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Minimally Invasive Minimally Invasive

Cardiac Cardiac SurgerySurgery

Tomislav Mihaljevic, M.D.

Minimally Invasive Minimally Invasive

Cardiac SurgeryCardiac Surgery

•• WhyWhy do it?do it?

•• HowHow is it done?is it done?

•• WhatWhat are the results?are the results?

Invasiveness in SurgeryInvasiveness in Surgery

•• InstrumentationInstrumentation

•• VisualizationVisualization

Designers of contemporary Designers of contemporary

surgical instrumentationsurgical instrumentation

Why Do It?Why Do It?

Minimally Invasive Cardiac Minimally Invasive Cardiac

SurgerySurgery

Patient demandPatient demand

•• Less traumaLess trauma

•• Cosmetic appealCosmetic appeal

•• More rapid recoveryMore rapid recovery

Surgeon abilitySurgeon ability

•• Equivalent result with proper selectionEquivalent result with proper selection

•• Build practiceBuild practice

TruthTruth

Patients will always choosePatients will always choose

•• Less invasive therapyLess invasive therapy

•• Even if less effective or Even if less effective or

greater riskgreater risk

ResponsibilityResponsibility

PhysicianPhysician’’s responsibilitys responsibility

•• Optimize less invasive Optimize less invasive

approachesapproaches

•• Inform and guide patientInform and guide patient

How Is It Done?How Is It Done?

Aortic Valve Aortic Valve

ReplacementReplacement

Minimally Invasive AVRMinimally Invasive AVR

•• Indicated for:Indicated for:

•• Isolated aortic Isolated aortic stenosisstenosis

•• Isolated aortic regurgitationIsolated aortic regurgitation

•• Aortic Aortic stenosisstenosis and ascending aortic and ascending aortic aneurysmaneurysm

•• Isolated ascending aortic aneurysmIsolated ascending aortic aneurysm

•• Isolated Isolated reoperativereoperative aortic valve aortic valve replacementreplacement

Vacuum Assisted Vacuum Assisted

Venous DrainageVenous Drainage

•• Small venous Small venous cannulaecannulae

•• Reduced pump primeReduced pump prime

•• Drier fieldDrier field

--5050

--5050

-50

Minimally Invasive AVRMinimally Invasive AVR

100

80

60

40

20

0

100

80

60

40

20

0Aortic

Occlusion

Aortic Occlusion

Mins.Mins.

C-P BypassC-P Bypass

Minimally Invasive AVRMinimally Invasive AVR

Operative TimesOperative Times

Mins.Mins.

P=.001P=.001 CC--P BypassP Bypass

Aortic OcclusionAortic Occlusion

100

80

60

40

20

0

100

80

60

40

20

02003200320022002200120012000200019991999199819981997199719961996

Minimally InvasiveAVR Mortality

Minimally InvasiveMinimally Invasive

AVR MortalityAVR Mortality

0.8 %0.8 %

TransTrans--Apical Aortic Valve Apical Aortic Valve

ImPlantationImPlantation (TAAP) Approach(TAAP) Approach

•• The apex of the heart is The apex of the heart is accessed via a small left accessed via a small left anterior anterior thoracotomythoracotomy

•• Indicated for patients with Indicated for patients with PVD and / or multi valve PVD and / or multi valve diseasedisease

Anterior Anterior ThoracotomyThoracotomy

Valve DeploymentValve Deployment

•• Rapid ventricular Rapid ventricular

pacing initiated to pacing initiated to ↓↓↓↓↓↓↓↓cardiac output to cardiac output to

prevent distal prevent distal

migration of the valvemigration of the valve

•• Valve is then Valve is then

deployed by balloon deployed by balloon

inflation inflation

Final PositionFinal Position

•• The valve sits within The valve sits within native annulus and native annulus and the the stenoticstenotic leaflets, leaflets, below the coronary below the coronary ostiaostia..

