Minimally Invasive Aortic Surgery With Emphasis On Technical Aspects, Extracorporeal Circulation Management And Cardioplegic Techniques

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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

LANKENAU HEART INSTITUTE Minimally Invasive Aortic Surgery It makes sense

Minimally Invasive Valve/ Root Surgery- Strategy Approach Instruments Cannulation Cardioplegia Knot tying

MIS Aortic Valve and Root Surgery 6 cm incision Sternal notch to 3d or 4th intercostal space J-type or T-type

Cannulation Strategy Ascending Aorta/Arch (Seldinger Technique) Superior Vena Cava via the Right Femoral Vein (Seldinger Technique)

CPB Strategy Minimize CPB circuit Y the venous line Avoid Hemodilution RAP Hemofiltration after Custodiol administration

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

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

Cor-Knot Cor-Knot (automated suturing device) Fast Uniformly pressured sutures Precise

Instruments 1. Vascular hook 2. MIS Needleholder 3. MIS Forceps 4. Knot Pusher 5. Crochet Hook 6. Heartport Fehling Resano Forcep 1 2 3 4 5 6

Aortic Valve Replacement

LANKENAU HEART INSTITUTE Case Presentation 83 yo male SOB Severe Aortic Regurgitation

LANKENAU HEART INSTITUTE Operation Mini AVR

Discharge Intubation Time 10 Hours ICU Days 2 Days Hospital Stay 5 Days

LANKENAU HEART INSTITUTE

Case Presentation AVR/MVR 86 yo male Severe AV Regurgitation Severe MV Regurgitation

Procedure Minimally invasive approach AVR MVR

Discharge Report Length of hospital stay: 7 days No complications

Mini AVR N=168 Years : 2010-2015 FT Group (n=56) Cor-Knot HTK cardioplegia Non-FT Group (n=112) blood cardioplegia hand tying

Demographics FT Group Non-FT Group Males 33 59% 55 49.1% Mean Age* 70.5 (±10.7) 73.5 (±9.47) *p<0.05

Diagnosis FT Group Non-FT Group Aortic Stenosis 55 98.2% 105 93.7% Aortic Insufficiency 54 45.5% 31 69.6%

Demographics FT Group Non-FT Group NYHA class 3-4 23 44% 40 35% Hypertension 52 92.9% 89 79.5% Diabetes 13 23.2% 27 24.1% Hypercholesterolemia * 50 89.3% 82 73.2% CVA 3 5% 9 8% Mean Creatinine 1.1±0.4 1.1±0.5 *p<0.05

Intraoperative Data FT Group Non-FT Group Pump Time* 107.02±22.69 114.77±27.61 Cross Clamp Time* 82.18±18.25 88.11±19.73 *P<0.05

Outcomes FT Group Non-FT Group Mortality 1 1.79% 3 2.68% Stroke 1 1.79% 2 1.79% New onset RI 1 1.9% 6 5.36% RI- Renal Insufficiency

Outcomes FT Group Non-FT Group Intubation Time* 1±1.1 days 2.26± 9.37days Atrial fibrillation 18 32.14% 39 34.82% *(p<0.05)

Ejection Fraction Mean Follow-up TTE: 103.4±205 days Custodiol Blood Preoperative Ejection Fraction 61±8.8 60.39±10.42 Postoperative Ejection Fraction 60.7±9.3 61.7±10.75

Early Follow-up FT Group Non-FT Group Paravalvular leak*: 0 5 4.5% 2 mild 2 moderate 1 severe *(p<0.05)

Conclusion Facilitating technologies Simplify the MIAVR Do not affect outcomes Decrease the hospital stay Decrease incidence of early paravalvular leak rates

AAA Replacement

LANKENAU HEART INSTITUTE Case Presentation 31 yo female Asymptomatic Severe AI Bicuspid AV Ascending aortic aneurysm

Minimally Invasive Procedure Ascending aortic replacement Aortic valve repair Insertion of CardioCel in RCC of conjoint leaflet Subcomissural annuloplasty STJ adjustment (to 24mm)

