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ICU topic discussion. Minimal invasive mitral valve surgery Ri 施廷翰 2 0081027. I. Case report. Basic data. Name: 余 O 義 Chart no. 0973107 Age: 54 years old Gender: male BH: 167 BW 56.5 Past history: Severe MR CHF NYHA Fc II to III VSD s/p repair at our hospital decades ago Old TB

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Icu topic discussion l.jpg

ICU topic discussion

Minimal invasive mitral valve surgery

Ri施廷翰

20081027



Basic data l.jpg
Basic data

  • Name: 余O義 Chart no. 0973107

  • Age: 54 years old Gender: male

  • BH: 167 BW 56.5

  • Past history:

    • Severe MR

    • CHF NYHA Fc II to III

    • VSD s/p repair at our hospital decades ago

    • Old TB

    • COPD

    • GERD


Brief history 1 l.jpg
Brief history (1)

  • 09/06 short of breath, poor intake and general malaise

  • Decreased urine output since this September

  • 09/08 敏盛 H, cardiac echo:

    • LVEF: 30%

    • Huge LA, LV with global hypokinesia of LV

    • Severe MR; malcoapation of MV with AML protruding to LA

    • Moderate pulmonary hypertension


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Brief history (2)

  • 09/12 Holter EKG: frequent VPCs

    • Chest CT: emphysema+ old TB

  • 09/15 TEE: LVEF: 45%; mod-severe MR, CHF

  • 09/15 respiratory failure intubation CCU

    • CXR: RLL pneumonia Tazocin

  • 09/17 minimally invasive access MVR with xenograft+ V-A ECMO+ IABP


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Brief history (3)

  • Post-op cardiac echo: poor LV contractility

  • 09/22 difficulty in weaning ECMO

  • 09/24 referred to our hospital



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Brief history (4)

  • Fever, leukocytosis, bilateral lung consolidation

    • Vancomycin+ Tazocin

  • 09/25 TEE: poor LV function and paravalvular leakage

  • Try weaning or re-do MVR first


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Operation (09/26)

  • Op method: redo MVR (31mm, Hancock)+ LV aneurysm exclusion (SAVER)

  • Op findings: poor heart contractility, dilated LA, LV; apical, ant, LV wall akinesia; mitral valve prosthesis paravalvular leak at ant. edge


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Post-op course

  • 9/27 Decreased U/O Diuretics

  • 10/2 off ECMO

    low urine output CVVH (clotting 10/3 am)

  • 10/3AM, hypothermia; SC hemorrhage; SLEDD-f

    I/O +3001 ml

  • 10/4 AM, non-sustained VT with hypotension DC shock, biphasic 100J

  • Bradycardia, hypotension pacemaker

  • DNR turn off pacemaker expired 13:21


  • Summary l.jpg
    Summary

    • 54 y/o man, severe MR, DCM, CHF

    • 09/06 dyspnea, decreased urine output

    • 09/17 MVR+ ECMO+ IABP

    • 09/24 difficulty in weaning ECMO  referred

    • 09/26 MVR+ LV aneurysm exclusion (SAVER procedure)

    • 10/02 remove ECMO  ARF

    • 10/04 expired


    Ii discussion l.jpg

    II. Discussion

    Minimally invasive mitral valve surgery (MIMVS)


    Slide13 l.jpg
    Goal

    • Reduced size of the incision

    • The avoidance ofa sternotomy

    • The use of a partial sternotomy or minithoracotomy

    • Lack of need for cardiopulmonary bypass


    Evolving methods l.jpg
    Evolving methods

    • Level 1 Direct vision: Mini (10- to 12-cm) incisions

    • Level 2 Video-assisted: Micro (4- to 6-cm) incisions

    • Level 3 Video-directed and robot-assisted: Micro or port incisions (1 cm)

    • Level 4 Robotic telemanipulation: Port incisions (1 cm)


