Minimally Invasive Aortic Surgery With Emphasis On Technical Aspects, Extracorporeal Circulation Management And Cardioplegic Techniques
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1 Minimally Invasive Aortic Surgery With Emphasis On Technical Aspects, Extracorporeal Circulation Management And Cardioplegic Techniques Konstadinos A Plestis, MD System Chief of Cardiothoracic and Vascular Surgery Professor Thomas Jefferson University Main Line Health
2 LANKENAU HEART INSTITUTE Minimally Invasive Aortic Surgery It makes sense
3 Minimally Invasive Valve/ Root Surgery- Strategy Approach Instruments Cannulation Cardioplegia Knot tying
4 MIS Aortic Valve and Root Surgery 6 cm incision Sternal notch to 3d or 4th intercostal space J-type or T-type
5 Cannulation Strategy Ascending Aorta/Arch (Seldinger Technique) Superior Vena Cava via the Right Femoral Vein (Seldinger Technique)
6 CPB Strategy Minimize CPB circuit Y the venous line Avoid Hemodilution RAP Hemofiltration after Custodiol administration
7 Custodiol Cardioplegia Solution (HTK solution) Low sodium inhibits rapid phase of action potential arrests the heart Histidine Tryptophan Ketogluterate Mannitol buffering capacity protects cell membrane stabilizes the cell membrane provides ATP during reperfusion reduces cellular edema
8 MIS Aortic Valve and Root Surgery: No Aortic valve insufficiency: 2 liter single dose Directly in the aortic root Aortic valve insufficiency Delivery strategy Initial dose in the root until heart arrests TEE to assess LV dilation Remaining custodial directly in the coronary ostia Retrograde administration
9 Cor-Knot Cor-Knot (automated suturing device) Fast Uniformly pressured sutures Precise
10 Instruments 1. Vascular hook 2. MIS Needleholder 3. MIS Forceps 4. Knot Pusher 5. Crochet Hook 6. Heartport Fehling Resano Forcep
11 Aortic Valve Replacement
12 LANKENAU HEART INSTITUTE Case Presentation 83 yo male SOB Severe Aortic Regurgitation
13 LANKENAU HEART INSTITUTE Operation Mini AVR
14
15 Discharge Intubation Time 10 Hours ICU Days 2 Days Hospital Stay 5 Days
16 LANKENAU HEART INSTITUTE
17 Case Presentation AVR/MVR 86 yo male Severe AV Regurgitation Severe MV Regurgitation
18 Procedure Minimally invasive approach AVR MVR
19
20 Discharge Report Length of hospital stay: 7 days No complications
21
22 Mini AVR N=168 Years : FT Group (n=56) Cor-Knot HTK cardioplegia Non-FT Group (n=112) blood cardioplegia hand tying
23 Demographics FT Group Non-FT Group Males 33 59% % Mean Age* 70.5 (±10.7) 73.5 (±9.47) *p<0.05
24 Diagnosis FT Group Non-FT Group Aortic Stenosis % % Aortic Insufficiency % %
25 Demographics FT Group Non-FT Group NYHA class % 40 35% Hypertension % % Diabetes % % Hypercholesterolemia * % % CVA 3 5% 9 8% Mean Creatinine 1.1± ±0.5 *p<0.05
26 Intraoperative Data FT Group Non-FT Group Pump Time* ± ±27.61 Cross Clamp Time* 82.18± ±19.73 *P<0.05
27 Outcomes FT Group Non-FT Group Mortality % % Stroke % % New onset RI 1 1.9% % RI- Renal Insufficiency
28 Outcomes FT Group Non-FT Group Intubation Time* 1±1.1 days 2.26± 9.37days Atrial fibrillation % % *(p<0.05)
29 Ejection Fraction Mean Follow-up TTE: 103.4±205 days Custodiol Blood Preoperative Ejection Fraction 61± ±10.42 Postoperative Ejection Fraction 60.7± ±10.75
30 Early Follow-up FT Group Non-FT Group Paravalvular leak*: % 2 mild 2 moderate 1 severe *(p<0.05)
31 Conclusion Facilitating technologies Simplify the MIAVR Do not affect outcomes Decrease the hospital stay Decrease incidence of early paravalvular leak rates
32 AAA Replacement
