Technologies & Innovation in Cardiothoracic Health Care (Surgical Perspective)
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1 Technologies & Innovation in Cardiothoracic Health Care (Surgical Perspective) Paneer Selvam Krishna Moorthy Department of Cardiothoracic Surgery, National Heart Institute (IJN), Kuala Lumpur, Malaysia
2 World History of Cardiothoracic Surgery
3 19 th Century Predictions Any surgeon who wishes to preserve the respect of his colleagues would never attempt to suture the heart - From a speech by Christian Albert Theodor Billroth at the Vienna Medical Society Meeting, 1880 Surgery of the heart has probably reached the limits set by Nature to all surgery; no new method, and no new discovery, can overcome the natural difficulties that attend a wound of the heart - Stephen Paget, The Surgery of the Chest, 1896
4 Revolution of Cardiac Surgery
5 History of Cardiac Surgery The first surgery on the heart itself was performed by Norwegian surgeon Axel Cappelen on 4 September 1895 at Rikshospitalet in Kristiania, now Oslo. He ligated a bleeding coronary artery in a 24- year-old man who had been stabbed in the left axillae and was in deep shock upon arrival. Access was through a left thoracotomy The first successful surgery of the heart, performed without any complications, was by Dr. Ludwig Rehn of Frankfurt, Germany, who repaired a stab wound to the right ventricle on September 7, 1896.
6 In 1925, operations on the heart valves were unknown. Henry Souttar operated successfully on a young woman with mitral stenosis. He made an opening in the appendage of the left atrium and inserted a finger into this chamber in order to palpate and explore the damaged mitral valve. The patient survived for several years Souttar's physician colleagues at that time decided the procedure was not justified and he could not continue
7 Mayo-Gibbon Bypass Machine 1953 John Gibbon realised his 20-year vision and performed the first successful operation on a human using the heart-lung machine. The patient, Cecelia Bavolek, whose heart was connected to the machine for 45 minutes, recovered fully from the operation. March 5, 1955
8 Cardioplegia In the 1980s, researchers at St Thomas s Hospital found that by cooling the heart to below 28 C and treating it with the right cocktail of chemicals, the heart could be stopped for many hours while intricate surgeries were performed, and then restarted with minimal damage. A similar cocktail of chemicals is now used to keep hearts healthy while they are transported for transplantation.
9 DR. DWIGHT E. HARKEN Father of Heart Surgery The first surgeon to have repeated success with heart surgery. We discovered that the heart wasn t such a mysterious and untouchable thing after all.
10 Cardiac Surgery 70 years of Continuous Innovation -
11 Innovative Factors Cardiopulmonary Bypass Diagnostic Tools Improvements Surgical Techniques & Tools & Prosthesis Post-operative cares
12 Diagnostic Tools
13 Modern Cardiopulmonary Bypass
14
15 Tools in MICS
16 Hybrid OR
17 Effects of Innovations Refinement of the diagnosis Improvement in Surgical Techniques Decrease in mortality and morbidity Early recovery and shorter hospital stay Early return to functional status Low cost
18 Innovations & Developments Coronary Artery Surgery Surgery for Arrthymia Heart Failure Surgery Innovations Thoracic Surgery Surgery to Aorta Heart valve Surgery
19 Any Innovations in Cardiothoracic Surgery in Malaysia?
20 Cardiac Surgery in Malaysia 1977: Division of Cardiology, Medical Department, General Hospital Kuala Lumpur (GHKL) 1980: Department of Cardiology, GHKL 1981: Department of Cardiology Department of Cardiothoracic Surgery Department of Anesthesiology Royal Prince Alfred Hospital, Sydney Royal Alexandra Hospital, Sydney April 1982: Sept 1982: Cardiac catheterization and angiogram 1 st open heart surgery: surgical closure of ASD 1 st coronary artery bypass surgery in Malaysia
21 1984: KLINIK KARDIOLOGI & KLINIK PEMBEDAHAN JANTUNG
22 THE TURNING POINT 1 am 18 th Jan 1989 : 24 th Jan 1989 : CABGs performed July 1992 : IJN started operations Sept 1992 : corporatized 12 th June 1993 : Official Opening
23 IJN 1992 IJN 2005
24 Workload Expansion Cardiology Procedures 6,314 7,016 6,862 7,298 7,818 8,298 8,482 8,441 8,276 10,308 10,023 Thoracic Closed Heart Open Heart 1,925 1,770 1,697 1,950 2,048 2,100 2,012 2,145 2,154 2,560 2,864 Transplant
25 OPEN HEART SURGERY (ADULTS/PAEDS) Adu lt Number of patients (N) **SOURCE FROM : - YEARLY CT REPORT OT CENSUS -2015
26 CLOSE HEART SURGERY (ADULTS/PAEDS) Number of patients (N) Adu lt **SOURCE FROM : - YEARLY CT REPORT OT CENSUS -2015
27 Coronary Artery Bypass Grafting
