The Future of Minimally The Future of Minimally Invasive Cardiac SurgeryInvasive Cardiac Surgery
Marco A. Zenati, M.D.Marco A. Zenati, M.D.Professor of Surgery and Professor of Surgery and
BioengineeringBioengineering
University of Pittsburgh School of MedicineUniversity of Pittsburgh School of Medicine
Hans JacobeusHans JacobeusPioneer of Thoracoscopy Pioneer of Thoracoscopy
(Stockholm 1910)(Stockholm 1910)
Modified Cystoscope
Jacobeus HC. The Cauterization of Adhesions in Pneumothorax Treatment of Tuberculosis. Surg Gynecol Obster 1921:32:493-500 (40 patients)
Thoracic Endoscopy Thoracic Endoscopy Pioneers in PittsburghPioneers in Pittsburgh
1993 -1993 -
Landreneau
Luketich
From MIDCAB to TECABFrom MIDCAB to TECAB
Dexterity EnhancementDexterity Enhancement
““Intuitive” Surgery:Intuitive” Surgery:Can You Beat a Fifth Grader?Can You Beat a Fifth Grader?
Computer Motion’s ZEUS1999-2002
Intuitive Surgical’s DaVinci2004-
Robotic Surgery in PittsburghRobotic Surgery in Pittsburgh
April 5April 5thth, 2001 , 2001 University of Pittsburgh Medical CenterUniversity of Pittsburgh Medical Center
First U.S. Robotic First U.S. Robotic Off-Pump CABGOff-Pump CABG
Cardiac Surgeon: Marco A. Zenati, M.D. Patient: 63 yo JAC
Day of discharge home: April 8th, 2001 POD#2
Level 4 MIS for MVRLevel 4 MIS for MVR
““Ideal”Ideal”Minimally Invasive Minimally Invasive Surgical ProcedureSurgical Procedure Single PortSingle Port
Access ANYWHEREAccess ANYWHERE Local vs General Local vs General
AnesthesiaAnesthesia No need for No need for
unnecessary unnecessary invasion of pleural invasion of pleural spacesspaces
Minimize painMinimize painNEJM 2006;354:20
MIS Tools Constrained to MIS Tools Constrained to Pivot at the Body Entry PointPivot at the Body Entry Point
The New York Times May 2007
HEARTLANDER
HeartLanderHeartLander
Bilateral VATS for Bilateral VATS for Pulmonary Vein Isolation in AFPulmonary Vein Isolation in AF
SUBXIPHOID ACCESS
Patient-Specific Strategy for AFPatient-Specific Strategy for AF
Ganglionated PlexiGanglionated Plexi
Armour Anat Record 1997
Rigid Endoscope Rigid Endoscope and Instrument Arm and Instrument Arm ShaftShaft– Unable to navigate Unable to navigate
complex 3D geometry complex 3D geometry spaces (e.g. pericardial spaces (e.g. pericardial space)space)
Ann Thorac Surg 2007
LAA
RAA
Through Transverse Sinus
Entry point: Subxiphoid
RSS Design -Current Prototype-
RSS Design -Current Prototype-
Cardiac Surgeon Cardiac Electrophysiologist
Direct Endoscopic SVPVisualization
FluoroscopyContinuous EKG and hemodynamic monitoring
NAVx 3DImagingStJude Med
HYBRID INTERVENTIONAL SUITE
Subxiphoid ApproachSubxiphoid Approach
Myocor COAPSYSMyocor COAPSYS
Common Lesion Sets Common Lesion Sets Employed in AF AblationEmployed in AF Ablation
Cox-Maze IVCox-Maze IV
Future Clinical “Battlefields”Future Clinical “Battlefields”
Heart FailureHeart Failure– Ischemic Mitral RegurgitationIschemic Mitral Regurgitation– Prevention of Remodeling after MIPrevention of Remodeling after MI
Atrial FibrillationAtrial Fibrillation
• 8 Fr. catheter with an irrigated radiofrequency tip (Biosense Webster) •60ºC, 40 watt, 15 seconds × several times
Ablation procedure
Pathway
Closed Chest Epicardial AblationClosed Chest Epicardial Ablation
Subxiphoid Videopericardioscopy Subxiphoid Videopericardioscopy for CRTfor CRT
Lead
Zenati et al. Circulation 2002
Epicardial Lead Placement for CRTEpicardial Lead Placement for CRTwith DaVinci Robotic Systemwith DaVinci Robotic System
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