1 / 32

ICU topic discussion

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

KeelyKia
Download Presentation

ICU topic discussion

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. ICU topic discussion Minimal invasive mitral valve surgery Ri施廷翰 20081027

  2. I. Case report

  3. 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

  4. 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

  5. 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

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

  7. 09/24

  8. 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

  9. 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

  10. 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

  11. 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

  12. II. Discussion Minimally invasive mitral valve surgery (MIMVS)

  13. Goal • Reduced size of the incision • The avoidance ofa sternotomy • The use of a partial sternotomy or minithoracotomy • Lack of need for cardiopulmonary bypass

  14. 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)

  15. MIMVS-thoracotomy J Formos Med Assoc (2006) 105(9) 715-21

  16. MIMVS-thoracotomy J Formos Med Assoc (2006) 105(9) 715-21

  17. MIMVS-thoracotomy J Formos Med Assoc (2006) 105(9) 715-21

  18. Problems • Femoral cannulation – for CPB • Reduced access to the surgical field • Complexity of video assistance • Specialized surgical instruments

  19. 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

  20. MIMVS vs. conventional MVS MIMVS Conventional Dogan (2005) Ann thorac surg

  21. 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

  22. Spain experience Ernesto Greco, et al(2008) J Heart Valve Dis

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

  24. Taiwan experience Reoperation 2 Kuan-Ming Chiu(2006) JFMA

  25. 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

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

  27. 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

  28. Contraindications • Peripheral arteriosclerosis • Previous right lung surgery • Extreme obesity • With tricuspid valve repair Ernesto Greco, et al(2008) J Heart Valve Dis

  29. Minimally invasive cardiac surgery Helmut Fulbins, et al Expert Rev. Vardiocasc. Ther. 2(6) 2004

  30. 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

  31. 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.

  32. 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

More Related