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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 oldGender: 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

Minimal invasive mitral valve surgery

Ri施廷翰

20081027


I. Case report


Basic data

  • Name: 余O義Chart no. 0973107

  • Age: 54 years oldGender: 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)

  • 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


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


Brief history (3)

  • Post-op cardiac echo: poor LV contractility

  • 09/22 difficulty in weaning ECMO

  • 09/24 referred to our hospital


09/24


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


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


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

    • 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

    Minimally invasive mitral valve surgery (MIMVS)


    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

    • 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

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


    MIMVS-thoracotomy

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


    MIMVS-thoracotomy

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


    Problems

    • Femoral cannulation – for CPB

    • Reduced access to the surgical field

    • Complexity of video assistance

    • Specialized surgical instruments


    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 MVS

    MIMVS

    Conventional

    Dogan (2005) Ann thorac surg


    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 experience

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


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


    Taiwan experience

    Reoperation 2

    Kuan-Ming Chiu(2006) JFMA


    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


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


    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

    • 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

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


    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

    • 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

    • 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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