miami minimally invasive valves

Can you figure out what this is?

Miami Minimally Invasive Valves — Sat, 18 May 2013 22:45:43 +0000

Obese Patients Benefit from Minimally Invasive Valve Surgery

Miami Minimally Invasive Valves — Sat, 18 May 2013 15:38:14 +0000

I constantly hear that obese patients are not candidates for Minimally Invasive Surgery. I truly believe that these are the ones that benefit the most. They ambulate sooner due to improved chest wall stability. Physical therapy as well as pulmonary toilet is facilitated. In addition, the risk of sternal complications does not exist. I also have heard that the CT scan is essential in determining who is a candidate for a minimally invasive AVR. This is NOT true. I have enclosed a CT scan on a patient that I recently operated upon.( I do not order CT scans, but since she was being evaluated for a TAVR, it was performed). As you can clearly see, her aorta on the the left side of the chest. Some would say that this is a contraindication. Some even draw a line from the mid portion of the sternum and trace it back to the spine. If the aorta is to the left, then this is an exclusion criteria for a mini AVR. This is absolutely WRONG!!! In my experience, if the heart is further away from the chest wall, the visualization will be better. I have operated on many very obese patients, and the surgery has been easier than in some very slender patients.

This is an 83 y/o very obese ,wheelchair bound, O2 dependent female with multiple hematologic problems (which excluded her from being Corevalve candidate) as well as pulmonary issues and an IVC filter which was crossed with the 25 Fr. Biomedicus venous cannula. (FYI, I have been able to cross all but one of 12 Vena cava filters!) who have critical AS.

Minimally Invasive MVRepair, P2 Folding-plasty

Miami Minimally Invasive Valves — Sun, 14 Apr 2013 18:57:00 +0000

I have posted a 5 minute video of a minimally invasive MVRepair utilizing a folding-plasty. I truly believe that we need a “toolbox” of techniques to be able to repair valves. Not all valves are created equally. I personally perform 600 minimally invasive valve procedures a year and half of these are mitral valve operations. I can truly say that there is NOT one universal way to repair all valves because all valves are not created equally. In addition, not all valves can be, or should be repaired. The technique in this video demonstrates an alternative to a triangular or quadrangular resection of P2. The prolapsed P2 segment is inverted and the rolled edges are approximated. It is important to have primary chordae on either side of the rolled edges. At times, when the leaflet appears very redundant, I have also added one chordae and usually anchor it to the PM papillary muscle.

Axillary Cannulation, the next best option

Miami Minimally Invasive Valves — Thu, 21 Mar 2013 03:21:40 +0000

This is my approach to axillary cannulation. Once you watch the video you can convince yourself that you don’t need to add a side branch/graft to the axillary artery. I have used a Seldinger technique to cannulate the axillary artery but as you can see from the video, you do need to exert a little bit of pressure to pass the cannula. The axillary artery is more elastic and doesn’t allow passage of the cannula as freely as the femoral artery. With this in mind, as well as having to repair several arteries, I have been going to a more direct approach. This means that I obtain both proximal and distal control of the vessel, perform and arteriotomy, then directly cannulate the artery. I will pre-load a wire in the cannula so that once I introduce the cannula, I pass the wire into the artery, preferably with flouro guidance and thereafter, I will advance the cannula. I will almost always obtain an angio at this point. I have a few tricks to pass the wire if it becomes difficult to advance. I will follow up with another blog post with this trick. Remember, keep your tool box full !!!!

Femoral Cannulation, Is CT Angio necessary?

Miami Minimally Invasive Valves — Thu, 21 Mar 2013 00:33:48 +0000

I have enclosed a you tube video link to my technique for femoral cannulation.

If femoral cannulation is not possible, my second choice would be axillary.

I am constantly asked if a CT angio is absolutely required to perform these cases. The answer is NO,NO,and NO.

I know there will be those that will consider this crazy, not “by the book”, or even unethical. I am not saying that it should not be performed, but I have not found it necessary in over 2,000 cases!!! If I suspect severe PVD, then I might consider it. Where has it been “written is stone” that it must be performed before any minimally invasive case? If one utilizes an endo-balloon or performs a TAVR via a femoral platform, then it is necessary. The main reason is because a device is being passed and scraped along the vessel walls and can dislodge mobile plaque. Although, despite even when there is plaque within the aorta, these devices are used.

