Setting Up a Minimally-Invasive Cardiac Surgery Program Basel Ramlawi,MD, MMSc, FACS, FACC, FRCSC Co-Director, Methodist Aortic Network Cardiothoracic Surgery & Transplantation Methodist DeBakey Heart Center The Methodist Hospital Houston, TX
Basel Ramlawi, MD Bramlawi@TMHS.ORG
OUTLINE • • • •
Explore MICS definition Why do it? Procedures Requirements of a successful program
Basel Ramlawi, MD Bramlawi@TMHS.ORG
“It is not the strongest of the species that survives, nor the most intelligent that survives. It is the one that is the most adaptable to change.� Charles Darwin
Basel Ramlawi, MD Bramlawi@TMHS.ORG
What is minimally invasive? According to the STS: Minimally invasive cardiac surgery (MICS) is “Any cardiac procedure not performed with a full sternotomy and/or CPB support.�
Basel Ramlawi, MD Bramlawi@TMHS.ORG
Chitwood (Past STS President) MICS entails a collection of new techniques and technologies aimed at decreasing surgical trauma, thus increasing patient satisfaction and decreasing morbidity and cost.
Basel Ramlawi, MD Bramlawi@TMHS.ORG
MICS is a philosophy rather than a technique
***Includes Catheter-based procedures***
Basel Ramlawi, MD Bramlawi@TMHS.ORG
Adoption of Newer Procedures Depends on:
• Validation of Clinical Benefit •Training and education -Teachable procedure? •User friendly vs. Patient friendly
Basel Ramlawi, MD Bramlawi@TMHS.ORG
Buy-In from majority of stakeholders… • • • • • • • •
Cardiac Surgeon Department leadership / Chair Surgical partners Anesthesiologist Referring cardiologists Imaging cardiologists Intensivits OR / Cath lab Staff (RNs, perfusionists, techs etc.)
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Administration / Hospital Execs: – Capital purchasing, OR time etc. – Marketing – Infrastructure support Basel Ramlawi, MD Bramlawi@TMHS.ORG
Healthcare Economics 2013 Increased Emphasis on Value Value = (Safety + Outcomes) X Volume Cost
Basel Ramlawi, MD Bramlawi@TMHS.ORG
Skeptics… • Surgeon: “Why mess with a perfect operation?” • IC: “my incision will always be smaller than yours” • Administrator: “These instruments/Robot are not cheap” • Nurse: “Will I have to stay longer today?” • Anesthesia: “Do I need to stay in room for whole case?”
Basel Ramlawi, MD Bramlawi@TMHS.ORG
Kleiman’s Dictionary of Interventional Cardiology Hybrid (Hôb-brĭd) adj. – 1. Neither 2. A manner to combine the worst of coronary bypass surgery with the worst of coronary intervention. 3. A way to assure that the patient has both surgical bleeding and stent thrombosis. 4. A manner to assure that both surgeon and interventional cardiologist are able to bill for the same procedure (see administrator gratification.) Basel Ramlawi, MD Bramlawi@TMHS.ORG
Why Do It?
Basel Ramlawi, MD Bramlawi@TMHS.ORG
Reasons • Improved or equal clinical outcomes Most important • Quicker recovery • Patient demand • Maintain competitive edge
– vs. other programs, surgeons, cardiologists etc.
• Offer full spectrum of procedures • Improved visualization • Sexy / slick cases!
Basel Ramlawi, MD Bramlawi@TMHS.ORG
Basel Ramlawi, MD Bramlawi@TMHS.ORG
Results Longer – Operative time – Bypass time – Myocardial ischemic time
Basel Ramlawi, MD Bramlawi@TMHS.ORG
Results… in general Superior – Blood loss – Postoperative pain control – Length of stay – Cosmesis – Patient satisfaction Equivalent – Safety – Repair rate – Repair durability
Basel Ramlawi, MD Bramlawi@TMHS.ORG
Minimally Invasive Mitral Surgery Patient demand – Less trauma – Cosmetic appeal – More rapid recovery
Basel Ramlawi, MD Bramlawi@TMHS.ORG
Patient Questions • Can I do the same operation with: – Equivalent safety – Equal efficacy – Smaller incision / less trauma / quicker recovery
Basel Ramlawi, MD Bramlawi@TMHS.ORG
Fact Patients will almost always choose – Less invasive therapy – Even if less effective or greater long-term risk
Basel Ramlawi, MD Bramlawi@TMHS.ORG
Key Findings No difference – Safety – Repair rate – LOS
• Main Advantages: – – – –
Improved cosmetics Less transfusions Length of stay Patient satisfaction Basel Ramlawi, MD Bramlawi@TMHS.ORG
Key points to successfully starting a MICS program •
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Thorough planning of every case – Know every step of procedure and best instrument for task – Contingency planning: learn pitfalls and bailout strategies Converting to open approach is NOT failure… let team and patient know that! SAFETY first. First, do no harm. Know your limitations
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Be paranoid about YOUR outcomes.
