Developments in Valve Surgery

Transcription

1 Developments in Valve Surgery

2 Introduction Will discuss Aortic Valve and Mitral Valve surgery What is a mini valve operation? When do we do traditional valve surgery (SAVR, SMVR) vs. mini valve surgery vs. TAVR? What are the advantages and disadvantages of each approach?

3 Evolution of Incisions MICS Hemi Sternotomy AVR Full Median Sternotomy MICS Thoracotomy AVR MICS Thoracotomy MVR

4 MICS Valve surgical approaches Right mini-thoracotomy Incision in 4 th intercostal space for Mitral Valve Right anterior minithoracotomy in 2 nd intercostal space for Aortic Valve

5 Cannulation Strategies

6 Aortic Valve Surgery Aortic stenosis More commonly treated. Decades of experience with standard, sternotomy AVR Tissue valve vs metal valve Why change? Multiple approaches Initially started as a R parasternal incision R minithoracotomy vs mini sternotomy

7 Is there compelling evidence to proceed with minimally invasive aortic valve surgery? Cosmesis Blood loss Decreased post op pain Shorter length of stay Articles

8 Not every patient is a candidate Contraindications Issues with perfusion strategy Diseased pelvic vessels/pad Ascending aortic aneurysm Porcelain or calcified aorta Inflammatory issues in the R chest

9 Which approach is better to proceed with mini AVR? There are surgeons who feel that the only way to do a mini AVR is via a R mini thoracotomy, although most think that a ministernotomy is a better option I started with the minithoracotomy technique then transitioned to the mini sternotomy technique. I find the latter a lot more confortable.

10 Advantages/Disadvantages of a mini thoracotomy Advantages No sternotomy (Pt s perception of a cracked chest) Low risk of infection Disadvantages Aortic position is variable. If the aorta sits behind the L chest, the aorta can be very difficult to visualize. If the pt needs conversion to open surgery, pt will have two incisions (reasons to convert) Higher learning curve

11

12 Video 1

13 Advantages/Disadvantages for a hemi sternotomy Advantages Feels very similar to a standard operation Shorter learning curve If conversion to full sternotomy is required, simple to extend the incision. Stay with one incision Lower complication rate compared to minithoracotomy option

14 Video 2

15 TAVR???? TAVR has thus far been used for pts that are considered high risk for surgical AVR. TAVR will be soon used for pts at intermediate surgical risk. Why are we hassling with all of these mini operations if TAVR is taking the valve world by storm? No incision, home in 1-2 days? Low risk pts. Aortic valve surgery has been around for decades and is safe, reliable, and durable. Surgery allows for debridement of the aortic annulus, minimizing the risk of paravalvular leak (the Achilles heel of TAVR) If a durable valve can be replaced by removal of the diseased valve, precise placement of the valve without leaks, and can be done in a minimally invasive way, Which method would you chose for yourself?

16 Minimally Invasive Mitral Valve Allows a non-rib spreading approach to the mitral valve Peripheral cannulation is simple and easily reproduced.

17 Minimally invasive mitral surgery Advantages Less blood loss Less pain Earlier discharge More direct view to the mitral valve Lower risk of infection (no sternotomy, a lot of musculature in the chest) Economics Disadvantages Learning curve Adjunctive surgeries (esp cox maze iv), not done as effectively

18

19

20 Video 3

21 Developing Mitral technologies TAVR like mitral technology coming Mitral clip is here Only for high risk, inoperable pts. Mainly involving transapical delivery (small L thoracotomy) Transapical neochord placement The mitral apparatus is far more complex that the aortic valve. Mitral repair and replacement via surgery is likely to be around for awhile