Clinical Professor, Director of Cardiovascular Surgery ......Modern cardiac operations increasingly...
Transcript of Clinical Professor, Director of Cardiovascular Surgery ......Modern cardiac operations increasingly...
Serdar Gunaydin, MD, PhDClinical Professor,
Director of Cardiovascular Surgery,Numune Training & Research Hospital,
University of Health Sciences,Ankara-Turkey
No Disclosures
✓ Modern cardiac operations increasingly use minimallyinvasive techniques, such as less invasive incisions andapproaches, and extracorporeal support is often reduced oreven avoided
✓ Even so, less than 20% of isolated aortic valve proceduresand about 45% of isolated mitral valve operations in Germany are performed in a minimally invasive fashion
✓ In contrast, approximately 4% of cardiopulmonary supportis minimally invasive in Europe
✓ Innovations in alternative methods for cannulation and cardiopulmonary bypass (CPB), new visualization systems, retractors and stabilizers, and robotic platformshave facilitated the development of minimally invasive cardiac surgery
✓ Complications associated with the endoclamp include balloon migration/ruptureand retrograde aortic dissection
✓ Elevated atherosclerotic plaques greater than 2 mm in height in the descendingthoracic aorta or arch may increase the risk of retrograde cerebral and othersystemic embolization and constitutes a contraindication to femoral artery-perfused minimally invasive mitral valve surgery
✓ Relative contraindications for a mini-right thoracotomy mitral approach includeprevious right thoracotomy with dense pleural adhesions, significant obesity, severe chest deformity (e.g., pectus excavatum), scoliosis, and prior breast implantor reconstruction
✓ Other operations that can be performed through a small right thoracotomy includetricuspid valve surgery, atrial septal defect closure, atrial myxoma resection, andseptal myectomy
✓ Minimally invasive approaches for aortic valve surgery generally consist of limitedsternotomies
➢ May-August 2017
➢ 20 Cases (16 female, Age: 76∓8.2)
➢ 17 AVR, 2 ASD, 1 MVR
➢ J-Sternotomy (5), R.Ant. Thoracotomy (15)
➢ Central Cannulation (8), Femoral (8), Femoral+Jugular (4)
➢ ICU: 1.2 ∓ 0.2 days
➢ Blood Tx : 0.4 ∓ 0.03 U (No Tx in 13 cases)
➢ LOS: 4.2 ∓ 1.3 days
✓ VAVD (-20/-40mmHg)
✓ Single dose Cardioplegia(Del Nido/HTK)
✓ NIRS
✓ RAP
✓ Cell-saver/HemoSep
MiECC Features
MICS• Equivalent early/late clinical
outcome
• Less pain, blood tx, wound infection
• Shorter LOS
• Better cosmetics
• Better results in high-risk patients
• Reoperations
• Easy penetration into a cost-sensitive environment
MiECC▪ A complete physiologically-based
strategy and not just a CPB circuit or a particular product
▪ All types of complicated cardiacsurgery
▪ Destination therapy: Bridge-to-bridge, bridge-to-transplant, orbridge-to-recovery
▪ Postcardiotomy cardiogenic shock, high-risk cardiology interventions, pulmonary embolism, myocarditisand accidental hypothermia
▪ Closed chest temporary mini-CPBusing peripheral cardiopulmonary bypass (salvage approach in patients with cardiogenic shock or cardiopulmonary arrest)
▪ Commercially available device thatcombines portability, rapid and easy deployment, and safe operation, withadaptability to various applications and patient requirements, along withlow cost
• No clear scientific evidnce due tomethodologic concerns: small numberof high-risk patients, surrogate endpoints, confounding factors
• The strong interest might be accountedfor the expected reductions in mortalityin subgroups of patients of highher risk with comorbidities
• New, large randomized controlled trialswill clarify this intriguing aspect