“Mini-MVR Is Better than Conventional MVR” Conaz9194.vo.msecnd.net/pdfs/120401/08.24.pdf“Mini-MVR Is Better than Conventional MVR” - Pro • It is less invasive • We are

“Mini-MVR Is Better than Conventional MVR” - Con Ani Anyanwu, MD, FRCS

Associate Professor

Department of Cardiothoracic Surgery

The Mount Sinai Medical Center

New York, USA

I have no conflicts of interest or disclosures

Things are not always as they seem

There is more to mini-

MVR than a beautiful scar

There is more to mini-

MVR than beautiful data

“Mini-MVR Is Better than Conventional MVR” - Pro • It is less invasive • We are doing same operation through smaller

incision • Morbidity and mortality is less • Aesthetically superior • Less bleeding and blood transfusion • Less hospital stay • Better option for elderly and high-risk patient groups

TEN MYTHS OF MINIMALLY

INVASIVE CARDIAC SURGERY

Myth 1) MICS is Minimally Invasive

• MICS is invasive

• Invasion is not more different than with

sternotomy

‘Minimally Invasive Surgery’

Seeburger et al. Semin Thorac Cardiovasc Surg 2007; 19:289-98

‘Minimally Invasive Surgery’

22F venous can

18F arterial can

Cardiotomy

suction and

CO2 insufflation

Diaphragm

retraction

sutures

LV vent

Antegrade

cardioplegia

Aortic clamp

Videoscope

Left atrial

retractor

Coronary sinus

catheter

Bypass

machine

Not shown:

16F Int jugular

venous cannula

Seeburger et al. Semin Thorac Cardiovasc Surg 2007; 19:289-98

The principal difference is the size

and/or location of the incision and not

the invasiveness

General

Anesthesia

Tracheal

Intubation

MICS

Cardiopulmonary

bypass

Cardioplegic

arrest

Cardiotomy

Direct valve

repair

Closure

Elective

ventilation &

hospitalization

Limited Incision

General

Anesthesia

Tracheal

Intubation

STERNOTOMY

Cardiopulmonary

bypass

Cardioplegic

arrest

Cardiotomy

Direct valve

repair

Closure

Elective

ventilation &

hospitalization

Standard Incision

Casselman et al. Circuation 2003;108:II48-54

But sternotomy scars need not

be several inches

Myth 1) MICS is Minimally Invasive

• MICS is invasive

• ‘Invasion’ is not much different from

sternotomy

• Many MICS are merely cardiac surgery via

thoracotomy

• The term Minimally Invasive as applies to

cardiac surgery is an oxymoron

A lot goes under the name of ‘Minimally

Invasive surgery’

Scar from a ‘minimally invasive mitral valve repair’

done 8 weeks previously. Patient had severe residual

regurgitation requiring valve reoperation

A great con?

1st repair

via ‘MICS’

Valve

rerepair via

sternotomy

In reality many ‘MICS’

incisions are of similar

size to modern

sternotomy incisions

Real definition and meaning of MICS

• The most invasive aspects of cardiac surgery

relate to the anesthesia, pericardiotomy,

cardiotomy, cardiopulmonary bypass and

cardiac repair and not the incision

• In some ways MICS paradoxically introduces

invasiveness

– More exposure to cardiopulmonary bypass

– More gadgetry and invasive devices

Myth 2) MICS is the same operation

done through lesser access

Key changes in technique, philosophy

and principles occur with MICS

Sternotomy Robotic

Arterial Perfusion Antegrade Retrograde

Venous drainage Peripheral Central

Aortic Occlusion Clamp. Site selected by

palpation/ultrasound

Clamp or Balloon. Site

selected by TEE or none

Myocardial cooling Direct, monitored Indirect, not monitored

Annuloplasty type As desired Flexible band (typical)

Annuloplasty sutures Braided polyester Nitinol clips, running

prolene

Repair techniques As desired Less resection

Visualization Wide, including

assistants

Narrow – limited to

endoscope view

Lungs/Pleura No direct trauma, always

both ventilated

Direct trauma to R Lung,

diaphragm, pleura .

Single lung ventilation

2) Is MICS is the same operation done

through lesser access?