My question to those that question why not do a CT angio on everyone would be, 1.what will you do with the findings? 2. how do you interpret the findings to guide your operative strategy? 3. How do you really know that the findings are really dangerous and contraindicate cannulation?

I have performed over 2000 cases with this approach and my incidence of stroke is less than 1.5% for all risk groups. I truly believe that the stroke risk is not related to the cannulation technique, but more so to inadequate de-airing or particulate matter in the heart or from aortic cross clamping. We will be publishing our results soon.

Redo Mini AVR

Miami Minimally Invasive Valves — Sun, 17 Mar 2013 21:28:51 +0000

Most Redo AVR are still being performed via a sternotomy. The next most common approach is a mini-upper sternotomy. This approach is probably better than a full sternotomy because I believe that the sternum is the major source of post operative bleeding. Few have ventured into performing this operation through a mini- thoracotomy approach. One reason is lack of familiarity of the operative field and anatomy from a more lateral access site. Once experience is gained performing a mini-thoracotomy AVR , one should attempt a redo mini- AVR with this technique. Despite being a technically more challenging operation because of adhesions, the post operative benefits are enormous. I consistently see that this subset of patients (redo AVR’s) have the best post operative course. I am constantly amazed to see this. I have performed 4 redo mini- AVR’s this week with the average age being 85 years old, average EF was 40 % , one was 87 years old and was a 3rd time redo, and one had a 20 % EF and severe MR and required a trans-aortic Alfieri stitch. BTW, all are doing well. The 3rd time redo was discharged on post op day 4.

I have enclosed a few pictures of the 3rd time redo. I initially begin by entering the chest and dissecting adhesions of the lung to the heart. Once I identify the region of the right atrial appendage, I will place a purse string suture and insert a retrograde CP cannula. Most of the time I do this prior to going on CPB. Once on bypass, I will identify the RSPV and place an LV vent. Usually the greater curvature of the aorta has few or no adhesions. On the other had, the anterior aspect of the aorta requires careful dissection. I will usually drop the flow of the pump and pull down the aorta while my assistant uses a retractor to elevate the sternum. Dropping the flows really facilitates the dissection. Care is taken to identifying all of the grafts. I do NOT dissect between the aorta and PA, although I will dissect the tissue on the undersurface of the aorta and develop a plane between the aorta and right branch of the PA. This is where my cross-clamp is placed. If there is a patent graft to the Right coronary system, it is crucial to dissect as much of the graft to allow it to be mobilized laterally. This will allow an aortotomy to be performed under this graft. The rest of the operation proceeds in the usual fashion. If the patient has a patent LIMA and native LAD, there will be constant blood return into the aorta from the left main. I will connect a red rubber catheter to a sump suction and drop this into the sinus or the LM. One other point is to have your anesthesiologist insert a temporary transvenous pacer pre-operatively so you don’t need to worry about placing a pacing wire.

Overall, this is a more technically challenging operation, but the bleeding is minimal and the recovery is surprisingly spectacular!!!!

Minimally Invasive Aortic Valve Replacement (VIDEO)

Miami Minimally Invasive Valves — Sat, 16 Mar 2013 19:30:49 +0000

I have enclosed a you tube link to an 8 minute video that briefly and comprehensively demonstrates my approach to Minimally Invasive AVR (“The Miami Method”).

