Less Invasive Reoperations for Aortic and Mitral Valve Disease. Peter Bent Brigham Hospital 1913

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1 Shapiro CV Center 2008 Peter Bent Brigham Hospital 1913 Lawrence H. Cohn, MD, Professor of Cardiac Surgery, HMS Division of Cardiac Surgery, BWH, Boston, MA

2 70% of US valve patients select bioprosthetic valves Millions of CABG patients are living longer and developing AS Reoperations are far safer in past over the world decade all

3 Minimally Invasive Valve Surgery 1. DECREASES TRAUMA 2. DECREASES BLOOD TRANSFUSION 3. DECREASES COST 4. SAME QUALITY OF SURGERY 5. MORE PATIENT SATISFACTION

4 Minimally Invasive Valve Surgery Mitral Valve 1004 Aortic Valve 1596 Total 2600 Operative mortality 43/1596 (2.7%) Operative mortality 8/1004 (0.87%)

5 Mini-Aortic Valve Surgery DEMOGRAPHICS Age 22-95, 66 M/F 943/653 NYHA F.C. 36% III-IVIV Reoperations 208 (12.7%)

6 Mini-Aortic Valve Surgery 7/ N = 1596 AVR 1577 Hemisternotomy 1543 R. Parasternal 33 R. Thoracotomy 5 AVP 19 Hemisternotomy 18 R. Parasternal 1

7 Mini-Aortic Valve Surgery OPERATIVE OUTCOMES Perioperative Bleeding (2%) Blood Transfusions (35%) Units/patient 1.2

8 Reop Mini-Aortic Valve Surgery REOPERATIONS = 208 (13%) CABG 154 AVR 28 CABG/AVR 11 Congenital 4 MVR 3 AVP 5 AVR/MVR 1 CABG/MVR 1 ASD 1

9 Reoperation team to include.. Radiology CT Scan to delineate structures Anesthesia TEE is manadatory

10 Mini-Aortic Valve Surgery OPERATIVE OUTCOMES Op Mortality 43/1596 (2.7%) AVR 31/1369 AVR reop 12/208 AVP 0/19 PREDICTED MORTALITY (4.2%)

11 Necessary operative techniques for MI AVR 1. TEE a. position of right atrial catheter b. position of coronary sinus catheter c. Evacuation of air 2. Venous side suction 3. Trans-femoral right atrial catheter 22 Fr 4. Special wire reinforced vent 12 Fr 5. Gensini technique aortic perfusion cannula

12 Myocardial protection MI reoperation AVR Fem-fem or axillary fem cannulation prior to sternotomy Systemic hypothermia K+ reperfusion to arrested heart Lower flow where applying valve sutures under LCA

13 Tabata M, Khalpey Z, Shekar PS, Cohn LH. Brigham and Women s Hospital, Boston, MA Reoperative minimal access aortic valve surgery: Minimal mediastinal dissection and minimal injury risk. J Thorac Cardiovasc Surg 2008 Dec; 136 (6): Conclusion: An upper hemi-sternotomy approach for reoperative aortic valve surgery is safe and feasible. This approach minimizes tissue dissection and trauma, thereby reducing the risk of injury to patent grafts and mediastinal organs.

14 Reoperation Mini-Aortic Valve Surgery CASE REPORT ALTERNATE INCISION SITES 93 YEAR OLD PHYSICIAN Porcine AVR/CABG x3 Porcine SVD-1997 Catheterization > 2/3 grafts open Operation: reoperation mini AVR Discharged post-op day 6

15 ALTERNATE PERFUSION SITES

16

17 After previous CABG needing AVR or MVR.. Do you need to isolate the LIMA (LITA) NO!!!

18 174 patients to be presented at WTSA no difference, many variables when left open.

19 No dissection technique is safe for reoperative aortic valve replacement with a patent left internal thoracic artery graft Kaneko T, Nauta F, Borstlap W, McGurk S, Khalpey Z, McClure S, Rawn J, Cohn LH Brigham & Women s Hospital, Boston, MA Conclusion: Reoperative AVR in patients with a previous CABG and patent LITA graft may be treated safely without dissection or clamping of the LITA. Myocardial protection using systemic hyperkalemia and hypothermia appears equivalent to the protection achieved in patients who had no LITA graft. We believe this method will prevent unnecessary injury during dissection of the LITA graft. To be presented at the WTSA 2012 Hawaii

20 Percutaneous AVR Caution: Investigational Device. Limited by Federal (US) Law to Investigational Use

21 Robotic system for transapical AVR with MRI Guidance Li M, Mazilu D, Horvath KA: CT Surgery Research Program, Bethesda, MD Med Image Comput Assist Interv 2008;11 (Pt2): Picture of the robotic system for MRI guided transapical AVR. It shows an Innomotion arm for the positioning module and the prototype of the new developed valve delivery module affixed on the robotic arm

22 CONCLUSION Technical advances in aortic valve surgery have been remarkable to date, but the near future will see more less invasive surgical techniques to further improve patient outcomes, especially in the elderly.

23 Less Invasive Mitral Valve Reoperations

24 Mitral valve surgery after previous CABG with functioning IMA grafts Byrne JG, Aranki SF, Adams DH, Rizzo RJ, Couper GS, Cohn LH BWH, Boston, MA Ann Thorac Surg 1999 Dec;68: Conclusions: Reoperative mitral valve surgery in the setting of functioning IMA grafts even in the face of depressed LV function, can be done safely and with minimal morbidity

25 Mitral valve surgery after previous CABG with functioning IMA grafts Ann Thorac Surg 1999 Dec;68: Fem-fem bypass Hypothermia Air removal via ascending aorta and left atrium

26 ALTERNATE INCISION SITES Myocardial Protection for Reoperative Cardiac Surgery in Acquired Heart Disease. Lawrence H. Cohn, M.D., Division of Cardiac Surgery, Brigham and Women s Hospital. Seminars in Thoracic and Cardiovascular Surgery Vol. 5 No pp

27 Minimally Invasive Mitral Valve Surgery Expands the Surgical Options for High-Risks Patients Petracek MR, Leacche M, Solenkova N Umakanthan R, Ahmad RM, Ball SK, Hoff SJ, Absi TS, Balaguer JM, Byrne JG. Vanderbilt Heart & Vascular Institute, Nashville, TN. Annals of Surgery Volume 254 Number 4, October 2011 Conclusions: This study demonstrates that MIMVS without aortic cross-clamp clamp is reproducible with low mortality and morbidity rates. This approach expands the surgical options for high-risk patients and yields to superior results than the conventional median sternotomy approach.

28 CONCLUSION Less invasive surgical approaches to mitral and aortic disease are safe and reproducible The future of new catheter based devices may obviate mitral and aortic reoperations but not for a long while

29 In experienced hands, minimally invasive valve surgery is not about marketing. It s about improved patient outcomes, especially in the elderly. Try new innovation, but critically and consistently review and re-review. review.