•• Radial expansion Radial expansion and friction prevent and friction prevent distal migration of distal migration of the expanded valvethe expanded valve

PercutaneousPercutaneous AVR AVR --

Potential ImpactPotential Impact

•• Indications Indications -- device / procedure specificdevice / procedure specific

•• Definition of high risk populationDefinition of high risk population

•• Size of potential patient populationSize of potential patient population

•• Expansion of indications Expansion of indications

•• Practice of Practice of valvularvalvular interventionsinterventions

•• Physicians education and trainingPhysicians education and training

ConclusionConclusion

•• Minimally invasive AVR represents the Minimally invasive AVR represents the

procedure of choice for majority of procedure of choice for majority of

patients with ASpatients with AS

•• PercutaneousPercutaneous AV implantation is feasible AV implantation is feasible

and potentially life saving for patients who and potentially life saving for patients who

are not surgical candidatesare not surgical candidates

•• Hybrid approaches may enhance the Hybrid approaches may enhance the

safety of catheter based AV implantationsafety of catheter based AV implantation

MitralMitral Valve SurgeryValve Surgery

MitralMitral Repair:Repair:

The Gold StandardThe Gold Standard

The Gold StandardThe Gold Standard

Is ChangingIs Changing

MitralMitral SurgerySurgery

•• Partial Partial sternotomysternotomy

•• Rt. Rt. ThoracotomyThoracotomy

•• Rt. Rt. ThoracotomyThoracotomy/Robotic Assistance/Robotic Assistance

MitralMitral SurgerySurgery

•• Partial Partial sternotomysternotomy

•• Rt. Rt. ThoracotomyThoracotomy

•• Rt. Rt. ThoracotomyThoracotomy/Robotic Assistance/Robotic Assistance

One size does NOT fit all patientsOne size does NOT fit all patients

MitralMitral SurgerySurgery

•• Partial Partial sternotomysternotomy

•• Rt. Rt. ThoracotomyThoracotomy

•• Rt. Rt. ThoracotomyThoracotomy/Robotic Assistance/Robotic Assistance

One size does NOT fit all patientsOne size does NOT fit all patients

One size does NOT fit all surgeonsOne size does NOT fit all surgeons

Partial Partial SternotomySternotomy

Right Right ThoracotomyThoracotomy

RoboticsRobotics

Robotic Surgical Robotic Surgical

InstrumentationInstrumentation

•• StateState--ofof--thethe--art art

robotic technology robotic technology

–– intuitive motion intuitive motion

control of surgical control of surgical

instrumentsinstruments

•• Surgeon in controlSurgeon in control

•• Assistant has direct Assistant has direct

accessaccess

InSiteInSite®® Vision SystemVision System

•• Surgeon Surgeon

immersed in 3D immersed in 3D

image of the image of the

surgical fieldsurgical field

•• 3D image 3D image

produced by produced by

special 2special 2--channel channel

cameracamera

The surgeon directs the The surgeon directs the

instrumentsinstruments

•• Surgeon directs the Surgeon directs the

instrument instrument

movements using movements using

Console controlsConsole controls

•• Motion of the Motion of the

surgeonsurgeon’’s hand s hand

translates in the translates in the

motion of motion of

articulated surgical articulated surgical

instrumentsinstruments

•• Conventional Conventional

minimally invasive minimally invasive

instruments are rigid instruments are rigid

with no wristswith no wrists

•• EndoWristEndoWrist®®

Instrument tips move Instrument tips move

like a human wrist like a human wrist

•• Allows increased Allows increased

dexterity and dexterity and

precisionprecision

Wrist and finger movementWrist and finger movement

RoboticallyRobotically--Assisted Assisted

MitralMitral Valve Repair Valve Repair

RoboticallyRobotically--assisted assisted MitralMitral

Valve RepairValve Repair

•• Patient PreparationPatient Preparation

RoboticallyRobotically--assisted assisted MitralMitral