28 Evolution of Coronary Surgery May 2, 1960 Goetz RITA to RCA Tantalum ring Pt died in 8 months of AMI April 4, 1962 Sabiston SVG to RCA Suture Pt died 3 days later Feb. 24, 1964 Kolesov LITA to LCx Suture No angina at 3 years follow-up Nov 23, 1964 Garrett, DeBakey SVG to RCA Suture No angina at 7 years follow-up (The case first reported in 1973) March 22, 1967 Kolesov LITA to LAD Stapling No angina at 3 years follow-up May 9, 1967 Favaloro SVG to RCA Suture Successful Feb 29, 1968 Green LITA to LAD Suture Successful Robert H. Goetz Van Etten Hospital, New York
29 New Approaches to Coronary Bypass Surgery Arterial Graft Off Pump Imaging Graph flow monitoring
30 Coronary Bypass Surgery Arterial grafts
31
32 Coronary Bypass Surgery MID-CABG and MICS
33 Cardiac Valve Replacement
34 Surgical Treatment of Valvular Heart Disease Reconstruction Or Replacement
35 All 4 valves can be replaced
36 Ideal Prosthetic Valve Excellent hemodynamic characters unimpeded forward flow with minimal transvalvular gradient upon opening and produce a competent valve with minimal regurgitation upon closing Non thrombogenic Resistance to infection Non destructive to blood elements Durable Easy to implant Readily available at reasonable cost
37
38 Pulmonary Autograft(Ross Procedure)
39 Valve Reconstruction
40 All 4 valves can be reconstructed
41 Mitral Valve Repair Various Techniques Annulus Leaflet MVRepair Chordae Papillary Muscle
42 Mitral valve Repair Various Techniques
43 Mitral Valve Repair - Techniques
44 MV REPAIR PROCEDURE Number of patients (N) **SOURCE FROM : -MV REPAIR DATABASE TRAKCARE CT REGISTRY 2015
45
46
47 Aortic Valve Reconstruction
48 Aortic Valve Reconstruction
49 Ozaki's Method :Aortic Valve Reconstruction with Autologous Pericardium
50 How to do?? - cutting Pericardium is excised The excised pericardium is treated with 0.6% glutaraldehyde solution The each cusps and commissure distance is measured with Original sizing apparatus
51 How to do?? -stitch Draw cusps and Cusps are sutured put dots according to on annulus from the corresponding downward window on the template And, Cut them. Completion u.ac.jp/med/ohashi/cvs/treatment/aortic_valvular/self-
52 Completely Reconstructed Aortic Valve February 2016 to October 2106 : 10 cases done in IJN
53 Surgical Approaches to the Heart Valves
54 Conventional Median Sternotomy Minimally Invasive Surgery
55
56
57
58 MIS : Mitral Valve Repair/Replacement or Aortic Valve Repair/Replacement
59 Robotic Valve Surgery
60 Additional Combined Approaches
61 TAVI/TAVR TAVR is recommended in patients Who meet an indication for AVR (Section 3.4) Who have a Prohibitive risk for surgical AVR A predicted post TAVR survival greater than 12 months (71,72). (Level of Evidence: B) Consensus of Heart Valve Team
62
63 16 TAVI PROCEDURE Number of patients (N) **SOURCE FROM TAVI DATABSE
64 Aortic Surgery
65 Approaches to the Aortic Root Replacement Surgical mortality < 10%
66 Approaches to the Ascending Aorta/Arch Surgical mortality < 10% 17 th Annual Scientific Meeting of MATCVS
67 Replacement of thoracoabdominal aorta
68
69 17 th Annual Scientific Meeting of MATCVS Hybrid Approach
70 Technically Challenging
71
72
73 Thoraflex Hybrid Plexus Stented Distal Graft
74 CT Images 5.6 cm 6.6 cm 5.0 cm 5.0 cm 4.0 cm 5.0 cm 6.7 cm 3.0 cm 3.0 cm 2.5cm
75 PRE POST
76 PRE POST
77 Total Arch Replacement (Frozen Elephant Trunk) Jan 2016 to Nov No of cases
78 Congenital Heart Surgery
79 Arterial Switch
80 Tetralogy of Fallot
81
82 Mitral Valve Reconstruction in Children Contemporary long-term outcomes of an aggressive approach to mitral valve repair in children: is it effective and durable for both congenital and acquired mitral valve lesions? Mohd Azhari Yakub, Paneer Selvam Krishna Moorthy*, Sivakumar Sivalingam, Jeswant Dillon and Pau Kiew Kong + Author Affiliations Department of Cardiothoracic Surgery, National Heart Institute, Kuala Lumpur, Malaysia *Corresponding author. Department of Cardiothoracic Surgery, National Heart Institute, 145 Jalan Tun Razak, Kuala Lumpur, Malaysia. Tel: ; fax: ; paneer@ijn.com.my (P.S. Krishna Moorthy). Presented at the 28th Annual Meeting of the European Association for Cardio- Thoracic Surgery, Milan, Italy, October Received September 20, Revision received January 28, Accepted February 17, 2015.
83 Thoracic Surgery
84 Thoracotomy
85
86 VATS
87 VATS
88 Hyperhidrosis
89 What level should we perform surgery? Hyperhidrosis Craniofacial Denervation T2 Palmar T2-T3 Axillary Heart (Long QTS) T2-T4 or T3-T4 T1-T4
90
91
92 Surgery for Heart and Lung Failure
93
94 Ventricular Assist Devices
95 Medium and Long Term VAD
96 VAD Statistic of 24 VAD patients from Number of patients (N) LVAD PROCEDURE Type of VAD device used Thoratec - 6 (2 IVAD & 4 PVAD) HeartMate II - 8 HeartWare - 9 HeartMate 3-1
97 Heart Lung Transplant
98 TRANSPLANT PROCEDURE Number of patients (N) Procedure Year Total Cases Heart Transplant Lung Transplant Heart & Lung Transplant pts 26 surgeries (1 redo) pts (1 single lung tx 5 double lungs tx) pts
99 Is Innovations essential?
100
101
102 Thank You
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