The Pursuit of Minimally Invasive Pulmonary Thromboendarterectomy

Size: px

Start display at page:

Download "The Pursuit of Minimally Invasive Pulmonary Thromboendarterectomy"

Dana Barber
5 years ago
Views:

1 The Pursuit of Minimally Invasive Pulmonary Thromboendarterectomy Michael M Madani, MD, FACS Professor & Chief, Cardiovascular & Thoracic Surgery Director, UCSD - Surgery University of California San Diego

2 Disclosure No conflict with this presentation Consultant Bayer Actelion Wexler Surgical

4 Midterm Results Operated (60%) Non-operated (40%) Age (years) PAP (mmhg) PVR (dyn sec cm 5 ) NYHA I-II/III/IV (%) 19/69/12 18/69/13 PAP, pulmonary artery pressure. ICA European registry data. Delcroix M et al. Circulation 2016;133:859.

5 Treatment of CTEPH in 2017: PTE, BPA, Medical Therapy Adapted from: Madani, Ogo, Simonneau, The changing landscape of chronic thromboembolic pulmonary hypertension management, in Press ERR Vessel diameter Lesion types φ 3cm Fibrotic clots φ 2mm φ mm Microvasculopathy (Intimal thickening and proliferation)

6 Determination of Operability Extremely important as surgical therapy can be potentially curative Challenging Multifactorial Need more clear definition of Operability or Resectability vs Surgical Candidacy Requires an expert CTEPH team

7 Factors in Patient Selection Severity of patient s symptoms Severity of PH and RV dysfunction Extent and level of obstruction (high-quality imaging) Severity of the PH versus the degree of obstruction Patient s Comorbidities Technical concerns ( hostile chest ) A clear assessment of risk/benefit ratio based on the patient s individual expectation and acceptance of the risks Sulpizio Cardiovascular 7 Center

8 Potential Red Flags: Limited distal disease and severe PH Parenchymal lung disease LV diastolic dysfunction Advanced Age Acceptable outcomes in octogenarians Venous access catheters VA shunts Pacemaker leads Splenectomy Sickle Cell Anemia

9 Factors considered in Evaluation and CTEPH operability assessment Reliable and Precise Imaging Surgeon s experience # s, outcomes, distal disease Clot burden Operability Hemodynamics Center s experience Patient factors: Age, comorbidities, Technical

10 Illustration courtesy of Hotten, M. Thesis, Master Scientific Illustration, Jamieson et al. Cur Prog Surg 2000, 37: Madani et al. Op Tech in Tho & Card Surg 2006, 11:

12 Who benefited from surgery? PVR 1169 to 294 PVR 1290 to 204 PVR 858 to 365 PVR 527 to 188

13 UC San Diego Experience Total Number ~ 3800 Mortality 1-2%

1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

14 UCSD Experience 250 PTE Volume per Year

15 Recent Advances: Surgery More distal disease resection Refinements in imaging, instruments and surgical techniques allow distal resection Higher risk patients Severe PH Severe RHF Morbid Obesity Elderly, PTE in octogenarians Better ability to address post-op compilations Pulmonary Reperfusion Injury Residual PH Hemoptysis

16 Despite clear advantage of surgery, new advances, and many new centers, only about PTEs are performed in the US Physician Factors: Delay in Diagnosis Treatment options Delay in Referral Uncertainty about outcomes Self-screening of patients Patient Factors: Personal reasons Risks Proximity of the center AND Fear of surgery

17 Pushing the boundaries Relying on: Advancements in MIS valve and CABG operations and gained experience Understanding the potential pitfalls and contraindications Availability of newer imaging technology and disease correlation Improved Surgical instruments All Leading to laboratory work and development of MIS PTE Techniques Professor Heinz Günther Jakob in Essen

18 Definition of MIS cardiac surgery Variety of definitions: Based on Access Partial Sternotomy Mini Anterior or Lateral Thoracotomies / Avoidance of sternotomy Port access and endoscopic Robotic Assisted Robotic Avoiding CPB? Off-pump CABG

19 MIS Cardiac Surgery

Sternotomy In Other Cardiac Procedures Drawbacks Patient s Perception Long recovery period 2-3 months for full recovery Longer Hospital Stay Higher risk of infection Blood utilization Cosmetics

20 Sternotomy In Other Cardiac Procedures Drawbacks Patient s Perception Long recovery period 2-3 months for full recovery Longer Hospital Stay Higher risk of infection Blood utilization Cosmetics Competing with growing catheter based interventions as well as medical therapy Advantages: Proven technique and safety Faster operating times: OR, CPB, X-Clamp No need for peripheral cannulation Easier aortic cross-clamping Perhaps more secure cardiac protection and de-airing

21 Results of Minimally Invasive Valve Surgeries Similar short and long-term outcomes Shorter Ventilation Times Shorter ICU stays Shorter hospital Stay Decrease in post-op bleeding Lower infection rate Lower Blood Transfusion Rates Earlier Return to Work Tomislav Mihaljevic, et al Annals of Surgery Volume 240, Number 3, September 2004 Joseph Lamelas, et al, Semin in Th & Cardiovasc Surg, Volume 27, Issue 1, Spring 2015, Ismail Bouhout, et al, Canadian Journal of Cardiology, Volume 33, Issue 9, September 2017

22 Early in our experience Recurrent quotes from my mentor running through my head The system is working perfectly fine, until some idiot comes along and tries to change it Why change decades of success? It takes a genius to make things simple, any idiot can make it more complicated Why take an operation and make it even more challenging?

