PROMINENT. OPEN AND ENROLLING: Please Refer Patients! MHIF FEATURED STUDY:

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1 MHIF FEATURED STUDY: PROMINENT OPEN AND ENROLLING: Please Refer Patients! CONDITION: High triglycerides, low HDL, T2DM, secondary cardiovascular prevention DESCRIPTION: Placebo controlled trial of a potent fibrate, pemafibrate, to prevent MI, ischemic stroke, unstable angina requiring revascularization, and CV death in adults with T2DM. CRITERIA LIST/ QUALIFICATIONS: PI: Dr. Matthew Chu SUB I S: Marc Newell, MD Thomas Knickelbine, MD Amy Cooley, CNP Inclusion TG > 200, HDL < 40, T2DM, LDL<70 or high dose statin or statin intolerant Exclusion Type 1 diabetes, HbA1c > 9.5%, NYHA Class IV HF, significant liver disease RESEARCH CONTACT: Ezi Ebere Ezi.Ebere@allina.com SPONSOR: Kowa Research Institute TRIGLYCERIDES MATTER AND THIS STUDY IS HELPING ADDRESS THEM! 1 of 23

2 Minneapolis Heart Institute Foundation Cardiovascular Grand Rounds Title: From sternotomy to thoracotomy: The evolving minimally invasive procedures in cardiac surgery Speaker: Bassam Shukrallah, MD Cardiac Surgeon Minneapolis Heart Institute at Abbott Northwestern Hospital Date: February 18, 2019 Time: 7:00-8:00 AM Location: ANW Education Building, Watson Room OBJECTIVES At the completion of this activity, the participants should be able to: 1. List the limits and benefits of minimally invasive procedures. 2. Review the literature behind minimally invasive procedures. 3. Explain how common procedures are performed in minimally invasive procedures. ACCREDITATION Physician - Allina Health is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. Allina Health designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credit(s) TM. Physicians should only claim credit commensurate with the extent of their participation in the activity. Nurse - This activity has been designed to meet the Minnesota Board of Nursing continuing education requirements for 1.0 hours of credit. However, the nurse is responsible for determining whether this activity meets the requirements for acceptable continuing education. DISCLOSURE POLICY & STATEMENTS Allina Health, Learning & Development intends to provide balance, independence, objectivity and scientific rigor in all of its sponsored educational activities. All speakers and planning committee members participating in sponsored activities and their spouse/partner are required to disclose to the activity audience any real or apparent conflict(s) of interest related to the content of this conference. The ACCME defines a commercial interest as any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. The ACCME does not consider providers of clinical service directly to patients to be commercial interests - unless the provider of clinical service is owned, or controlled by, an ACCME-defined commercial interest. Moderator(s)/Speaker(s) Dr. Bassam Shukrallah has disclosed that he DOES NOT have any real or apparent conflicts with any commercial interest as it relates to presenting the content in this activity/course. Planning Committee Dr. Alex Campbell, Jake Cohen, Jane Fox, Dr. Mario Gössl, Dr. Kevin Harris, Dr. Kasia Hryniewicz, Rebecca Lindberg, Amy McMeans, Dr. Michael Miedema, Dr. JoEllyn Moore, Pamela Morley, Dr. Scott Sharkey, and 2 of 23

3 Jolene Bell Makowesky have disclosed that they DO NOT have any real or apparent conflicts with any commercial interest as it relates to the planning of this activity/course. Dr. David Hurrell has disclosed the following relationship -Boston Scientific: Chair, Clinical Events Committee. NON-ENDORSEMENT OF COMMERCIAL PRODUCTS AND/OR SERVICES We would like to thank the following company for exhibiting at our activity. AtriCure Accreditation of this educational activity by Allina Health does not imply endorsement by Allina Learning & Development of any commercial products displayed in conjunction with an activity. A reminder for Allina employees and staff, the Allina Policy on Ethical Relationship with Industry prohibits taking back to your place of work, any items received at this activity with branded and or product information from our exhibitors. PLEASE SAVE YOUR SERIES FLIER When you request a transcript this serves as your personal tracking of activities attended. Most professional healthcare licensing/certification boards will not accept a Learning Management System (LMS) transcript as proof of credit; there are too many LMS s across the country and their validity/reliability are always in question. If audited by a licensing board or submitting for license renewal or certification renewal, boards will ask you not the entity providing the education for specific information on each activity you are using for credit. You will need to demonstrate that you attended the activity with a copy of your certificate/evidence of attendance, a brochure/flier and/or the conference handout. Each attendee at an activity is responsible for determining whether an activity meets their requirements for acceptable continuing education and should only claim those credits that he/she actually spent in the activity. Maintaining these details are the responsibility of the individual. PLEASE SAVE A COPY OF THIS FLIER AS YOUR CERTIFICATE OF ATTENDANCE. Signature: My signature verifies that I have attended the above stated number of hours of the CME activity. Allina Health - Learning & Development Chicago Ave - MR Minneapolis MN of 23

