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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)
