SHA24/068001

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.)

•

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 •

•

•

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

•

Be paranoid about YOUR outcomes.

•

ALWAYS have proctors for initial cases

•

Watch others… if possible do mini-fellowship.  SIMULATION… practice!

•

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

33

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

Basel Ramlawi, MD 54 Bramlawi@TMHS.ORG

A Simple Choice‌ MICS

vs

Standard

Basel Ramlawi, MD Bramlawi@TMHS.ORG

Thank You Questions

Basel Ramlawi, MD Bramlawi@TMHS.ORG