Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted...

81
Stay tuned…our webinar will begin shortly! (Please note that your line has been muted.) Market and Network Services Access Line A 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

Transcript of Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted...

Page 1: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

Stay tuned…our webinar will begin shortly! (Please note that your line has been muted.)

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

Page 2: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

Minimally Invasive Minimally Invasive

Cardiac Cardiac SurgerySurgery

Tomislav Mihaljevic, M.D.

Page 3: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

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?

Page 4: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

Invasiveness in SurgeryInvasiveness in Surgery

•• InstrumentationInstrumentation

•• VisualizationVisualization

Page 5: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

Designers of contemporary Designers of contemporary

surgical instrumentationsurgical instrumentation

Page 6: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

Why Do It?Why Do It?

Page 7: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

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

Page 8: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

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

Page 9: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

ResponsibilityResponsibility

PhysicianPhysician’’s responsibilitys responsibility

•• Optimize less invasive Optimize less invasive

approachesapproaches

•• Inform and guide patientInform and guide patient

Page 10: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

How Is It Done?How Is It Done?

Page 11: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

Aortic Valve Aortic Valve

ReplacementReplacement

Page 12: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

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

Page 13: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #
Page 14: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #
Page 15: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #
Page 16: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #
Page 17: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #
Page 18: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

Vacuum Assisted Vacuum Assisted

Venous DrainageVenous Drainage

•• Small venous Small venous cannulaecannulae

•• Reduced pump primeReduced pump prime

•• Drier fieldDrier field

Page 19: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

--5050

--5050

-50

Page 20: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #
Page 21: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #
Page 22: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

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

Page 23: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

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

Page 24: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

Minimally InvasiveAVR Mortality

Minimally InvasiveMinimally Invasive

AVR MortalityAVR Mortality

0.8 %0.8 %

Page 25: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

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

Page 26: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

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

Page 27: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

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

Page 28: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

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

Page 29: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

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

Page 30: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

MitralMitral Valve SurgeryValve Surgery

Page 31: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

MitralMitral Repair:Repair:

The Gold StandardThe Gold Standard

Page 32: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #
Page 33: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

The Gold StandardThe Gold Standard

Is ChangingIs Changing

Page 34: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

MitralMitral SurgerySurgery

•• Partial Partial sternotomysternotomy

•• Rt. Rt. ThoracotomyThoracotomy

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

Page 35: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

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

Page 36: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

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

Page 37: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

Partial Partial SternotomySternotomy

Page 38: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #
Page 39: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #
Page 40: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #
Page 41: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #
Page 42: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #
Page 43: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

Right Right ThoracotomyThoracotomy

Page 44: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #
Page 45: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #
Page 46: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #
Page 47: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #
Page 48: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

RoboticsRobotics

Page 49: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

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

Page 50: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

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

Page 51: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

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

Page 52: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

•• 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

Page 53: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

RoboticallyRobotically--Assisted Assisted

MitralMitral Valve Repair Valve Repair

Page 54: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

RoboticallyRobotically--assisted assisted MitralMitral

Valve RepairValve Repair

•• Patient PreparationPatient Preparation

Page 55: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

RoboticallyRobotically--assisted assisted MitralMitral

Valve RepairValve Repair

•• Port PlacementPort Placement

Page 56: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

RoboticallyRobotically--assisted assisted MitralMitral

Valve RepairValve Repair

•• CardioCardio--Pulmonary BypassPulmonary Bypass

Page 57: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

RoboticallyRobotically--assisted assisted MitralMitral

Valve RepairValve Repair

•• MitralMitral Valve ExposureValve Exposure

Page 58: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

RoboticsRobotics

250

200

150

100

50

02005 2006 2007 2008 2004

Page 59: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

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%

Page 60: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

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

Page 61: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

MortalityMortality

0%0%

Page 62: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

Repair RateRepair Rate

99%99%99%

Page 63: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

Conversion RateConversion Rate

2%2%2%

Page 64: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

When?When?

Page 65: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

•• 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

Page 66: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

Results?Results?

Page 67: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

Results Results

Minimally Invasive Minimally Invasive

vs. Conventionalvs. Conventional

Page 68: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

Transfusion: PRBCTransfusion: PRBC

NoneNone 11 22 3 +3 +

P<.0001

MiniFull

%%

100100

8080

6060

4040

2020

00

Page 69: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

Hospital DeathHospital Death

P<.0001 P=.2

UnadjustedUnadjusted

%%

55

44

33

22

11

00

MiniFull

MatchedMatched

0.2

1.6

0.5

1.1

Page 70: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

75

80

85

90

95

100

0 1 2 3 4 5 6 7 8

%%

YearsYears

Mini

Full

Matched SurvivalMatched Survival

Page 71: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

Minimally Invasive Minimally Invasive

MitralMitral Valve SurgeryValve Surgery

Fewer transfusionsFewer transfusions

Shorter ICU stayShorter ICU stay

Shorter LOSShorter LOS

Better early survivalBetter early survival

Page 72: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

ResultsResults

SuperiorSuperior

•• CosmesisCosmesis

•• Patient Patient

satisfactionsatisfaction

EquivalentEquivalent

•• SafetySafety

•• Repair rateRepair rate

Page 73: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

CostCost

Page 74: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

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

Page 75: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

CostCost

Robotic approachRobotic approach

•• Initial capital investmentInitial capital investment

•• More disposablesMore disposables

•• Decreased length of stayDecreased length of stay

Page 76: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

Mitral Valve Repair Mitral Valve Repair

Length of StayLength of Stay

Page 77: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

•• 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

Page 78: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

•• 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

Page 79: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

The SurgeonThe Surgeon’’s s

ResponsibilityResponsibility

OptimizeOptimize

•• SafetySafety

•• Repair rateRepair rate

MinimizeMinimize•• Incision/traumaIncision/trauma

EnhanceEnhance

•• OutcomeOutcome

•• Patient satisfactionPatient satisfaction

Page 80: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

Thank YouThank You

Page 81: Mini Inv Surg Webinar Mihaljevic Oct09Vacuum Assisted Venous Drainage ... Robotically-assisted Cardiac Surgery l October 22, 2009 l 60 Isolated MV Repair 360 300 240 180 120 60 0 #

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