Minimally invasive video-assisted mitral valve surgery: the CardioMISS experience in more than 200 cases

Transcription

1 Minimally invasive video-assisted mitral valve surgery: the CardioMISS experience in more than 200 cases V.G. RUGGIERI, A. Antonazzo, E. Gerbasi, A. Albertini, B. Madaffari, A. Agnino Cliniche Gavazzeni / Humanitas Bergamo Italy Chief: G. Esposito

2 CARDIO M.I.S.S.???? Associazione di Volontariato Ottobre 2013 Unione di intenti di Professionisti della Salute L'associazione persegue finalità di: Sede: Viale Lucrezia Della Valle CZ CELL.: FACEBOOK: - Solidarietà sociale - Educative - Assistenza sanitaria e tutela dei diritti civili nei confronti di soggetti svantaggiati, con particolare riferimento ai malati di cuore.

3 Minithoracotomy approach for valve surgery Introduction - Advantages - excellent short-term and long-term-term results - feasible, safe, effective and durable - reduced morbidity and mortality (cost-effective and cost-saving strategy) - benefits include less pain, faster postoperative recovery, and better cosmetic results

4 Minimally Invasive Mitral Valve Surgery 1 - Material

5 Minimally Invasive Mitral Valve Surgery 2 - Method Cardiac surgeon Cardiac Surgeon Perfusionist Perfusionist TEAM Cardiologist Anesthesiologist Nurse

6 Right mini-thoracotomy for Mitral Valve Teamwork learning curve EXTERNAL CLAMP Aorta Central Canulation Standard intubation Single venous cannula Fem Art Peripheral Canulation Endobronchial blocker ENDOCLAMP Double venous cannulae

7 Preoperative planning protocol THE CORRECT DEVICE/STRATEGY FOR EACH PATIENT CT SCAN AORTA ILIO FEM NORMAL VESSELS FEMORAL ART CANNULATION PERIPHERAL VASCULAR DISEASE SMALL FEM DIAMETER NORMAL FEM DIAMETER TOO SMALL FEM DIAMETER SMALL CANNULA 18Fr ENDORETURN AORTIC CANULATION Fr ENDODIRECT STRAIGHT SHOT EXTERNAL CLAMP ENDOCLAMP ENDOCLAMP EXTERNAL CLAMP

8 Right mini-thoracotomy for Mitral Valve Teamwork learning curve FIRST SURGERY IDEAL PATIENT REGULAR AORTIC, ILIAC AND FEMORAL ANATOMY RIGHT PLEURAL CAVITY FREE FROM ADHESION NO CHEST WALL DEFORMITY GOOD LUNG FUNCTION: ABILITY TO MAINTAIN SINGLE LUNG VENTILATION NORMAL BSA VALUE REDO SURGERY DIFFICULT PATIENT IRREGULAR AORTIC, ILIAC AND FEMORAL ANATOMY RIGHT PLEURAL ADHESIONS CHEST WALL DEFORMITY POOR LUNG FUNCTION: INABILITY TO MAINTAIN SINGLE LUNG VENTILATION HIGH BSA VALUE

9 ENDOCLAMP The IntraClude occlusion device (10.5 Fr) LESS TRAUMATIC INTRA-AORTIC OCCLUSION ANTEGRADE CARDIOPLEGIA DELIVERY AORTIC ROOT PRESSURE MONITORING AORTIC ROOT VENTING ENDORETURN ENDODIRECT

10 Minimally Invasive Mitral Valve Surgery OPERATIVE FIELD Vs Ao Cannul. + External clamp Fem Cannul + Endoclamp

11 Mitral View EndoCAMeleon (Storz): 0-120

12 Minimally Invasive Mitral Valve Surgery CardioMiss Experience

13 The CardioMISS Experience Minimally Invasive Mitral Valve Surgery Oct 2009 Mar pts M/F: 122/96 Age: 61.6 ± 22.6 yo (24 84) BSA: 1.80 ± 0.6 ( ) NYHA III/IV: 56% LVEF: 53% (30-60) EuroScore I Log: 5.6 ± 4.4 % ( )

14 The CardioMISS Experience Comorbidities Diabetes 22 % Renal Insufficiency 6 % Hepatic Insufficiency 9 % Lung Disease 18 % CVA 4 % Hematol. Disorders 10 % Recent AMI (< 30 days) 3 % Heart failure (L or R) 3.5 % Redux 2.8% (6 pts) Mitral disease: Degenerative: 54% Barlow 8% Ischemic: 18% Rheumatic: 11.1% Endocarditis: 8.9%

15 The CardioMISS Experience Minimally Invasive Mitral Valve Surgery PLM 85% Oct 2009 Mar pts SVM N = 185 N = isolated 21 PLT 3 ASD 3 RF ablation isolated 5 PLT/SVT /

16 Surgical access Art. Cannulation Venous Cannulation Aortic cross clamp 183 (83.9%) IV i.s III i.s. 187 (85.7%) fem art - 31 direct aortic 198 (90.8%) double - 20 single (30 percut.) 149 (68%) Endoclamp 69 Cl. ext. Cardioplegia 62% Custodiol 22% Cold blood Mitral Replacement Mitral Repair Repair failure The CardioMISS Experience Intra-operative Data 14% Warm blood 2% Beating Heart 90.6% (29/32) biological Ring 100% (85% complete) PL plasty: 44% (82/185); PL neochordae: 7%(13/185) Ant Leafl neocordae: 5.4%(10/185) 1.4% (3 pts)

17 The CardioMISS Experience Aortic cross clamping 68% Endoclamp N = 149 CPB time: 119,8 ± 50,6 min ACC time: 97,1 ± 49,3 min CPB time: 137,7 ± 41,8 min ACC time: 94,7 ± 34,7 min Clamp ext N = 69 CPB time: 147,8 ± 46,8 min ACC time: 92,5 ± 36,9 min /

18 The CardioMISS Experience Early postoperative data Conversion to full sternotomy 0.9% (1 LA app tear, 1 temp PM) Vascular complications 0.9% (2 femoral artery) Low output syndrome 2.3% (5 pts) Postop 24h bleeding 460 cc ( ) Re-exploration for bleeding 6% (13) Blood transfusion 20.9%

19 The CardioMISS Experience Early postoperative data Stroke 0.4% (1 pts) Pulmonary complications 0.4% (1 Pneumothorax) Lymphocele 2.2% Atrial Fibrillation 4% Renal failure 1.3% Wound infection 0.9% In-Hospital Mortality 1.8% 1 PLM (0.45%), 3 SVM (1 Ao diss, 1 stroke, 2 MOF) ICU stay < 48h: 66% Postoperative hospital stay 7.5 ± 4.2 days (4 22)

20 The CardioMISS Experience Mid-Term Follow-up 100% complete mean 23 ± 13 months (3-55) Late deaths: 2 not cardiac related 212 patients 1 year FU : 98.2±0.9 (n=164) 2 years FU : 98.2±0.9 (n=100) 3 years FU : 97.1±1.4 (n=44) 4 years FU : 94.7±2.8 (n=14) Improved NYHA class: Residual MR (PLM): 100% (6.5% in class II NYHA) 92% no or trivial 8% moderate (2+)

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22 Conclusion Safe Reproducible Few postop. complications Excellentmid-term results Endoclamp = MIS Standard approach for Mitral Valve Surgery

23 CardioMISS TEAMWORK V.G. Ruggieri A. Agnino Cardiac Cardiac Surgeon surgeon A. Antonazzo A. Albertini Perfusionist Perfusionist Nurse THANK YOU Cardiologist Anesthesiologist A. Marvelli B. Madaffari E. Gerbasi