I hope that this is informative and will help surgeons realize that this technique is important to learn due to its multiple patient benefits.

http://www.youtube.com/watch?v=HAd5oTmZVug

http://www.youtube.com/watch?v=HAd50TmZVug

Minimally Invasive Repair of Ostium Primum ASD and cleft mitral leaflet

Miami Minimally Invasive Valves — Mon, 11 Mar 2013 01:59:56 +0000

I have now been able to successfully repair every ASD via a minimally invasive approach. I utilize the same cannulation strategy as I would for a mini TVR. I will utilize a femoral platform for the arterial and venous cannulation. After entering the chest via a 5-6 cm incision (4-5th ICS, lateral to the anterior axillary line), I will institute CPB, drop the lungs, then encircle both the IVC and SVC with silastic vessel loops. Since there is an ASD, the aorta needs to be cross-clamped. The operation cannot be performed fibrillating. After arresting the heart, I pull the femoral venous cannula into the IVC and then snare both the SVC and IVC. I then open the right atrium and insert a sump suction, which has been passed via my chest tube incision, through the atriotomy and into the SVC. I then snare the SVC. With an Ostium Primum ASD, a pericardial patch needs to be placed over the defect as well as incorporating the coronary sinus. This means that the CS will now be draining into the left atrium. This is done to avoid injury to the conduction system (AV Node). I place a running suture on the septal edge of the tricuspid valve leaflet which extends over and beyond the CS. Of note, prior to this, the cleft in the anterior leaflet of the MV is repaired. I believe that it is important to approximate the natural coaptation zone of the cleft leaflet. A direct approximation of the free edges may lead to valvular insufficiency. Overzealous approximation may also lead to mitral stenosis. Mild MR is better tolerated. Enclosed are pictures of the procedure.

Mini AVR,Replacement of Ascending Aorta and Hemi-Arch (Alternative Incision)

Miami Minimally Invasive Valves — Sat, 29 Dec 2012 19:22:54 +0000

I have performed 18 combined Mini AVR + Ascending Aorta/Hemi Arch Replacements. I have utilized 2 approaches. One via the 2-3rd ICS with the incision starting at the sternum and extending laterally and the other through the 4th ICS with the incision starting lateral to the anterior axillary line and the patients arm positioned over the head. This later approach gives more visualization of the entire operative field. Keep in mind that the compromise is that the aorta and AV are further away and one needs to feel comfortable with using the long shafted instruments and suturing at a distance. I have recently adopted the same technique for suturing a proximal or distal coronary anastomosis to suturing the hemashield graft to the hemiarch. I have my assistant hold the graft across from me and I begin suturing the graft to the to the lesser curvature of the aortic arch, then run each arm of the suture towards me. It seems to be easier. I also use a double row of sutures. The proximal suture line starts at posterior aspect of the sinotubular junction. I tie the suture down and then run each limb around. I will also use a second suture for reinforcement. This one is sutured on the inside and run along the suture line from the inside. I will stop at every 2cm along the way and tie the 2 limbs, which I believe will keep the sutures from becoming loose.

I have enclosed some pictures so that you can be the judge of the exposure. Each are in sequence from the incision to the proximal graft anastomosis. Notice on picture #2 the 24 Fr. venous cannula placed into the SVC (via the CT incision) which will be utilized for retrograde cerebral perfusion during the period of circulatory arrest.

All 18 patients have done well. Average LOS has been 5 days. Stay tuned for my publication with the results!

Mini Postero-lateral Thoracotomy Off Pump Bypass to OM

Miami Minimally Invasive Valves — Sat, 22 Dec 2012 22:47:32 +0000

This is a very nice approach for a single bypass to the OM. It is optimal if there is an old SVG placed to the vessel that needs to by grafted. The patient is placed in an almost lateral thoracotomy position with the left groin exposed. I usually place a line in the left femoral vein in the event that I need to insert a venous cannula. Arterial access can be obtained directly in the descending aorta if need be. The incision is made in the lateral aspect of the chest and usually at the level of the lower aspect of the scapula. I use a soft tissue retractor as well. The descending aorta is exposed after the inferior pulmonary ligament is completely dissected free. The pericardium is opened below the phrenic nerve and retracted. The old SVG is followed until visualizing the OM. Of note, access to a high OM is not optimal via this approach. An off pump suction stabilizer is utilized to isolate the coronary. After this anastomosis is performed, a Satinsky clamp is placed on the descending aorta for the proximal anastomosis. The segment of vein is usually small and you need to let it loop down a little so that when the lung inflates, it does not place excessive tension on the graft. I also place a marker around the proximal in the event that the patient needs to be cathed, it can be easily identified. Usual LOS is 3 days in hospital.

pericardium opened and descending aorta dissected