Valve RepairValve Repair

•• Port PlacementPort Placement

RoboticallyRobotically--assisted assisted MitralMitral

Valve RepairValve Repair

•• CardioCardio--Pulmonary BypassPulmonary Bypass

RoboticallyRobotically--assisted assisted MitralMitral

Valve RepairValve Repair

•• MitralMitral Valve ExposureValve Exposure

RoboticsRobotics

250

200

150

100

50

02005 2006 2007 2008 2004

Distribution of Robotic Operations Distribution of Robotic Operations

2006 2006 -- 20092009

N = 620N = 620

Isolated MV Isolated MV

RepairRepair

64%64%

MV Repair + OtherMV Repair + Other

19%19%

CABG 3%CABG 3%

PFO/ASD/PFO/ASD/

MyxomaMyxoma

14%14%

Robotically-assisted Cardiac Surgery l October 22, 2009 l 60

Isolated MV RepairIsolated MV Repair

360

300

240

180

120

60

0

##

20002000 20042004 2006200620022002

Robotic

2008200820072007

MortalityMortality

0%0%

Repair RateRepair Rate

99%99%99%

Conversion RateConversion Rate

2%2%2%

When?When?

•• ValveValve

�� RepairRepair

�� Replacement Replacement

(simple)(simple)

•• PatientPatient

�� Relatively healthyRelatively healthy

•• ValveValve

�� MACMAC

�� Very complexVery complex

•• PatientPatient

�� LV dysfunctionLV dysfunction

�� AIAI

�� PADPAD

�� Small Small femoralsfemorals

Indications and Contraindications

Indications and Indications and

ContraindicationsContraindications

YESYES NONO

Results?Results?

Results Results

Minimally Invasive Minimally Invasive

vs. Conventionalvs. Conventional

Transfusion: PRBCTransfusion: PRBC

NoneNone 11 22 3 +3 +

P<.0001

MiniFull

%%

100100

8080

6060

4040

2020

00

Hospital DeathHospital Death

P<.0001 P=.2

UnadjustedUnadjusted

%%

55

44

33

22

11

00

MiniFull

MatchedMatched

0.2

1.6

0.5

1.1

75

80

85

90

95

100

0 1 2 3 4 5 6 7 8

%%

YearsYears

Mini

Full

Matched SurvivalMatched Survival

Minimally Invasive Minimally Invasive

MitralMitral Valve SurgeryValve Surgery

Fewer transfusionsFewer transfusions

Shorter ICU stayShorter ICU stay

Shorter LOSShorter LOS

Better early survivalBetter early survival

ResultsResults

SuperiorSuperior

•• CosmesisCosmesis

•• Patient Patient

satisfactionsatisfaction

EquivalentEquivalent

•• SafetySafety

•• Repair rateRepair rate

CostCost

CostCost

NonNon--robotic approachesrobotic approaches

•• Small capital investmentSmall capital investment

•• Decreased length of stayDecreased length of stay

•• OverallOverall--equal or less expensiveequal or less expensive

CostCost

Robotic approachRobotic approach

•• Initial capital investmentInitial capital investment

•• More disposablesMore disposables

•• Decreased length of stayDecreased length of stay

Mitral Valve Repair Mitral Valve Repair

Length of StayLength of Stay

•• If you can do the same operation withIf you can do the same operation with

•• Equal repair rateEqual repair rate

•• Equivalent safetyEquivalent safety

•• Smaller incisionSmaller incision

•• Superior Superior cosmesiscosmesis

QuestionQuestion

•• If you can do the same operation withIf you can do the same operation with

•• Equal repair rateEqual repair rate

•• Equivalent safetyEquivalent safety

•• Smaller incisionSmaller incision

•• Superior Superior cosmesiscosmesis

•• Why not?Why not?

AnswerAnswer

The SurgeonThe Surgeon’’s s

ResponsibilityResponsibility

OptimizeOptimize

•• SafetySafety

•• Repair rateRepair rate

MinimizeMinimize•• Incision/traumaIncision/trauma

EnhanceEnhance

•• OutcomeOutcome

•• Patient satisfactionPatient satisfaction

Thank YouThank You

Thank you for participating in our webinar today!

Market and Network Services Access LineA new, one-stop, easy to use service dedicated for Case Managers, Medical

Directors and Corporate Leaders who need assistance in referring patients to

Cleveland Clinic, Main Campus. This line is open from 7am – 11pm, seven

days a week.

216-738-5439