4 MINIMALLY INVASIVE MITRAL VALVE SURGERY: Is it necessary? Bassam Shukrallah, MD Outline Benefits/drawbacks Indications/contraindications Review results, morbidity, mortality, QOL Building a program 4 of 23

5 Vanderbilt Michael Petracek, MD Mini-mitral with cold fib. arrest AATS 2014 Toronto Patrick McCarthy, MD In Defense of The Sternotomy We no long perform open Nissen fundoplication. Our trainees are trained in laparoscopic NF, why are we not capable of doing the same in cardiac surgery? 40 right single lung transplant 27 mini-hvad Began considering Mini-mitral valve surgery 5 of 23

6 MHIF CV Grand Rounds Feb 18, 2019 Right lung transplant Mini-HVAD 6 of 23

7 Endocarditis 20 mini-mitral valve replacement (5 combined with tricuspid valve replacement) Traditional Approach for MVR/r Sternotomy Cardiopulmonary bypass Arrested heart 7 of 23

8 Traditional Approach for MVR/r Advantages Comfort Provides full access Provides ideal operating conditions Allows surgical team full control of circulation and oxygenation Disadvantages Pain Increased blood loss Prolonged healing time (2-3 months) Sternal wound complications Cosmesis Minimally Invasive approach Advantages Cosmesis Less pain Less blood loss More rapid healing (2-4 weeks) Minimization/avoidance of sternal wound complications Shortened postop ICU and total hospital length of stay More cost-effective (?) Disadvantages Technically demanding Not appropriate for every surgical team Not appropriate for every patient Expensive technology 8 of 23

9 Alternative approach Three approaches APPROACH Right thoracotomy Partial sternotomy Robot AORTA Cross-clamp or no cross-clamp. (arrest or fibrillate) Tool or approach? 9 of 23

10 Minimally Invasive approach Same Operation as with Sternotomy Same durability Same results Different Technologies (different tools) Thoracoscopic Robotic Direct Vision Who s Eligible All valve patients are potential candidates Relative contra-indications Other cardiac pathology e.g. CAD Peripheral vascular disease Body habitus Extreme obesity Severe pectus excavatum Previous thoracic surgery 10 of 23

11 Demystifying Mitral Valve Repair 95% of degenerative MVD can repaired utilizing 5 techniques 1.Triangular resection- posterior leaflet 2. Sliding repair- posterior leaflet 3. Artificial chords- anterior leaflet 4. Closure of commissures 5. Annuloplasty- all patients 11 of 23

12 MHIF CV Grand Rounds Feb 18, of 23

13 MHIF CV Grand Rounds Feb 18, 2019 NO difference in mortality between conventional vs. minimally invasive approach Despite MIVS having increased CPB times, there was NO difference in mortality. 13 of 23

14 Survival at 1,3,5 years: Mini 98,97,95% Conv 97,91,86% Neurologic events Risk of stoke 2.1 vs. 1.2 % (95% CI , RR 1.79) Subanalysis 3 fold increase without aortic occlusion Grossi et al Retrograde perfusion in elderly, PVD, and EF <30%, and no aortic occlusion all increased risk of stroke (each with P <0.05) Murphy et al CT screening in robot MVS 1.6% stroke 14 of 23

15 Bleeding, transfusion, reexploration Robotics Two studies no difference, but decreased CT output. Two studies reduction in all Thoracotomy and hemisternotomy 3 out of 10 studies found a decrease in all, and remaining showed no difference Atrial fibrillation 4 studies showed no difference (539 pt., OR.86, 95% CI , P =.45) Infection 3 studies 1.8% and 7.7% incidence MIVS vs. sternotomy (P <0.03) Pain and quality of live 2 studies demonstrated less pain, and analgesic use with MIVS Return to normal activity was seen at 4 weeks ahead of sternotomy 15 of 23

16 Length of stay Mean 3 day shorter Median 1 day shorter 16 of 23

17 Other benefits of alternative approaches hybrid procedures Zebra s (special/complex cases) 17 of 23

18 Ruptured mycotic aneurysm 18 of 23

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22 MHIF CV Grand Rounds Feb 18, 2019 Building a program Program Patient selection Team training- learn from established successful programs Addressing challenges Institutional support Ongoing quality improvement and results review 22 of 23

23 Final Thoughts Minimally invasive mitral valve surgery is a safe and viable alternative to sternotomy Same surgery, different cut Alternative approaches in cardiac surgery expand the spectrum of disease treated (hybrid procedures) We can and should build a program! THANK YOU 23 of 23