MINIMALLY INVASIVE VALVE SURGERY

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• MINIMALLY INVASIVE VALVE SURGERY

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HOW FAR WE HAVE COME

• THE MORTALITY FOR VALVE REPLACEMENT SURGERY IN
  1968 WAS 42

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WHY MINIMALLY INVASIVE VALVE SURGERY?

• SMALLER INCISION/SCAR
• LESS PAIN
• EARLIER MOBILIZATION
• EARLIER RETURN TO LIFESTYLE/WORK
• LESS TRAUMATIC
• LOWER INFECTION RATE
• LESS BLEEDING
• SHORTER LENGTH OF STAY
• SAFER REOPERATION

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• PATIENT DEMAND

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GOALS

• SMALL INCISION
• GOOD EXPOSURE
• IDENTICAL QUALITY TO FULL OPEN PROCEDURES
• IDENTICAL MITRAL VALVE REPAIR RATE
• SIMILAR COSTS
• SIMILAR OPERATING/BYPASS TIME
• ABILITY TO GET OUT OF TROUBLE

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• cardiologists are strongly encouraged to refer
  patients who are candidates for complex MV repair
  to surgical centers experienced in performing MV
  repair.
• Surgery for asymptomatic patients with severe MR
  and normal LV function should only be considered
  if there is a greater than 90 likelihood of
  successful valve repair in a center experienced
  in this procedure.

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• MV repair should be able to be achieved by
  experienced surgeons for the majority of patients
  with degenerative MV disease and ischemic valve
  disease, and patients should be referred to
  surgeons expert in repair.

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APPROACHES
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PARASTERNAL
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• ADVANTAGES
• GOOD ACCESS TO THE AORTIC VALVE
• DISADVANTAGES
• CHEST WALL HERNIA CAN RESULT

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LOWER STERNAL
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• ADVANTAGES
• GOOD EXPOSURE FOR THE MITRAL VALVE
• EXCISION CAN BE EXTENDED IF NECESSARY

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TRANSECTING STERNAL
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• ADVANTAGES
• EXCELLENT EXPOSURE OF THE AORTIC VALVE AND GREAT
  VESSELS
• DISADVANTAGES
• BREASTBONE INSTABILITY
• LOSS OF INTERNAL MAMMARY ARTERIES FOR FUTURE USE

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PORT ACCESS
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• ADVANTAGES
• TINY INCISIONS
• DISADVANTAGES
• GREATLY INCREASED OPERATIVE TIME AND OPERATING
  ROOM TIME
• MULTIPLE DEVICE INSERTIONS
• ENDOVASCULAR AORTIC CLAMP HAS RESULTED IN TORN
  AORTAS
• MORE DIFFICULTY IN ACHIEVING VALVE REPAIRS
• SOMEWHAT HIGHER MORTALITY

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• ADVANTAGES
• LOTS OF TINY INCISIONS
• SOUNDS EXCITING
• DISADVANTAGES
• GREATLY LONGER OPERATIVE TIME AND OPERATING ROOM
  TIME
• MAY USE ENDOVASCULAR AORTIC CLAMP WITH INCREASED
  RISK OF TORN AORTA

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• GENERALLY RESTRICTED TO THE MITRAL VALVE
• LOWER MITRAL VALVE REPAIR RATE
• HIGHER REOPERATION RATE FOR VALVE REPAIR FAILURE
• HIGHER MORTALITY
• HIGHER COSTS
• REPLACEMENT OF ROBOTIC INSTRUMENTS

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• IN THE INITIAL FDA STUDY, 65 OF PATIENTS WERE
  EXCLUDED

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RIGHT THORACOTOMY
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• ADVANTAGES
• EXCELLENT RESULTS ACHIEVED BY SOME SURGEONS
• PATIENT PREFERENCE
• DISADVANTAGES
• GENERALLY RESTRICTED TO THE MITRAL VALVE
• LONG INSTRUMENTS REQUIRED
• CANNOT EXTEND INCISION

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UPPER STERNOTOMY
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• ADVANTAGES
• ALL VALVES CAN BE ACCESSED WITH EXCELLENT
  EXPOSURE, AS WELL AS AORTIC PATHOLOGY
• STANDARD INSTRUMENTS
• SHORTER OPERATIVE TIME
• STANDARD AORTIC CLAMPING
• EXCELLENT HEALING WITH NO INSTABILITY
• CAN EXTEND INCISION IF NECESSARY
• DISADVANTAGES
• IRREGULAR HEART RHYTHMS WITH MITRAL PROCEDURES
• ?NOT AS EXCITING AS ROBBY THE ROBOT

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HOW WE DO IT

• 6-8 CM MIDLINE INCISION BEGINNING 6 CM BELOW THE
  NECK
• STERNUM IS DIVIDED FROM THE STERNAL NOTCH INTO
  THE FOURTH INTERCOSTAL SPACE
• TO THE RIGHT FOR AORTIC PROCEDURES
• TO THE LEFT FOR MITRAL VALVE AND COMBINED
  PROCEDURES

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• AORTA IS OPENED IN THE STANDARD FASHION
• THE RIGHT ATRIUM IS OPENED TO APPROACH THE MITRAL
  VALVE

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CONTRAINDICATONS

• MORBID OBESITY
• REOPERATIONS
• PECTUS EXCAVATUM
• NEED FOR ASSOCIATED PROCEDURES
• CAN REVASCULARIZE THE RIGHT CORONARY ARTERY

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PROCEDURES AT LRMC

• AVERAGE AGE 70
• (AVERAGE AGE AT CLEVELAND CLINIC 55)
• HAVE PERFORMED ALL COMBINATIONS OF VALVE REPAIRS
  AND REPLACEMENTS
• NOW PERFOMING THE MAZE PROCEDURE FOR ATRIAL
  FIBRILLATION

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• AORTIC VALVE REPLACEMENT
• MITRAL VALVE REPAIR
• MITRAL VALVE REPLACEMENT
• AORTIC VALVE REPLACEMENT/MITRAL VALVE REPAIR
• MITRAL VALVE REPAIR/TRICUSPID VALVE REPAIR
• AORTIC VALVE REPLACEMENT/MITRAL VALVE
  REPAIR/TRICUSPID VALVE REPAIR

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• AORTIC VALVE REPLACEMENT/ROOT REPLACEMENT
• RESECTION/GRAFTING ASCENDING AORTIC/ARCH
  ANEURYSMS
• AORTIC VALVE REPLACEMENT/CORONARY ARTERY BYPASS
  GRAFTING
• LEFT ATRIAL MYXOMA
• MITRAL VALVE REPAIR/MAZE PROCEDURE