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Minimally Invasive

Aortic Surgery With Emphasis On

Technical Aspects, Extracorporeal

Circulation Management And

Cardioplegic Techniques

Konstadinos A Plestis, MD

System Chief of Cardiothoracic and

Vascular Surgery

Professor Thomas Jefferson University

Main Line Health

Minimally Invasive Aortic Surgery

It makes sense

LANKENAU HEART INSTITUTE

Minimally Invasive Valve/ Root

Surgery- Strategy

• Approach

• Instruments

• Cannulation

• Cardioplegia

• Knot tying

• 6 cm incision

• Sternal notch to 3d or 4th intercostal space

• J-type or T-type

MIS Aortic Valve and Root Surgery

Cannulation Strategy

•Ascending Aorta/Arch

(Seldinger Technique)

•Superior Vena Cava via the

Right Femoral Vein

(Seldinger Technique)

CPB Strategy

•Minimize CPB circuit

•Y the venous line

•Avoid Hemodilution

•RAP

•Hemofiltration after Custodiol administration

•Low sodium inhibits rapid phase of action potential

arrests the heart

• Histidine buffering capacity

• Tryptophan protects cell membrane

• Ketogluterate stabilizes the cell membrane

provides ATP during reperfusion

• Mannitol reduces cellular edema

Custodiol Cardioplegia Solution (HTK solution)

•No Aortic valve insufficiency:

•2 liter single dose

•Directly in the aortic root

• Aortic valve insufficiency

• Initial dose in the root until heart arrests

TEE to assess LV dilation

Remaining custodial directly in the

coronary ostia

• Retrograde administration

MIS Aortic Valve and Root Surgery:

Delivery strategy

Cor-Knot

•Cor-Knot (automated suturing device)

• Fast

• Uniformly pressured sutures

• Precise

Instruments

1. Vascular hook

2. MIS Needleholder

3. MIS Forceps

4. Knot Pusher

5. Crochet Hook

6. Heartport Fehling

Resano Forcep

1 2 3 4 5 6

Aortic Valve Replacement

Case Presentation

83 yo male

–SOB

–Severe Aortic Regurgitation

LANKENAU HEART INSTITUTE

Operation

• Mini – AVR

LANKENAU HEART INSTITUTE

Discharge

• Intubation Time – 10 Hours

• ICU Days – 2 Days

• Hospital Stay 5 Days

LANKENAU HEART INSTITUTE

Case Presentation

AVR/MVR

86 yo male

• Severe AV Regurgitation

• Severe MV Regurgitation

Procedure

•Minimally invasive approach

•AVR

•MVR

Discharge Report

• Length of hospital stay: 7 days

• No complications

Mini AVR

N=168

Years : 2010-2015

• FT Group (n=56) Cor-Knot

•HTK cardioplegia

• Non-FT Group (n=112) blood cardioplegia

•hand tying

Demographics

FT Group Non-FT Group

Males 33 59% 55 49.1%

Mean Age* 70.5 (±10.7) 73.5 (±9.47)

*p<0.05

FT Group Non-FT Group

Aortic Stenosis 55 98.2% 105 93.7%

Aortic Insufficiency 54 45.5% 31 69.6%

Diagnosis

FT Group Non-FT Group

NYHA class 3-4 23 44% 40 35%

Hypertension 52 92.9% 89 79.5%

Diabetes 13 23.2% 27 24.1%

Hypercholesterolemia * 50 89.3% 82 73.2%

CVA 3 5% 9 8%

Mean Creatinine 1.1±0.4 1.1±0.5

Demographics

*p<0.05

Intraoperative Data

FT Group Non-FT Group

Pump Time* 107.02±22.69 114.77±27.61

Cross Clamp Time* 82.18±18.25 88.11±19.73

*P<0.05

Outcomes

FT Group Non-FT Group

Mortality 1 1.79% 3 2.68%

Stroke 1 1.79% 2 1.79%

New onset

RI

1 1.9% 6 5.36%

RI- Renal Insufficiency

FT Group Non-FT Group

Intubation Time* 1±1.1 days 2.26± 9.37days

Atrial fibrillation 18 32.14% 39 34.82%

Outcomes

*(p<0.05)

Custodiol Blood

Preoperative

Ejection Fraction

61±8.8 60.39±10.42

Postoperative

Ejection Fraction

60.7±9.3 61.7±10.75

Ejection Fraction

Mean Follow-up TTE: 103.4±205 days

FT Group Non-FT Group

Paravalvular leak*:0 5 4.5%

2 mild

2 moderate

1 severe

*(p<0.05)

Early Follow-up

Conclusion

•Facilitating technologies

–Simplify the MIAVR

–Do not affect outcomes

–Decrease the hospital stay

–Decrease incidence of early paravalvular

leak rates

AAA Replacement

Case Presentation

31 yo female

•Asymptomatic

•Severe AI

•Bicuspid AV

•Ascending aortic aneurysm

LANKENAU HEART INSTITUTE

Minimally Invasive Procedure

• Ascending aortic replacement

• Aortic valve repair

• Insertion of CardioCel in RCC of conjoint leaflet

• Subcomissural annuloplasty

• STJ adjustment (to 24mm)

