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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

ICU topic discussion

Minimal invasive mitral valve surgery

Ri施廷翰

20081027

basic data
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
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
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
Brief history (3)
  • Post-op cardiac echo: poor LV contractility
  • 09/22 difficulty in weaning ECMO
  • 09/24 referred to our hospital
brief history 4
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
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
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
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

II. Discussion

Minimally invasive mitral valve surgery (MIMVS)

slide13
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
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
MIMVS-thoracotomy

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

mimvs thoracotomy16
MIMVS-thoracotomy

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

mimvs thoracotomy17
MIMVS-thoracotomy

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

problems
Problems
  • Femoral cannulation – for CPB
  • Reduced access to the surgical field
  • Complexity of video assistance
  • Specialized surgical instruments
mimvs vs conventional mvs
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
MIMVS vs. conventional MVS

MIMVS

Conventional

Dogan (2005) Ann thorac surg

spain experience
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
Spain experience

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

taiwan experience
Taiwan experience

Reoperation 2

Kuan-Ming Chiu(2006) JFMA

germany experience
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

clinical outcomes
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
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
Minimally invasive cardiac surgery

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

back to our case
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
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
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