16.03.2013 by Dr. M. D. Dixit MS (Gen. Surg.), DNB (CVTS), PhD Professor & HOD, CVTS Director, KLES Heart Foundation, KLES Dr. Prabhakar Kore Hospital & MRC, Belgaum
Standard AVR Full Sternotomy CPB
Mini Sternotomies Minimal Invasive AVR Mini Thoracotomies
Partial sternotomy Para-sternal incision (Cohn et al., 1997; Navia & Cosgrove 1996) Trans-sternal incision (Cohn et al., 1997) Upper sternotomy (Byrne et al., 2000) T mini-sternotomy (Stamou et al., 2003) V-shaped incision (Corbi et al., 2003) Inverted L incision (Stamou et al., 2003) Reversed L incision (Detter et al., 2002) J incision (Cohn et al., 1997; Doll et al., 2002) Reversed C incision Inverted T incision (Farhat et al., 2003) Thoracotomy Right anterior thoracotomy 2º or 3º inter-costal space (Burfeind et al., 2002) Right anterior thoracotomy 4º or 5º inter-costal space (Sharony et al., 2003) Video-assisted vision Port access (Galloway et al., 1999) Video-direct vision AESOP 3000 (Computer Motion, Goleta, CA) ( Falk et al., 1998) Da Vinci System (Intuitive Surgical, Sunnyvale, CA) (Carpentier et al., 1998) Zeus (Computer Motion, Goleta, CA) (Cohn et al., 1997)
any procedure that has not been performed with a full sternotomy and cardiopulmonary bypass support. All other procedures, on or off pump with a small incision or off pump with a full sternotomy are considered minimally invasive. -(STS National Database, 2003).
The concept of minimally invasive surgery is not limited to a specific approach, but is a philosophy in surgical treatment which aims to reduce the degree of surgical aggression- Chitwood
Fig. 1. Right anterior thoracotomy 2º Fig. 2. Reversed C incision 3º inter-costal space Fig. 3. T mini-sternotomy Fig. 4. Reversed L incision
Mini thoracotomy Peripheral Cannulation
External Defib pads. Trans-oesophageal Echo. Fast track Anaesthesia.
Helps in placing venous cannula at SVC/ RA junction. Helps in placing Retrograde cannula into coronary sinus. Assessment of air in cavities before patient weaned off CPB. Assessment of aortic wall. Assessment of valve repair / replacement.
Supra Inguinal Incision Open Seldinger Tech Left Side -
-Aortic valve -3 rd Space 82% -2 nd Space- 17% -4 th Space- 1%
Pleural adhesions Pericardial adhesions Redo Surgeries
External Clamping
Antegrade through the root. Antegrade through Coronary ostia. Retrograde.
Standard Procedure. Bioprosthetic / Metallic valve.
Difficult because of limited exposure. Use of CO2 gas throughout procedure. Early pulmonary ventilation. Use of TEE.
Less Blood Loss. Less Pain. Improved Pulmonary function. Less duration of hospital stay and improved functional recovery. Reduction of infections Cosmetic effects. Overall reduction in the cost.
Increase in operation time. Limited exposure Deairation
No definite contraindication. Not recommended. Requiring concomittant CABG. Pectus Excavatum Peripheral vascular disease. Morbid obesity. Porcelain aorta Root enlargement.
n=27 Gender : M- 20, F-7 Age - Range : 18 yrs 76 yrs (Mean 62 yrs) Diagnosis: - AS- 19, AR- 8 Cannulation Lt. - 26 cases, Rt. 1 case Cardioplegia Antegrade 21 cases Retrograde- 6 cases Valve Used- Bioprosthesis 21 cases, Metallic- 6 cases Average CPB Time : 95 mins. Average Clamp Time: 71 mins. Use of Co2 All cases Conversion to Sternotomy- 1 case
Average duration of ventilation- 6.5 hrs Average blood loss- 142 ml Average ICU stay 2.5 days Average Hospital stay- 5 days No mortality. No Infection. No Re-exploration for bleeding.
Conventional Cardiac surgery
Chronic pain Length of incision Prolonged healing time Sternal Wound complication Cosmesis not appealing
Inflammatory response Risk of stroke Risk of end organs dysfunction Bleeding Ventricular dysfunction
Reduced pain Reduced surgical trauma- Scar tissue Faster recovery time Shorter ICU stay Better cosmesis Reduced inflammatory response
Reduced surgical exposure Increase operating time Technical demanding Expensive technology Increase learning curve
Innovations in CPB Technology Special single shaft instruments Practice Practice Practice
Cannulation site and positioning Deairation Completion of repair Ventricular function
Mitral Valve Repair/ Replacement Aortic Valve Repair/ Replacement CABG Root replacement ASD/ VSD Maze procedure
Conventional Surgery Interventional Procedure