = 0.015)
53. • no differences between the matched
groups
– 30-day mortality (7.7% vs 6.3%, p = 0.82)
– combined major adverse cardiac
– cerebrovascular events (11.2% vs 12.6%, p =
0.86)
– other postoperative outcome
54. • postoperative arrhythmias and pacemaker
implants was higher in the sternotomy
group (65.7% vs 50.3% p = 0.023 and
18.9% vs 10.5%, p = 0.059)
• Long-term survival was 66% ± 5.6% vs 56
± 5.5% at 5 years and 35% ± 12% vs 40%
± 7.9% at 8 years, and did not show
significant differences
57. Mortality
• No difference
• Mihaljevic
– Largest study 474 MIMVS vs 337 MS
– (0.2-0.3%)
– MIMVS lower risk group
• Grossi
– Matched group
– Hospital mortality (3.7 vs 3.4%)
58. Neurologic events
• Mohr
– 18% incidence of postoperative confusion
– No CO2
• 10 studies
– no difference in stroke
• 2 studies
– Reduced stroke rate
• 6 studies
– No difference in neurologic events
59. Bleeding, transfusion, re-exploration
• Chitwood
– No difference in blood loss or blood product
transfusion
– MIMVS fewer re-explorations for bleeding
• Glower
– No difference in chest tube drainage or transfusion
requirements despite longer CPB time in MIMVS
• Cohn
– MIMVS transfused 1.8 units less
• 5 studies
– MIMVS showed significant reduction in reoperation
for bleeding
60. Atrial Fibrillation
• 5/6 studies
– No difference
• Asher
– 100 MICS patients
– 10% incidence of new onset AF with port
access lower than sternotomy
62. Pain and speed of recovery
• MIMVS (4/4 studies)
– Reduction in pain and faster return to normal
activity
• Most consistent finding
• Walther
– Equivalent pain for 1st 2 days with significant
reduction afterwards with difference widening with
time
• Glower
– Postop pain resolved more quickly with MIMVS
– Patient returned to normal activity 5 weeks earlier
63. Pain and speed of recovery
• Cohn
– Less pain in hospital
– Less analgesic usage
– Greater patient satisfaction
– Return to normal activity 4.8 weeks ahead
• Felger and Vleissis
– In Re-do’s, their 2nd procedure (MI) all felt that
their recovery was more rapid and less painful
than their original sternotomy
64. Hospital stay and costs
• Trend for shorter stay in MIMVS but not
statistically significant
• Chitwood -34%
• Cohn -20%
• Cosgrove -7%
65. Discharge disposition
• Mihaljevic and Cohn
– fewer requirements for post-hospital
rehabilitation
– significant advantage in terms of healthcare
savings
• 91% being discharged home compared to 67%
with a conventional approach
66. Intermediate and long term results
• Grossi
– Equivalent 1 year freedom from operation
– Mihaljevic et al.
• significantly better actuarial survival at 5 years for
MI patients (95% vs 86%)
• explained by a lower risk profile
68. Long Term Survival
• 100% at mean of 2.3 years to 83% at 6.8
years
• vs
• Mayo Clinic 5 year survival 86.4%
• Cleveland Clinic 5 year survival 82%
69. Freedom from Re-operation
• 99.9% at 3.2 years to 91 % at 4 years
• Longest followup was 6.3 years with
96.2% freedom
• vs Mayo clinic data risk of reoperation
– 0.5% per year for isolated posterior leaflet
prolapse
– 1.64% per year for isolated anterior leaflet
prolapse
70. Special Situations
• Reoperative surgery
– Avoid sternal re-entry
– Limited dissection of adhesions
– Avoid risk of injury to cardiac structures or
patent grafts
– Limit post-op bleeding
– Less blood loss
– Less transfusions
– Faster recovery
71. Re-operative surgery case
control(Sharony et al)
• Equal mortality at 5%
• Fewer wound complications
• Less blood product
• Decreased hospital stay
• slightly more favorable mid-term outcomes
73. MIMVS risks
• vascular risks with femoral cannulation
• Groin seromas can be problematic but are kept to a
minimum by
– dissection only of the anterior surface of the vessels
– clipping lymphatics
• phrenic nerve palsy
– When the pericardium is opened too posteriorly
– place the pericardiotomy at least 3 cm anterior to it.
– Excess tension by pericardial retraction
74.
75.
76.
77.
78.
79.
80. Conclusions:
• Less invasive procedures are demanded
but at the same time proven safety,
efficacy and durability are expected
• No level one evidence to justify switching
to minimally invasive mitral valve surgery
81. • All evidence demonstrates that MIMVS is
associated with equal
– mortality
– neurological events
• despite longer cardiopulmonary bypass
and aortic cross-clamp times
82. • However, MIMVS compared to
conventional sternotomy-based surgery,
there is less morbidity in terms of
– reduced need for reoperation for bleeding
– trend towards shorter hospital stay
– less pain
– faster return to preoperative function levels
83. • translates into improved utilization of
limited healthcare resources
• long-term outcomes are equivalent to
those of conventional surgery
84. • Data for MIMVS after previous cardiac surgery is limited
but consistently demonstrates reduced
– blood loss
– fewer transfusions
– faster recovery compared to re-operative sternotomy
• patients who undergo a MIMVS as their second
procedure feel their recovery is more rapid and less
painful than their original sternotomy
85. Bottomline
• Most patients do not want a sternotomy
• traditional cardiac operations still enjoy
proven long-term success and ever-
decreasing M&M
86. Case Four: Mini ASD Repair
• 32-year-old male presents with heart murmur.