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ALWAYS have proctors for initial cases
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Watch others… if possible do mini-fellowship. SIMULATION… practice!
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Make it a multidisciplinary team effort and success.
Master one MICS procedure at a time CABG vs. Valve – Mini vs. Robot Highest volume and most familiar case Same quality operation
Basel Ramlawi, MD Bramlawi@TMHS.ORG
Be familiar with setup & instruments
Basel Ramlawi, MD Bramlawi@TMHS.ORG
Technical Approach Every technique combines different prefered options of the following: 1.Access (UHS, LHS, Ant thor, Anterolat thor, ‌). 2.Cannulation (Peripheral, central or combination). 3.Aortic clamping (Trans-thoracic or endovascular). 4.Cardioplegia delivery - antegrade aortic root and/or RJV-CS retrograde. 5.Venting (Aortic root and LA) 6.Valve visualization (direct, video or both)
Basel Ramlawi, MD Bramlawi@TMHS.ORG
Necessary adjuncts to most techniques: 1.Small non-kinking cannulae. 2.Vacuum-assisted venous drainage. 3.Continuous CO2 insufflation.
Maximum utilization of exposed space
Perfect de-airing
4.TEE.
Basel Ramlawi, MD Bramlawi@TMHS.ORG
PORT ACCESS System
Aortic Instruments Mitral Instruments
Basel Ramlawi, MD Bramlawi@TMHS.ORG
PORT ACCESS Minimally Invasive Valve Surgery
Provides • Systemic perfusion • Aortic and pulmonary venting • Aortic occlusion • Antegrade and/or retrograde cardioplegia delivery with remote cannulation • Pressure monitoring
Basel Ramlawi, MD Bramlawi@TMHS.ORG
MICS Areas
Basel Ramlawi, MD Bramlawi@TMHS.ORG
TAVR
Basel Ramlawi, MD Bramlawi@TMHS.ORG
Basel Ramlawi, MD 30 Bramlawi@TMHS.ORG
Aortic Valve
Basel Ramlawi, MD Bramlawi@TMHS.ORG
Mitral Valve
Basel Ramlawi, MD Bramlawi@TMHS.ORG
Video-Assisted Complete Maze Procedure with LAA Ligation
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Basel Ramlawi, MD Bramlawi@TMHS.ORG
My MICS Repertoire… • Catheter skills – TAVR – Hybrid thoracic aortic repair
• Mini-thoracotomy MVRepair and Afib ablation • Conscious decision – No MICS-CABG, VADs or Robotics
Basel Ramlawi, MD Bramlawi@TMHS.ORG
Robotics (CABG, Valve, myxomas, etc‌)
Basel Ramlawi, MD Bramlawi@TMHS.ORG
Incisions for MICS LVAD Insertion
Basel Ramlawi, MD Bramlawi@TMHS.ORG
The case for a hybrid room
Basel Ramlawi, MD Bramlawi@TMHS.ORG
Basel Ramlawi, MD Bramlawi@TMHS.ORG
Not all hybrid rooms are equal‌
Basel Ramlawi, MD Bramlawi@TMHS.ORG
Basel Ramlawi, MD Bramlawi@TMHS.ORG
Interest in Hybrid Rooms Increasing
Basel Ramlawi, MD Bramlawi@TMHS.ORG
Who uses it?
Basel Ramlawi, MD Bramlawi@TMHS.ORG
Planning
Basel Ramlawi, MD Bramlawi@TMHS.ORG
Why should hospital invest 2-4 Million dollars?
Basel Ramlawi, MD Bramlawi@TMHS.ORG
Basel Ramlawi, MD Bramlawi@TMHS.ORG
Planning for Hybrid OR
Basel Ramlawi, MD Bramlawi@TMHS.ORG
Basel Ramlawi, MD Bramlawi@TMHS.ORG
Basel Ramlawi, MD Bramlawi@TMHS.ORG
Basel Ramlawi, MD Bramlawi@TMHS.ORG
The Anesthesia Challenge‌
Basel Ramlawi, MD Bramlawi@TMHS.ORG
Imaging Techniques and Processing
Basel Ramlawi, MD Bramlawi@TMHS.ORG
Basel Ramlawi, MD Bramlawi@TMHS.ORG
MITIE Procedural Lab
Basel Ramlawi, MD 53 Bramlawi@TMHS.ORG
Houston Rodeo! Rodeo! Houston, Texas
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A Simple Choice‌ MICS
vs
Standard
Basel Ramlawi, MD Bramlawi@TMHS.ORG
Thank You Questions
Basel Ramlawi, MD Bramlawi@TMHS.ORG