Elective Ascending Aortic Repair Outcomes 2000-2015 Mini Full n = 58 n = 251 Age 60.0 ± 11.0 65 ± 12.0 Males 17 60% 159 64%

Concomitant Procedures Sternotomy Mini Full AV Repair 10 (18%) 34 (14%) AV Replacement 28 (50%) 114 (44%)

Etiology Sternotomy Mini Full Chronic Dissection 0 0% 20 8% Medial Degeneration 40 69% 131 453% Marfan 2 3.5% 5 2% Bicuspid AV 26 45% 52 21%

Comorbidities Sternotomy Mini Full Hypertension 38 70% 190 76% Diabetes 6 10% 24 10% COPD 2 3% 35 14% Renal Insufficiency 2 3% 15 6% Redo 6 10% 29 11%

Operative times Sternotomy Mini Full Pump time* 110 ± 24 152 ± 50 Cross Clamp time* 81 ± 25 115 ± 45 *P<0.05

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%

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

Blood Utilization Sternotomy Mini Full PRBC Units* 0.4 ± 0.9 1.7 ± 2.6 FFP Units 0.6 ± 1.1 1 ± 1.7 Platelets Units 0.6 ± 0.7 0.9 ± 1.4 Cryoprecipitate Units 0.4 ± 1.0 1.4 ± 7 *P<0.05

Hospital stay Sternotomy Mini Full ICU days* 3.2 ± 1.6 5 ± 5.4 Hospital stay days 6.6 ± 1.6 10 ± 14

Aortic Root Reconstruction

LANKENAU HEART INSTITUTE Aortic Root Repair Root Aneurysm Bentall procedure David procedure

LANKENAU HEART INSTITUTE Case Presentation Bentall Procedure 57 yo male Root and Ascending Aortic Aneurysm Moderate AR

LANKENAU HEART INSTITUTE Operation Mini-sternotomy Bentall Procedure Button technique

LANKENAU HEART INSTITUTE

Follow up- 2 weeks

Case Presentation David Procedure 34 yo male Asymptomatic

Preoperative diagnosis Root Dilation Ascending Aorta Dilatation

Operation Mini David Procedure

LANKENAU HEART INSTITUTE

Elective Aortic Root Outcomes 2000-2015 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%)

Etiology Sternotomy Mini Full Medial Degeneration 34 85% 116 63% Bicuspid AV 14 35% 38 21% Chronic Dissection 0 0% 17 9% Marfan 0 0% 21 11%

Comorbidities Sternotomy Mini Full Hypertension 26 65% 135 73% Diabetes 2 5% 19 10% COPD 2 5% 28 15% Renal Insufficiency 0 0% 9 5. % Redo 8 20% 32 17%

Operative times Sternotomy Mini Full Pump time* 179±33 207±48 Cross Clamp time* 152±26 173±36 *P<0.05

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

Complications Sternotomy Mini Full Bleeding 0 0% 18 9% MI 0 0% 1 0.5% Afib 3 15% 42 22% Vfib 0 0 11 4.91% CHF 0 0 2 2% MI- Myocardial Infarction CHF- Congestive Heart Failure

Blood Utilization Sternotomy Mini Full PRBC* 1.0±1.6 2.4±4.5 FFP 1.3±1.3 1.7±2.4 Platelets 0.3±1.2 1.6±2.3 Cryoprecipitate 0.8±1.2 1.6±3.3

Hospital stay Sternotomy Mini Full ICU days* 3.3±2.6 4.9±5.9 Hospital stay days* 7±2.9 10.6±7.9

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

LANKENAU HEART INSTITUTE Thank you

Cardiovascular Services - 12 Month Rolling Report (Ending: December 31, 2015) 66 Volume/Outcomes 1000 900 891 10,00% 9,00% 800 681 8,00% 700 600 589 7,00% 6,00% 500 400 513 555 5,00% 4,00% Volume Mortality 300 200 100 3,12% 2,70% 1,87% 3,08% 1.70% 3,00% 2,00% 1,00% 0 2011 2012 2013 2014 2015 0,00%

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