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W. Randolph Chitwood, Jr., M.D FACS, FRCS
The benefits of minimally invasive cardiac surgery have been demonstrated, yet many surgeons have failed to embrace these methods for valve surgery. Reasons cited include concerns of impaired patient safety, inferior long-term results, and altered technical flexibility. The attached bibliography includes most large clinical series of minimally invasive valve operations, and these papers define the safety and efficacy of these methods. Although results have been shown to be similar to the traditional sternotomy approach for valve repair and replacement, all of the benefits expected initially have not come to fruition. Nevertheless, blood loss and transfusion requirements as well as decreased ventilator support and length of hospitalization remain constants at large volume institutions and surgeons doing minimally invasive valve surgery. Surgeons had hoped that improved comfort, more rapid recovery and less cost would be uniform proven findings; however, clinical series are variable regarding these benefits and decreased procedural cost. More and more patients are expecting less invasive valve operations. To them newer percutaneous valve insertion and repair methods even seem optimal although with unproven results. Less invasive approaches are achieving maturity, and surgeons who can deliver optimal results using these new approaches are being increasingly sought by the public.
The Ideal Valve Operation
To minimize trauma and maximize surgical access surgeons are seeking to develop what they hope will be the ideal valve operation. Any operation that is ideal for the patient but difficult for surgeons to perform will generally not mature or expand. Major requirements for an ideal valve operation relate to access, dexterity, visualization, and perfusion. Access through endoscopic ports seems optimal for thoracic surgeons to reach the heart. However, cardiac surgeons are reluctant to abrogate optimal vision, a full range of access, and tactile feed back for this approach. Reconstructive operations could be optimized by endoscopic tools that provide three-dimensional vision, no tremor, a wide range of motion and tactile feedback for the surgeons hands. Endoscopic methods can now provide an eye-brain like topographic perspective but are limited to surgical robotic devices. Without a full range of motion within the aorta or atrium, long endoscopic instruments often are encumbered by convergence collisions. Modifications are emerging to help avoid these difficulties. Because of limited access cardiopulmonary perfusion must be altered to fit the approach and with newer cannula technology there are more options than ever. If all of these issues were satisfied through an endoscopic operation, the addition of rapid deployment or attachment devices for valves and navigational methods could help seal the endoscopic or robotic approach as the ideal valve operation.
Direct Vision Minimally Invasive Mitral Valve Operations
In 1996 Cohn, Cosgrove, Gundry, and Arom, first showed encouraging results using modified sternal operations with a low surgical mortality (13%). The hemi-sternotomy approach, initially described by Cosgrove, Cohn, Gundry, Koernitz, Machler, von Sagesser and others, has been the most common incision use by minimally invasive valve surgeons. In a randomized study, comparing the conventional sternotomy (N = 60 patients) to an upper hemi-sternotomy (N=60 patients) for aortic valve surgery, Machler found the latter to provide reduced trauma, less ventilation requirements, less blood loss, and better cosmesis. Comparatively, Aris found no differences in results; however, he used two different hemi-sternotomy approaches, therefore confounding his conclusions. Between 1996 and early 2002, the Cleveland Clinic group had done 1427 minimally invasive mitral operations, using direct vision, the upper hemi-sternotomy, and modified perfusion methods. Perfusion and aortic occlusion times averaged 80 and 60 minutes, respectively. They had an impressive (0.3%) operative mortality with complication rates of bleeding (3.1%), strokes (1.8 %), and respiratory insufficiency (0.8%). Grossi and associates compared 100 minimally invasive mitral operations, done through a 6 - 8 cm mini-thoracotomy using direct vision and Port-accessÔ methods, to a cohort of 100 conventional mitral operations. They reported a peri-operative mortality of 1.0%. Thus, these and other groups have shown that for valve repairs and replacements several approaches can be used for minimally invasive access using direct vision and that the have similar repair longevity and safety of traditional full sternotomy operations. Cohn began performing minimally invasive aortic valve surgery at the Brigham and Womens Hospital in June of 1996. In over 1000 minimally invasive valve operations, his group has reports results that either parallel or are better than traditional approaches. Initially his group used a parasternal approach but now embrace the upper hemi-sternotomy.
Endoscopic and Robotic Minimally Invasive Mitral Valve Operations
In early 1996, Carpentier performed the first video-assisted mitral valve repair through a mini-thoracotomy using hypothermic ventricular fibrillation. In 1997 Mohr began to use an Aesop 3000Ô voice-activated camera robot in minimally invasive videoscopic mitral valve surgery. Shortly thereafter, we began using the Aesop 3000Ô to perform both video-assisted and video-directed minimally invasive mitral valve repairs. In early 2001 our group reported our first 128 successful video-assisted mitral valve operations. Shortly thereafter Mohr and associates reported in 154 video-assisted mitral valve operations done with video-assistance with AesopÔ 3000 with a mortality of 2.5%. In early 2002 Vanermen and associates reported 187 patients undergoing totally endoscopic repairs using the Port-accessÔ method. They used a two-dimensional endoscopic camera and performed complex repairs with excellent results at follow-up 19 months later. The hospital mortality was 0.5%, and there were two conversions to a sternotomy for bleeding. Freedom from re-operation was 95% at four years. Later reports from this group continue to show good long term results and low risk for patients. Our group has performed over 600 minimally invasive videoscopic mitral operations with an overall 2.4% 30day mortality. This series includes re-operations and complex repairs. We have used a transthoracic clamp in preference to aortic balloon occlusion with no aortic or pulmonary artery injuries tears. Of these 204 have been robotic mitral repairs and the remainder were done using a two-dimensional endoscope. We now use the robotic system for all primary mitral repairs and the videoscopic approach fro replacements and re-operations. For the endoscopic operations cardiopulmonary bypass and aortic cross-clamp times averaged 140 and 87 minutes, respectively. Comparatively robotic operations take longer because of setup and robot positioning as well as valve exposure, even after the learning curve is flattened. Now, the mean operative time to repair the valve and place an annuloplasty band is 1 hour and 12 minutes. Thus, there remains a great opportunity to reduce cross clamp and perfusion times through technologic innovations. Our cross clamp times remain at nearly 2 hours but with increasing complexity of repairs. Despite this, our hospital length of stay for these later patients averages 4.8 days.
We were the principle investigator for two FDA trials that that led to approval of the da Vinci robotic surgical system for use in minimally invasive mitral surgery. In May of 2000 at East Carolina University we performed the first da Vinci mitral repair in the United States. In our series of 204 da Vinci mitral repairs, quadrangular leaflet resections; leaflet sliding plasties, chordal transfers, PTFE chord replacements, and annuloplasty band insertions are being done with facility. We have had no robot related complications, but one operative death from a protamine reaction. Two patients required re-exploration for chest wall bleeding and only 14.5 % were transfused. We had no frank strokes but had one reversible neurologic injury. There were no perfusion related complications, such as caval injuries or retrograde aortic dissections. Four patients had to be reoperated upon within the first year for either repair failures or hemolysis. The device has functioned optimally in 98% of operations and in the others the back-up operation became a video-scopic repair through the same incision. We now operate on anterior leaflet and Barlow's pathology weekly and with excellent echocardiographic results. The technical learning curve seems to be about 50 mitral repair operations with our cross clamp and perfusion times paralleling our initial sternotomy operations. Nitinol-U Clips have facilitated annuloplasty band insertion and are proving to have long-term efficacy. To date we have trained over 300 individual surgeons and teams in robotic mitral repair surgery.
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