CARDIOCHIRURGIA MINI-INVASIVA: INVASIVA: efficacia per il paziente efficienza per la sanita. Dott. Davide Ricci

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1 CARDIOCHIRURGIA MINI-INVASIVA: INVASIVA: efficacia per il paziente efficienza per la sanita Dott. Davide Ricci SC Cardiochirurgia U Universita degli Studi di Torino

2 Minimally Invasive Surgical approaches Antero-lateral right minithoracotomy Mitral Valve Tricuspid Valve ASD VSD Myxoma Ministernotomy Aortic Valve Ascending Aorta Antero-lateral left minithoracotomy CABG (MIDCABG) LV aneurysm TAVI Robotic Surgery CABG Mitral Valve Tricuspid Valve ASD Myxoma

3 Antero-lateral right mini-thoracotomy

4 1996 : FIRST EXPERIENCE Schwartz DS. Minimally invasive cardiopulmonary bypass with cardioplegic arrest: a closed chest technique with equivalent myocardial protection. J Thorac Cardiovasc Surg 1996;111(3).

5 Reduce surgical trauma Minimize disruption of the chest wall Provide a safe and reproducible approach to CPB and myocardial protection Be applicable to the majority of patients and procedures Provide same safety and efficacy as conventional cardiac surgery

6 Surgeon Comfort Conventional Surgery Less Invasive Surgery Patient Comfort

7 Contraindications to the Port-Access Approach Moderate to severe aortic or peripheral atherosclerosis Small femoral vessels Ascending aorta aneurysm ( 45 mm) Moderate - severe aortic regurgitation Chest deformity - adhesions Oesophageal pathology (TEE assistance)

8 Short and long-term outcomes after minimally invasive cardiac surgery are equivalent to results achieved with sternotomy by many groups (surgeons) throughout the world

9 MINI vs ST similar mortality rates 30 days 1.2% vs 1.5% - 1 year 0.9% vs 1.3% - 3 years 0.5% vs 0.5% - 9 years 0.2% vs 0.7% Advantages Decreased bleeding Reduced transfusions Shorter ICU and hospital stay Shorter ventilation time Reduced time to return to normal activity Reduced surgical pain Better cosmesis Disadvantages Increased risk of stroke Increased risk of aortic dissection Increased ECC and aortic clamp time Groin infections/complications Cheng et al, Innov 2011;6:66-76 Falk et al, Innov 2011;6:84-103

10 Relatively longer CPB and aortic clamping time Svensson et al, JTCS. 2010;139: Cleveland Clinic

11 Svensson et al, JTCS. 2010;139: Cleveland Clinic

12 FEV1 PAIN SURVIVAL p<0.001 Svensson et al, JTCS. 2010;139: Cleveland Clinic

13 Goldstone et al, JTCS. 2013;145:748-56

14 Overall MV cohor Degenerative cohor Goldstone et al, JTCS. 2013;145:748-56

15 217 MI vs 217 ST pts ( ) Propensity matched showed no difference in morbidity and long term survival Iribarne et al, JTCS. 2011;142:

16 Hospital Costs Median ST ± 2659 $ MINI ± 1887 $ Difference 9054 ± 3302 $ *p<0.05 Iribarne et al, JTCS. 2011;142: Reduction in: Cardiac imaging p=0.004 Laboratory tests p=0.005 Nursing p=0.001 Radiology p=0.002 Higher rate of home discharge with no nursing service in the MI group p=0.01

17 MINI vs ST similar mortality rates 30 days 1.2% vs 1.5% - 1 year 0.9% vs 1.3% - 3 years 0.5% vs 0.5% - 9 years 0.2% vs 0.7% Advantages Decreased bleeding Reduced transfusions Shorter ICU and hospital stay Shorter ventilation time Reduced time to return to normal activity Reduced surgical pain Better cosmesis Disadvantages 1.2vs1.9% Increased risk of stroke Increased risk of aortic dissection Increased ECC and aortic clamp time Groin infections/complications Cheng et al, Innov 2011;6:66-76 Falk et al, Innov 2011;6:84-103

18 Need for appropriate patient and technique selection Grossi et al, JTCS. 2012;143:S68-70

19 Pre-operative aorto-iliac-femoral imaging Iliac Vessels Variations

20 External clamps Cosgrove Portaclamp

21 EndoClamp Aortic (Endodirect) Femoral (Endoreturn)

22 EndoClamp (Femoral artery cannulation) - EndoReturn -

23 EndoClamp (Direct aortic cannulation) - EndoDirect -

24 Turin MIS Port Access global experience

25 July 2005 May 2013: 629 procedures Consecutive unselected patients

26 July 2005 May 2013: 629 procedures -Myxomas -VSD

27 1st redo 122 (66%) Redo surgery: 185/629 (29.4%) 2nd redo 35 (19%) 3rd redo 24 (13%) 4th redo 4 (2%) 63 (34 %)