23 Minimally Invasive and yet maximally painful for the surgeon

24 But Why? Better appeal, Faster Recovery, and Better Outcomes

25 Increasing Threat of Percutaneous Options

26 HOW?

27 Keeping the main principles: CPB and cooling Circulatory arrest for a perfect visualization Clear identification of the correct plane Full bilateral Endarterectomy Avoid Sternotomy

28 Issues to Address Perfusion and CPB Aortic Cross clamp and myocardial protection Exposure of the vessels Visualization? Inability to move the heart

29 Perfusion Consideration Aortic / Arterial Can be Central or Peripheral Distal antegrade perfusion of the leg Surface oximetry reading of both legs Venous Multi-stage peripheral venous cannulation with tip of the cannula in the SVC In larger patients, or patients with IVC filter, Additional cannulation can be performed directly in the right atrium or through IJ line.

30 Peripheral Cannulation

Cannulation and Myocardial Protection If aortic cross clamp is utilized: Direct aortic root administration of cardioplegia Del Nido at 45 minute

31 Cannulation and Myocardial Protection If aortic cross clamp is utilized: Direct aortic root administration of cardioplegia Del Nido at 45 minute intervals But in PTEs: Since circ arrest times are 20 minute intervals, surgery can be performed without X-clamp Smaller incision on the right side

32 Central Aortic Cannulation Highly Valuable Space Avoiding X-Clamp and Venous cannulation Provides more room

34 Pre-Discharge Photo POD 9

35 Pre & Post V/Q scans

36 Unilateral Disease

39 Pre & Post V/Q Scans

40 Results MIS Patient 1 MIS Patient 2 MIS Patient 3 MIS Patient 4 MIS Patient 5 MIS PTE (mean) (n 5) Sternotomy PTE (mean) (n 918) History 39 y/o F, exercise induced dyspnea with complete occlusion RML/RLL 27 y/o F, history of LE DVT, complete occlusion of LPA 15 y/o M, Hx PE, DVT, antiphospholipi d antibody syndrome, polysubstance abuse 35 y/o M Hx DVT, methamphetam ine use, Factor V Leiden 43 y/o M hx PE, MTHFR gene mutation Age (mean) 31.8 years Age (mean) 51.9 years Circulatory arrest times UCSD Classification Disease Level Right: 9min Left: 4min Right- level 2 Left- level 0 Right:13min Left-:15min Right- level 3 Left- level 1C Right: 20+8 Left: Right: level 1 Left: level 1 Right: 18min Left : 19min Right: Level 1 Left: Level 2 Right: 0 Left: 17min Right: Level 0 Left: Level 1C (mean) 31.4 min (mean) min PVR dynes.s.cm-5 Pre- 173 Post Postop LOS Pre- 386 Post- 196 Pre-1000 Post-271 Pre-311 Post-108 Pre- 462 Post days 12 days 10 days 9days 10 days (mean) Pre Post-161 (mean) 9.8 days (mean) Pre Post (mean) 13.4

41 Current Limitations: Morbid Obesity / Increased BMI Significant chest wall collaterals Severe PH and RV failure IVC filter Disease limited to segmental or subsegmental vessels only Prior thoracotomies Unsuitable chest and great vessels anatomy

42 Factors considered in CTEPH operability assessment for MIS Patient s Height and Weight Clot burden Reliable and Precise Imaging Prior Thoracotomies Operability Surgeon s experience # s, outcomes, distal disease Need of Concomitant procedures Hemodynamics Anatomy of the chest and mediastinal Structures Center s experience Patient factors: Peripheral vascular disease, Organ Patient factors: Dysfunction Age, comorbidities, Technical Severe PH, RV Failure

43 Conclusion PTE surgery remains the best treatment option and should always be the first line of treatment for CTEPH MIS PTE is in its infancy, but it offers comparable visualization and appears safe Requires judicious patient selection. Good early outcomes The key ingredient to innovation and success is the support of an excellent and dedicated team

44 Thank you!

DISTAL PULMONARY THROMBOENDARTERECTOMY: IS IT WORTH IT?

DISTAL PULMONARY THROMBOENDARTERECTOMY: IS IT WORTH IT? Bob Moraca, MD Associate Professor of Surgery Surgical Director of The CTEPH Program Director of Thoracic Aortic and Arrhythmia Surgery Allegheny