Elective Ascending Aortic Repair

Outcomes

2000-2015

Mini Full

n = 58 n = 251

Age 60.0 ± 11.0 65 ± 12.0

Males 17 60% 159 64%

Concomitant Procedures

Sternotomy

Mini Full

AV Repair 10 (18%) 34 (14%)

AV Replacement 28 (50%) 114 (44%)

Etiology

Sternotomy

Mini Full

Chronic Dissection 0 0% 20 8%

Medial

Degeneration40 69% 131 453%

Marfan 2 3.5% 5 2%

Bicuspid AV 26 45% 52 21%

Comorbidities

Sternotomy

Mini Full

Hypertension 38 70% 190 76%

Diabetes 6 10% 24 10%

COPD 2 3% 35 14%

Renal Insufficiency 2 3% 15 6%

Redo 6 10% 29 11%

Sternotomy

Mini Full

Pump time* 110 ± 24 152 ± 50

Cross Clamp time* 81 ± 25 115 ± 45

Operative times

*P<0.05

Complications

Sternotomy

Mini Full

Death 0 0% 2 0.7%

Stroke 0 0% 7 3%

New RI 0 0% 4 1%

PVS* 4 3% 22 9%

Bleeding* 0 0% 15 6%

Complications

Sternotomy

Mini Full

CHF 0 0% 14 6%

Afib 6 21% 62 24%

Vfib 0 0% 7 3%

MI 0 0% 1 0.3%

MI- Myocardial Infarction

CHF- Congestive Heart Failure

Blood Utilization

Sternotomy

Mini Full

PRBC Units 0.4 ± 0.9 1.7 ± 2.6

FFP Units 0.6 ± 1.1 1 ± 1.7

Platelets Units 0.6 ± 0.7 0.9 ± 1.4

Cryoprecipitate Units 0.4 ± 1.0 1.4 ± 7

*

*P<0.05

Hospital stay

Sternotomy

Mini Full

ICU days* 3.2 ± 1.6 5 ± 5.4

Hospital stay

days6.6 ± 1.6 10 ± 14

Aortic Root Reconstruction

Aortic Root Repair

LANKENAU HEART INSTITUTE

Root Aneurysm Bentall procedure David procedure

Case Presentation

Bentall Procedure

57 yo male

–Root and Ascending Aortic Aneurysm

–Moderate AR

LANKENAU HEART INSTITUTE

Operation

•Mini-sternotomy

•Bentall Procedure

•Button technique

LANKENAU HEART INSTITUTE

LANKENAU HEART INSTITUTE

Follow up- 2 weeks

Case Presentation

David Procedure

34 yo male

–Asymptomatic

Preoperative diagnosis

– Root Dilation

– Ascending Aorta Dilatation

Operation

• Mini David Procedure

LANKENAU HEART INSTITUTE

Elective Aortic Root Outcomes

2000-2015

Sternotomy

Mini Full

n=40

David = 6

Bentall = 34

n=217

David = 37

Bentall = 187

Age 58±12 57±14

Males 17 (85%) 149 (80%)

Etiology

Sternotomy

Mini Full

Medial Degeneration 34 85% 116 63%

Bicuspid AV 14 35% 38 21%

Chronic Dissection 0 0% 17 9%

Marfan 0 0% 21 11%

Comorbidities

Sternotomy

Mini Full

Hypertension 26 65% 135 73%

Diabetes 2 5% 19 10%

COPD 2 5% 28 15%

Renal Insufficiency 0 0% 9 5. %

Redo 8 20% 32 17%

Operative times

Sternotomy

Mini Full

Pump time* 179±33 207±48

Cross Clamp time* 152±26 173±36

*P<0.05

Complications

Sternotomy

Mini Full

Death 0 0% 2 1%

Stroke 0 0% 0 0%

New RI 0 0% 4 2%

PVS* 1 5% 22 11%

PVS-Prolonged Ventilatory Support

RI- Renal Insufficiency

Sternotomy

Mini Full

Bleeding 0 0% 18 9%

MI 0 0% 1 0.5%

Afib 3 15% 42 22%

Vfib 0 0 11 4.91%

CHF 0 0 2 2%

MI- Myocardial Infarction

CHF- Congestive Heart Failure

Complications

Sternotomy

Mini Full

PRBC* 1.0±1.6 2.4±4.5

FFP 1.3±1.3 1.7±2.4

Platelets 0.3±1.2 1.6±2.3

Cryoprecipitate 0.8±1.2 1.6±3.3

Blood Utilization

Hospital stay

Sternotomy

Mini Full

ICU days* 3.3±2.6 4.9±5.9

Hospital stay days* 7±2.9 10.6±7.9

Conclusion

Minimally invasive aortic surgery with

facilitating technologies

–Does not affect mortality

–Decreases X clamp and bypass times

–Decreases blood utilization

–Decreases ICU and hospital stay

Thank you

LANKENAU HEART INSTITUTE

Volume/Outcomes

66

513555

589

681

891

3,12%

2,70%

1,87%

3,08%

1.70%

0,00%

1,00%

2,00%

3,00%

4,00%

5,00%

6,00%

7,00%

8,00%

9,00%

10,00%

0

100

200

300

400

500

600

700

800

900

1000

2011 2012 2013 2014 2015

Volume

Mortality

Cardiovascular Services - 12 Month Rolling Report (Ending: December 31, 2015)