28 ,1 22,2 Elective Urgency Emergency ,9 10 7,9 5,5 11,0 5,6 10 6,7 8,6 4.9% 5 3, operation redo overall 0 Prior CAB Prior Valve Prior other cardiac Ricci et al, EJCTS. 2010;37:920-7

29 1178 pts ( ) Mortality: 0.8% isolated MVP 3.9% isolated MVR Modi et al, JTCS. 2009;137: MIS is effective and safe and provides as durable results as traditional surgery it should be the technique of choice in REDO

30 Conversion to sternotomy 11 cases (1.7%) EndoDirect: 59/618 cases (9.4%) EndoReturn: 397/618 cases (64.2%) Transthoracic : 134/618 cases (22.1%) Beating heart: 28/618 cases (4.3%)

31 Overall MV surgeries: 546/618 (88.3%) Mean ± SD Median ECC (min) ± Aortic clamp (min) 76.1 ± ICU stay (gg) 2.9 ± Ventilation (h) 33.5 ± Reop. for bleeding (%) (n) 5.1 % (28/546) Drainage blood loss (cc) 439 ± Hospital stay (gg) 11.5 ± Mortality (%) (n) 1.8% 10/546 Operative mortality 0%

32 p=ns p=ns Seeburger et al, EJCTS. 2009;36:532-38

33 Overall MV surgeries: 546/618 (88.3%) Degenerative MV: 274/546 (50.1%) MV repair: 240/260 (92.3%) - MV replacement 34/274 (12.4%) Previous MV repair 14/274

34 Actuarial survival rates 97,4% 94,9% P=NS 98,2% 94,9% P=NS

35 Complications of femoral artery cannulation (Endoreturn+Transthoracic+Peripheral cann) Requiring additional incision dehiscience/infection lymphocele Retrograde aortic dissection Femoral/Iliac artery dissection/perforation/thrombosis

36 Complications of direct aortic cannulation (Endodirect) 2/59 (3.3%) Posterior aortic wall perforation 1 Purse-string laceration requiring side-biting aortic clamping and repair 1

37 Aortic dissection 0.35%

38 Conversion to sternotomy 11 cases (1.7%) EndoDirect: 59/618 cases (9.4%) EndoReturn: 397/618 cases (64.2%) Transthoracic : 134/618 cases (22.1%) Beating heart: 28/618 cases (4.3%)

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42 64 consecutive unselected pts Mean log euroscore 11.6±11.7 mm Mean TV annulus diameter 45.7±7.2 mm Ricci et al, JTCS [Epub ahead of print]

43 TV repair 2.8% TV replac. 13.8% STS database mortality for standard sternotomy 11 69% 0% Groin wound infections 0% Femoral artery complications Ricci et al, JTCS [Epub ahead of print] 5-year freedom from reoperation 100%

44 14 consecutive unselected pts ( ) Minimally invasive video-assisted surgery for left atrial myxoma resection is a safe, reproducible and cosmetic operation and can be considered an effective oncologic approach as an alternative to standard sternotomy. Vistarini et al, ICTS. 2010;10:9-11

45 Ministernotomy Aortic Valve Ascending Aorta

46 26 studies (4586 pts; 2054 MINI 2532 FULL) Ventilation time Blood loss Brown et al, JTCS 2009;137:670-9

47 ICU stay Hospital stay Brown et al, JTCS 2009;137:670-9

48 Post-op Pain 30-day Mortality Brown et al, JTCS 2009;137:670-9

49 Glauber et al, JTCS. 2013;145:1222-6

50 Mini-invasive aortic valve surgery Turin experience /325 (28.3%)

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52 PARTNER B TAVI vs medical treat. PARTNER A TAVI vs ST procedure

53 May May TF 168 TAVI 45 TA 35 ES 88 CV

54 PARTNER B TAVI vs medical treat.

55 PARTNER A TAVI vs ST procedure

56 334 SV vs 150 DV ( ) Bonatti et al, JTCS 2012;144:1061-6

57 ROBOTIC CARDIAC SURGERY Globally safe and reproducible techniques with good early, mid and long term results but still few data. Technique not widely diffused few centers TECAB Meet standards of open CABG for SV Equivalent results respect to MIDCAB in single vessel lesions Now good results for double vessel lesions (few cases) MV Consistent data Repair for all categories of leaflet prolapse Fast recovery No difference respect minithoracotomy NOT superior to mini-thoracotomy

58 CONCLUSIONS Same or even better safety and efficacy respect to standard technique

59 CONCLUSIONS Need for learning curve with consulting and proctoring Need for Heart team with daily collaboration between Cardiac Surgeons Cardiologists Anesthesiologists Perfusionists and Nurses Need for appropriate patient/technique selection We must tailor the operation to the patient and not the patient to the operation Denton A. Cooley

60 Grazie per l attenzione