• Reality is there is shifting of goal posts to

fulfill MICS objective

• Invariable compromise and/or change in

principles and technique which is more

exaggerated the smaller the incisions get

• Additionally there may be benefits seen with

MICS not seen with sternotomy

– E.g. better visualization

• But the two are not the same operation

Raanani et al. J Thorac Cardiovasc Surg 2010; 140:86-90

*Posterior Leaflet Pathology only

Santana et al. Ann Thorac Surg 2011; 91:406-10



Myth 2) MICS is the same operation

done through lesser access

• There is invariable change in principles and

technique (whether positive or negative)

• The effect of these changes is often not

studied

• Some changes go against traditional surgical

belief and principles

• Tendency to make pathology conform to the

technique

– Everyone gets same technique

Myth 3) MICS does not compromise

valve repair rates


valve repair rates

• It has to by definition

• Primary focus is on incision and not the repair

Focus of most MICS papers are on the

incision and not on the valve surgery

• Typically detailed description of access

and cannulation but no description of

mitral repair techniques

Lamelas et al. Ann Thorac Surg 2011; 91:79-84

Umakanthan et al. Ann Thorac Surg 2008; 85: 1544-50


valve repair rates

• It has to by definition

• Primary focus is on incision and not the repair

• Certain repair techniques are more suited to

conventional instrumentation/exposure

• Also some valves are more difficult to repair.

Such valves will be even more difficult with

limited access

– Rheumatic valves

– Congenital

– Calcification

Can difficult repairs be replicated via MICS

or are these valves replaced?

Umakanthan et al. Ann Thorac Surg 2008; 85: 1544-50

Petracek et al. Ann Surg 2011;254:606-11

• 504 patients, 280 repairs (56%)

• Myxomatous 70% repair

• Ischemic 29% repair

Umakanathan et al. Ann Thorac Surg 2008;85:1544-50

Overall Repair Rate 66% (57/86)

Posterior Leaflet Repair 96% (48/50)

Anterior Leaflet Repair 66% (2/3)

Bileaflet Repair 21% (7/26)

Seeburger et al. Eur J Cardiothorac Surg. 2009 Sep;36(3):532-8

Overall Repair Rate 94% (1156/1230)

Posterior Leaflet Repair 97% (651/672)

Anterior Leaflet Repair 91% (142/156)

Bileaflet Repair 90% (363/402)

Does MICS compromise mitral valve

repair rates?

• Yes

– Maybe less so in the most experienced hands

– Maybe less so in those who have overcome

learning curve

– But otherwise there is direct and indirect evidence

that more valves are being replaced when MICS

is used

Myth 4) MICS is possible in ‘all’

patients

• Patient selection and referral bias gives a

false impression that MICS can be applied

consecutively to all comers without need for

conventional approach

• Even in reference centers, majority of valves

repaired via MICS are simple pathology

• Either via selection of referral patterns,

complex cases are not making there way into

MICS ORs

Mihaljevic et al. J Thorac Cardiovasc Surg 2011; 141: 72-80

Robotic repairs

• Mean age 56 y

• BMI 26

• Asymptomatic 50%

• 4+ MR 81%

• Mean EF 60%

• Diabetes 2%

•

Suri et al. J Thorac Cardiovasc Surg 2011; 142: 970-9

Robotic vs Sternotomy

• Mean age 54 y vs 59y

• Prior CVA 1% vs 7%

• NYHA I or II 90% vs 72%

• Mean EF 66% vs 63%

• Diabetes 1% vs 2%

• CHF 1% vs 13%

Many complex valves are not

making it to MICS ORs

Not all patients are suited to MICS

From Gillinov and Mihaljevic. Minimally Invasive Mitral Valve Surgery

in Bonser et al Mitral Valve Surgery. Springer-Verlag, London: 2011

Myth 5) MICS repair is reproducible by

‘all’ surgeons

• MICS requires unique skill-sets and training

possessed currently limited to only a minority

of surgeons

Myth 5) MICS repair is reproducible by

‘all’ surgeons

• MICS requires unique skill-sets and training

possessed currently limited to only a minority

of surgeons

• Unpredictable learning curve

• Widespread penetration of MICS will likely

compromise patient outcomes

The learning curve

• Takes about 100 cases to become proficient,

efficient, and have stable results* with right

thoracotomy or robotic approach.

