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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 Minimal invasive mitral valve surgery Ri施廷翰 20081027
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) • 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
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
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
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