• ECHO shows a large ASD, not suitable for
percutaneous device closure.
• Underwent mini ASD repair. Had a short hospital
stay.
88. Case Five: Hybrid CABG/Stent
• A 86-year-old female presents with angina.
• PMD: Obesity, COPD, DM, HTN, HLD; Bilateral
hip dysfunction; UTI.
• Angiogram shows severe CAD
• She underwent Robotic CABG and stenting
during the same hospital stay.
89.
90.
91.
92.
93.
94. What is the da Vinci® Surgical System?
• Powered by state-of-
the-art robotic
technology
• Surgeon is in control
and operates at the
console
• Assistant surgeon is
next to the patient
95. • 4 robotic arms enable Solo
Surgery™
• Fingertip control
• 7º of freedom 90º of articulation
• Motion scaling and tremor
reduction
da Vinci Surgical System
96. • 3-channel vision system
• High resolution 3-D image
• Panoramic view of the surgical field
da Vinci Surgical System
97. • EndoWrist®
Instruments fit
through dime-
sized incisions
• A wide range of
instruments are
available
98.
99.
100.
101.
102.
103.
104.
105.
106.
107.
108. Indications for Minimally Invasive Surgery
• 1. Aortic valve replacement
• 2. Mitral valve repair and replacement
• 3. CABG
• 4. LV pacing lead for biventricular pacing
treatment of CHF
• 5. Complex ASD
109. Indications for Minimally Invasive Surgery
• 6. High risk patients: elderly, immobile, DM,
respiratory compromise, osteoporosis
• 7. In some complex redo cardiac surgery
patients
• 8. Hybrid surgery:
– 1).Robotic CABG + stents for CAD
– 2). Mini AVR + stent
– 3). Mini MV repair/replacement + stent
– 4). Robotic CABG + mini valve
110. References:
• Colvin SB, Galloway AC, A Revolutionary Approach to Mitral Valve Repair, webcast, NYU Medical
Center, NY, 2005
• Petracek M, Minimally Invasive Mitral Valve Replacement and Surgical Ablation, Webcast, St Thomas
Heart Institute, Nashville TN' 2005
• Modi P, Hassan A, Chitwood WR, Minimally invasive mitral valve surgery: a systematic review and
meta-analysisEur J Cardiothorac Surg 2008;34:943-952
• Holzhey DM, Shi W, Minimally Invasive Versus Sternotomy Approach for Mitral Valve Surgery in
Patients Greater Than 70 Years Old: A Propensity-Matched Comparison, Annals of Thoracic Surgery,
Aug 2010
• Glauber M, Karimov JH, Minimally Invasive mitral valve surgery via right minithoracotomy, MMCTS,
Jan 2009.
• Cohn LH, Adams DH, Couper GS, Bichell DP, Rosborough DM, Sears SP, Aranki SF. Minimally
invasive cardiac valve surgery improves patient satisfaction while reducing costs of cardiac valve
replacement and repair. Ann Surg 1997;226(October (4)):421-426
• Grossi EA, LaPietra A, Ribakove GH, Delianides J, Esposito R, Culliford AT, Derivaux CC, Applebaum
RM, Kronzon I, Steinberg BM, Baumann FG, Galloway AC, Colvin SB. Minimally invasive versus
sternotomy approaches for mitral reconstruction: comparison of intermediate-term results. J Thorac
Cardiovasc Surg 2001;121(April (4)):708-713
111. References
• Grossi EA, Galloway AC, Ribakove GH, Buttenheim PM, Esposito R, Baumann FG, Colvin SB.
Minimally invasive port access surgery reduces operative morbidity for valve replacement in the
elderly. Heart Surg Forum 1999;2(3):212-215
• 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;240(September (3)):529-534
• Walther T, Falk V, Metz S, Diegeler A, Battellini R, Autschbach R, Mohr FW. Pain and quality of life
after minimally invasive versus conventional cardiac surgery. Ann Thorac Surg 1999;67(June
(6)):1643-1647
• Glower DD, Landolfo KP, Clements F, Debruijn NP, Stafford-Smith M, Smith PK, Duhaylongsod F.
Mitral valve operation via port-access versus median sternotomy. Eur J Cardiothorac Surg
1998;14(October (Suppl. 1)):S143-S147
• Vleissis AA, Bolling SF. Mini-reoperative mitral valve surgery. J Cardiac Surg 1998;13(November–
December (6)):468-470
• Felger JE, Chitwood Jr. WR, Nifong LW, Holbert D. Evolution of mitral valve surgery: toward a totally
endoscopic approach. Ann Thorac Surg 2001;72(October (4)):1203-1208
• Sharony R, Grossi EA, Saunders PC, Schwartz CF, Ursomanno P, Ribakove GH, Galloway AC, Colvin
SB. Minimally invasive reoperative isolated valve surgery: early and mid-term results. J Card Surg
2006 May-Jun;21(3):240-244
• Bolotin G, Kypson AP, Reade CC, Chu VF, Freund Jr. WL, Nifong LW, Chitwood Jr. WR. Should a
video-assisted mini-thoracotomy be the approach of choice for reoperative mitral valve surgery?. J
Heart Valve Dis 2004;13(March (2)):155-158
• Liao K, Personal Communication, April 18, 2011