Casselman et . J Thorac Cardiovasc Surg 2003; 125: 273-82

Chitwood et al, J Thorac Cardiovasc Surg 2008;136:436

Gammie et al, Ann Surg 2009; 250: 409-15

Cheng et al. J Thorac Cardiovasc Surg 2010; 139: 628

*low complications, high repair rate and durable repair

Mihaljevic et al. J Thorac Cardiovasc Surg 2011; 141: 72-80

645 MICS mitrals

over 3 year

period including

261 robotic

Gammie et al. Ann Thorac Surg 2010; 90: 1401-10


The average surgeon does 3 MICS mitrals per

year


year

It takes about 100 procedures to gain

proficiency


year

It takes about 100 procedures to gain

proficiency

• Most surgeons, by definition will never gain

proficiency in their lifetime

• Majority of MICS mitrals, at least in the USA,

are being performed by surgeons who lack

proficiency to do so

The result

Plethora of

• Complications

• Deaths

• Unnecessary valve replacements

• Early failures of repair

• Incomplete procedures

Directly attributable to use of MICS

Myth (6) MICS has been demonstrated

to be non-inferior in outcomes

(6) Has MICS has been demonstrated

to be non-inferior in outcomes?

• Non-inferior results seen in selected reports

from pioneering centers have not been

duplicated in large databases and other

single center series

• Be wary of outcome data from small series



What does no hospital deaths in

64 patients mean?

Hanley And Lippman-Hand. JAMA 1983; 249:1743-6


What does no hospital

deaths in 64 patients mean?




Means the true mortality risk

is no more than 3/64 or 4.7%




Means the true mortality risk

is no more than 4.7%

One has to do 1000 cases to

be reasonably sure the

mortality risk is <1%

Anyanwu and Treasure. J Thorac Cardiovasc Surg 2002: 123:16-20

Gammie et al 2010 STS N=28,143

“Less invasive MV

surgery independently associated with higher

incidence of perioperative stroke

(OR 1.96)”

Cheema et al 2006 STS N=6051

“Less invasive MV

surgery independently associated with higher

incidence of stroke within 24h (OR 2.45)”

Petracek et al. Ann Surg 2011;254:606-11

• 504 patients

• Fibrillatory no clamp approach

• Femoral perfusion in 89.5% (rest axillary)

• Mortality 11 (2.2%)

• Stroke or TIA 18 (3.6%)

• 4 fatal strokes (stroke responsible for a third

of deaths)



Schroeter et al. Thorac Cardiovasc Surg 2011;59:252-4

There are though some patients too

where Sternotomy is harmful…

• In these patients, MICS is potentially

advantageous

Santana et al. Ann Thorac Surg 2011;91:406-10

Myth 7) Patients recover quicker with

MICS

Suri RM et al. Ann Thorac Surg 2009; 88: 1185

Suri RM et al. Ann Thorac Surg 2009; 88: 1185

Modi et al. JTCVS 2009;137:1481-7:532-8

Suri RM et al. Ann Thorac Surg 2012; 93: 761-9


***No difference in chronic pain


Median sternotomy…four weeks later

Median sternotomy…five weeks later

Myth 8) Quality of repair is similar with

MICS

Chitwood et al, J Thorac Cardiovasc Surg 2008;136:436



*Posterior Leaflet Pathology only



Myth 9) MICS is the new standard

9) Is MICS is new standard?

• Reality is little penetration of MICS in recent

years

• Most growth comes from established MICS

centers


Falk et al. Innovations 2011; 6:66-76



Myth 10) MICS is better for the patient

• Only clear benefit to the patient is cosmesis

• MICS is more a marketing tool for surgical

egos and surgical programs

• MICS does not improve chances of a good

short or long-term outcome for the patient

Lets be honest….

• Only clear patient benefit of MICS is cosmesis

• MICS is largely an expression of the surgical

self

• We like challenges and technical evolution

We like to be at the cutting edge

We like to demonstrate our craft and ability

We like the sexy stuff

What really is best for the patient….

• Adherence to ‘Carpentier principles’ is most

important factor in achieving durable repair

– Competent valve

– Good surface of coaptation

– Preserve mobility and orifice

How the surgeon gets to the valve is of much less

importance

Anyanwu and Adams Curr Opinion Cardiol 2012; 2:118-24

Anyanwu and Adams Curr Opinion Cardiol 2012; 2:118-24

“Mini-MVR Is Better than Conventional MVR” - Con

• There is more morbidity • There is no tangible benefit • Less valves are repaired • Quality of repair is inferior

Thank You

Documents

“Mini-MVR Is Better than Conventional MVR” Conaz9194.vo.msecnd.net/pdfs/120401/08.24.pdf“Mini-MVR Is Better than Conventional MVR” - Pro • It is less invasive • We are