MINIMALLY
INVASIVE VALVE
SURGERY
HOW FAR WE HAVE COME

THE MORTALITY FOR VALVE
REPLACEMENT SURGERY IN
1968 WAS 42%
WHY MINIMALLY INVASIVE
VALVE SURGERY?









SMALLER INCISION/SCAR
LESS PAIN
EARLIER MOBILIZATION
EARLIER RETURN TO
LIFESTYLE/WORK
LESS TRAUMATIC
LOWER INFECTION RATE
LESS BLEEDING
SHORTER LENGTH OF STAY
SAFER REOPERATION
PATIENT DEMAND
GOALS



SMALL INCISION
GOOD EXPOSURE
IDENTICAL QUALITY TO FULL OPEN
PROCEDURES




IDENTICAL MITRAL VALVE REPAIR RATE
SIMILAR COSTS
SIMILAR OPERATING/BYPASS TIME
ABILITY TO GET OUT OF TROUBLE


“…cardiologists are strongly
encouraged to refer patients who are
candidates for complex MV repair to
surgical centers experienced in
performing MV repair.”
“Surgery for asymptomatic patients
with severe MR and normal LV
function should only be considered if
there is a greater than 90%
likelihood of successful valve repair
in a center experienced in this
procedure.”

“MV repair should be able to be
achieved by experienced
surgeons for the majority of
patients with degenerative MV
disease and ischemic valve
disease, and patients should be
referred to surgeons expert in
repair.”
APPROACHES
PARASTERNAL

ADVANTAGES


GOOD ACCESS TO THE AORTIC
VALVE
DISADVANTAGES

CHEST WALL HERNIA CAN RESULT
LOWER STERNAL

ADVANTAGES


GOOD EXPOSURE FOR THE MITRAL
VALVE
EXCISION CAN BE EXTENDED IF
NECESSARY
TRANSECTING STERNAL

ADVANTAGES


EXCELLENT EXPOSURE OF THE
AORTIC VALVE AND GREAT
VESSELS
DISADVANTAGES


BREASTBONE INSTABILITY
LOSS OF INTERNAL MAMMARY
ARTERIES FOR FUTURE USE
PORT ACCESS

ADVANTAGES


TINY INCISIONS
DISADVANTAGES





GREATLY INCREASED OPERATIVE TIME
AND OPERATING ROOM TIME
MULTIPLE DEVICE INSERTIONS
ENDOVASCULAR AORTIC CLAMP HAS
RESULTED IN TORN AORTAS
MORE DIFFICULTY IN ACHIEVING VALVE
REPAIRS
SOMEWHAT HIGHER MORTALITY

ADVANTAGES



LOTS OF TINY INCISIONS
SOUNDS EXCITING
DISADVANTAGES


GREATLY LONGER OPERATIVE TIME
AND OPERATING ROOM TIME
MAY USE ENDOVASCULAR AORTIC
CLAMP WITH INCREASED RISK OF
TORN AORTA





GENERALLY RESTRICTED TO THE
MITRAL VALVE
LOWER MITRAL VALVE REPAIR
RATE
HIGHER REOPERATION RATE FOR
VALVE REPAIR FAILURE
HIGHER MORTALITY
HIGHER COSTS

REPLACEMENT OF ROBOTIC
INSTRUMENTS

IN THE INITIAL FDA STUDY,
65% OF PATIENTS WERE
EXCLUDED
RIGHT THORACOTOMY

ADVANTAGES



EXCELLENT RESULTS ACHIEVED BY
SOME SURGEONS
PATIENT PREFERENCE
DISADVANTAGES



GENERALLY RESTRICTED TO THE
MITRAL VALVE
LONG INSTRUMENTS REQUIRED
CANNOT EXTEND INCISION
UPPER STERNOTOMY

ADVANTAGES







ALL VALVES CAN BE ACCESSED WITH
EXCELLENT EXPOSURE, AS WELL AS AORTIC
PATHOLOGY
STANDARD INSTRUMENTS
SHORTER OPERATIVE TIME
STANDARD AORTIC CLAMPING
EXCELLENT HEALING WITH NO INSTABILITY
CAN EXTEND INCISION IF NECESSARY
DISADVANTAGES


IRREGULAR HEART RHYTHMS WITH MITRAL
PROCEDURES
?NOT AS EXCITING AS ROBBY THE ROBOT
HOW WE DO IT


6-8 CM MIDLINE INCISION
BEGINNING 6 CM BELOW THE
NECK
STERNUM IS DIVIDED FROM
THE STERNAL NOTCH INTO THE
FOURTH INTERCOSTAL SPACE


TO THE RIGHT FOR AORTIC
PROCEDURES
TO THE LEFT FOR MITRAL VALVE
AND COMBINED PROCEDURES


AORTA IS OPENED IN THE
STANDARD FASHION
THE RIGHT ATRIUM IS OPENED
TO APPROACH THE MITRAL
VALVE
CONTRAINDICATONS




MORBID OBESITY
REOPERATIONS
PECTUS EXCAVATUM
NEED FOR ASSOCIATED
PROCEDURES

CAN REVASCULARIZE THE RIGHT
CORONARY ARTERY
PROCEDURES AT LRMC

AVERAGE AGE 70



(AVERAGE AGE AT CLEVELAND
CLINIC 55)
HAVE PERFORMED ALL
COMBINATIONS OF VALVE
REPAIRS AND REPLACEMENTS
NOW PERFOMING THE MAZE
PROCEDURE FOR ATRIAL
FIBRILLATION

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AORTIC VALVE REPLACEMENT
MITRAL VALVE REPAIR
MITRAL VALVE REPLACEMENT
AORTIC VALVE
REPLACEMENT/MITRAL VALVE
REPAIR
MITRAL VALVE REPAIR/TRICUSPID
VALVE REPAIR
AORTIC VALVE
REPLACEMENT/MITRAL VALVE
REPAIR/TRICUSPID VALVE REPAIR



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
AORTIC VALVE REPLACEMENT/ROOT
REPLACEMENT
RESECTION/GRAFTING ASCENDING
AORTIC/ARCH ANEURYSMS
AORTIC VALVE
REPLACEMENT/CORONARY ARTERY
BYPASS GRAFTING
LEFT ATRIAL MYXOMA
MITRAL VALVE REPAIR/MAZE
PROCEDURE