    Mimvs thoracotomy l.jpg
    MIMVS-thoracotomy

    J Formos Med Assoc (2006) 105(9) 715-21


    Mimvs thoracotomy16 l.jpg
    MIMVS-thoracotomy

    J Formos Med Assoc (2006) 105(9) 715-21


    Mimvs thoracotomy17 l.jpg
    MIMVS-thoracotomy

    J Formos Med Assoc (2006) 105(9) 715-21


    Problems l.jpg
    Problems

    • Femoral cannulation – for CPB

    • Reduced access to the surgical field

    • Complexity of video assistance

    • Specialized surgical instruments


    Mimvs vs conventional mvs l.jpg
    MIMVS vs. conventional MVS

    • An prospective randomized trial

    • 40 elective patient with MV diseases

      • NYHA class III

      • Preserved LV function

    • Group I: Right small anterior thoracotomy

    • Group II: Full median sternotomy

    Dogan (2005) Ann thorac surg


    Mimvs vs conventional mvs20 l.jpg
    MIMVS vs. conventional MVS

    MIMVS

    Conventional

    Dogan (2005) Ann thorac surg


    Spain experience l.jpg
    Spain experience

    • 2003~2006

    • 100 Patient with MV diseases

    • 16-84 years old

    • Mean LVEF 65%

    • Right anterior minithoracotomy.

    Ernesto Greco, et al(2008) J Heart Valve Dis


    Spain experience22 l.jpg
    Spain experience

    Ernesto Greco, et al(2008) J Heart Valve Dis



    Taiwan experience l.jpg
    Taiwan experience

    Reoperation 2

    Kuan-Ming Chiu(2006) JFMA


    Germany experience l.jpg
    Germany experience

    • 1339 patient between 1999-2007, in Heart center, Leipzig University

    • Surgery for MR

    • Right lateral mini-thoracotomy

    • Perioperative outcome

      • Op time 165 ± 47 min.

      • CPB duration 121 ± 38 min.

      • Cross-clamp time 70 ± 32 min.

      • Incision length 5.3 ± 1.1 cm

    • Post operative course

      • Reoperation for bleeding5.1%

      • Without ICU stay 11.7%

      • Less than 24-h ICU stay 52%

      • Neurological impairment 3.1%

      • Hospital stay 12.4 ± 9.8

      • 30-d mortality 2.4%

    Joerg Seeburger, et al(2008) Eu J Cardiothoracic Surg


    Slide26 l.jpg

    Joerg Seeburger, et al(2008) Eu J Cardiothoracic Surg


    Clinical outcomes l.jpg
    Clinical outcomes

    • Lower pain levels

    • Better stability of the bony thorax

      • Earlier mobilization

      • Rapid return to daily activities

    • Similar mortality

    • Shorter intensive care unit and hospital stays

    Ernesto Greco, et al(2008) J Heart Valve Dis


    Contraindications l.jpg
    Contraindications

    • Peripheral arteriosclerosis

    • Previous right lung surgery

    • Extreme obesity

    • With tricuspid valve repair

    Ernesto Greco, et al(2008) J Heart Valve Dis


    Minimally invasive cardiac surgery l.jpg
    Minimally invasive cardiac surgery

    Helmut Fulbins, et al Expert Rev. Vardiocasc. Ther. 2(6) 2004


    Back to our case l.jpg
    Back to our case

    • Poor pre-op LV function

    • Pre-op pneumonia

    • Right thoracotomy approach

    • Complicated with post-op mitral insufficiency

    • Failed weaning ECMO and IABP

    • Re-op: redo MVR + SAVER

    • Failed weaning ECMO, ARF

    • Expired


    Take home message l.jpg
    Take home message

    • Minimally invasive surgery is a trend in all subspecialty.

    • Although development of MIS in CVS was delayed, it is under intensive survey now.

    • An incision of right thoracotomy 4~6cm is probably feasible for experienced surgeons, regarding operation time, CPB duration, clamp time, morbidity and mortality, re-op-free survival, and QOL.

    • Although no clinical thesis discussing minimally invasive technique in urgent MV surgery, MIMVS was possibly feasible too.

    • More investigations need to be done.

    • Video- and robot-assisted surgery are also a hot topic.


    Reference l.jpg
    Reference

    • Helmut Fulbins, et al. Minimally invasive heart valve surgery: already established in clinical routine? Expert Rev. Vardiocasc. Ther. 2(6) 2004

    • J. Seeburger et al. Minimal invasive mitral valve repair for mitral regurgitation: results of 1339 consecutive patients. Eu J Cardio-thoracic Surg 34 (2008) 760-5

    • Kuan-Ming Chiu, et al. Less Invasive Mitral Valve Surgery via Right Minithoracotomy J Formos Med Assoc (2006) 105(9) 715-21

    • Ernesto Greco, et al. Video-Assisted Mitral Surgery through a Micro-Access: A Safe and Reliable Reality in the Current Era. J Heart Valve Dis 2008 17(1) 48-53


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