33 LANKENAU HEART INSTITUTE Case Presentation 31 yo female Asymptomatic Severe AI Bicuspid AV Ascending aortic aneurysm
34 Minimally Invasive Procedure Ascending aortic replacement Aortic valve repair Insertion of CardioCel in RCC of conjoint leaflet Subcomissural annuloplasty STJ adjustment (to 24mm)
35
36 Elective Ascending Aortic Repair Outcomes Mini Full n = 58 n = 251 Age 60.0 ± ± 12.0 Males 17 60% %
37 Concomitant Procedures Sternotomy Mini Full AV Repair 10 (18%) 34 (14%) AV Replacement 28 (50%) 114 (44%)
38 Etiology Sternotomy Mini Full Chronic Dissection 0 0% 20 8% Medial Degeneration 40 69% % Marfan 2 3.5% 5 2% Bicuspid AV 26 45% 52 21%
39 Comorbidities Sternotomy Mini Full Hypertension 38 70% % Diabetes 6 10% 24 10% COPD 2 3% 35 14% Renal Insufficiency 2 3% 15 6% Redo 6 10% 29 11%
40 Operative times Sternotomy Mini Full Pump time* 110 ± ± 50 Cross Clamp time* 81 ± ± 45 *P<0.05
41 Complications Sternotomy Mini Full Death 0 0% 2 0.7% Stroke 0 0% 7 3% New RI 0 0% 4 1% PVS* 4 3% 22 9% Bleeding* 0 0% 15 6%
42 Complications Sternotomy Mini Full CHF 0 0% 14 6% Afib 6 21% 62 24% Vfib 0 0% 7 3% MI 0 0% 1 0.3% MI- Myocardial Infarction CHF- Congestive Heart Failure
43 Blood Utilization Sternotomy Mini Full PRBC Units* 0.4 ± ± 2.6 FFP Units 0.6 ± ± 1.7 Platelets Units 0.6 ± ± 1.4 Cryoprecipitate Units 0.4 ± ± 7 *P<0.05
44 Hospital stay Sternotomy Mini Full ICU days* 3.2 ± ± 5.4 Hospital stay days 6.6 ± ± 14
45 Aortic Root Reconstruction
46 LANKENAU HEART INSTITUTE Aortic Root Repair Root Aneurysm Bentall procedure David procedure
47 LANKENAU HEART INSTITUTE Case Presentation Bentall Procedure 57 yo male Root and Ascending Aortic Aneurysm Moderate AR
48 LANKENAU HEART INSTITUTE Operation Mini-sternotomy Bentall Procedure Button technique
49 LANKENAU HEART INSTITUTE
50 Follow up- 2 weeks
51
52 Case Presentation David Procedure 34 yo male Asymptomatic
53 Preoperative diagnosis Root Dilation Ascending Aorta Dilatation
54 Operation Mini David Procedure
55 LANKENAU HEART INSTITUTE
56 Elective Aortic Root Outcomes Mini Sternotomy Full n=40 David = 6 Bentall = 34 n=217 David = 37 Bentall = 187 Age 58±12 57±14 Males 17 (85%) 149 (80%)
57 Etiology Sternotomy Mini Full Medial Degeneration 34 85% % Bicuspid AV 14 35% 38 21% Chronic Dissection 0 0% 17 9% Marfan 0 0% 21 11%
58 Comorbidities Sternotomy Mini Full Hypertension 26 65% % Diabetes 2 5% 19 10% COPD 2 5% 28 15% Renal Insufficiency 0 0% 9 5. % Redo 8 20% 32 17%
59 Operative times Sternotomy Mini Full Pump time* 179±33 207±48 Cross Clamp time* 152±26 173±36 *P<0.05
60 Complications Mini Sternotomy Full Death 0 0% 2 1% Stroke 0 0% 0 0% New RI 0 0% 4 2% PVS* 1 5% 22 11% PVS-Prolonged Ventilatory Support RI- Renal Insufficiency
61 Complications Sternotomy Mini Full Bleeding 0 0% 18 9% MI 0 0% 1 0.5% Afib 3 15% 42 22% Vfib % CHF % MI- Myocardial Infarction CHF- Congestive Heart Failure
62 Blood Utilization Sternotomy Mini Full PRBC* 1.0± ±4.5 FFP 1.3± ±2.4 Platelets 0.3± ±2.3 Cryoprecipitate 0.8± ±3.3
63 Hospital stay Sternotomy Mini Full ICU days* 3.3± ±5.9 Hospital stay days* 7± ±7.9
64 Conclusion Minimally invasive aortic surgery with facilitating technologies Does not affect mortality Decreases X clamp and bypass times Decreases blood utilization Decreases ICU and hospital stay
65 LANKENAU HEART INSTITUTE Thank you
66 Cardiovascular Services - 12 Month Rolling Report (Ending: December 31, 2015) 66 Volume/Outcomes ,00% 9,00% ,00% ,00% 6,00% ,00% 4,00% Volume Mortality ,12% 2,70% 1,87% 3,08% 1.70% 3,00% 2,00% 1,00% ,00%
67
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