1. MINIMALLY INVASIVE VALVE SURGERY

2. HOW FAR WE HAVE COME  THE MORTALITY FOR VALVE REPLACEMENT SURGERY IN 1968 WAS 42%

3. WHY MINIMALLY INVASIVE VALVE SURGERY?  SMALLER INCISION/SCAR  LESS PAIN  EARLIER MOBILIZATION  EARLIER RETURN TO LIFESTYLE/WORK  LESS TRAUMATIC  LOWER INFECTION RATE  LESS BLEEDING  SHORTER LENGTH OF STAY  SAFER REOPERATION

4. PATIENT DEMAND

5. GOALS  SMALL INCISION  GOOD EXPOSURE  IDENTICAL QUALITY TO FULL OPEN PROCEDURES IDENTICAL MITRAL VALVE REPAIR RATE  SIMILAR COSTS  SIMILAR OPERATING/BYPASS TIME  ABILITY TO GET OUT OF TROUBLE

7.  “ …cardiologists are strongly encouraged to refer patients who are candidates for complex MV repair to surgical centers experienced in performing MV repair. ”  “ Surgery for asymptomatic patients with severe MR and normal LV function should only be considered if there is a greater than 90% likelihood of successful valve repair in a center experienced in this procedure. ”

8.  “ MV repair should be able to be achieved by experienced surgeons for the majority of patients with degenerative MV disease and ischemic valve disease, and patients should be referred to surgeons expert in repair. ”

9. APPROACHES

10. PARASTERNAL

11.  ADVANTAGES GOOD ACCESS TO THE AORTIC VALVE  DISADVANTAGES CHEST WALL HERNIA CAN RESULT

12. LOWER STERNAL

13.  ADVANTAGES GOOD EXPOSURE FOR THE MITRAL VALVE EXCISION CAN BE EXTENDED IF NECESSARY

14. TRANSECTING STERNAL

15.  ADVANTAGES EXCELLENT EXPOSURE OF THE AORTIC VALVE AND GREAT VESSELS  DISADVANTAGES BREASTBONE INSTABILITY LOSS OF INTERNAL MAMMARY ARTERIES FOR FUTURE USE

16. PORT ACCESS

18.  ADVANTAGES TINY INCISIONS  DISADVANTAGES GREATLY INCREASED OPERATIVE TIME AND OPERATING ROOM TIME MULTIPLE DEVICE INSERTIONS ENDOVASCULAR AORTIC CLAMP HAS RESULTED IN TORN AORTAS MORE DIFFICULTY IN ACHIEVING VALVE REPAIRS SOMEWHAT HIGHER MORTALITY

20.  ADVANTAGES LOTS OF TINY INCISIONS SOUNDS EXCITING  DISADVANTAGES GREATLY LONGER OPERATIVE TIME AND OPERATING ROOM TIME MAY USE ENDOVASCULAR AORTIC CLAMP WITH INCREASED RISK OF TORN AORTA

21. GENERALLY RESTRICTED TO THE MITRAL VALVE LOWER MITRAL VALVE REPAIR RATE HIGHER REOPERATION RATE FOR VALVE REPAIR FAILURE HIGHER MORTALITY HIGHER COSTS  REPLACEMENT OF ROBOTIC INSTRUMENTS

22.  IN THE INITIAL FDA STUDY, 65% OF PATIENTS WERE EXCLUDED

23. RIGHT THORACOTOMY

24.  ADVANTAGES EXCELLENT RESULTS ACHIEVED BY SOME SURGEONS PATIENT PREFERENCE  DISADVANTAGES GENERALLY RESTRICTED TO THE MITRAL VALVE LONG INSTRUMENTS REQUIRED CANNOT EXTEND INCISION

25. UPPER STERNOTOMY

26.  ADVANTAGES ALL VALVES CAN BE ACCESSED WITH EXCELLENT EXPOSURE, AS WELL AS AORTIC PATHOLOGY STANDARD INSTRUMENTS SHORTER OPERATIVE TIME STANDARD AORTIC CLAMPING EXCELLENT HEALING WITH NO INSTABILITY CAN EXTEND INCISION IF NECESSARY  DISADVANTAGES IRREGULAR HEART RHYTHMS WITH MITRAL PROCEDURES ?NOT AS EXCITING AS ROBBY THE ROBOT

28. HOW WE DO IT  6-8 CM MIDLINE INCISION BEGINNING 6 CM BELOW THE NECK  STERNUM IS DIVIDED FROM THE STERNAL NOTCH INTO THE FOURTH INTERCOSTAL SPACE TO THE RIGHT FOR AORTIC PROCEDURES TO THE LEFT FOR MITRAL VALVE AND COMBINED PROCEDURES

31.  AORTA IS OPENED IN THE STANDARD FASHION  THE RIGHT ATRIUM IS OPENED TO APPROACH THE MITRAL VALVE

35. CONTRAINDICATONS  MORBID OBESITY  REOPERATIONS  PECTUS EXCAVATUM  NEED FOR ASSOCIATED PROCEDURES CAN REVASCULARIZE THE RIGHT CORONARY ARTERY

38. PROCEDURES AT LRMC  AVERAGE AGE 70 (AVERAGE AGE AT CLEVELAND CLINIC 55) HAVE PERFORMED ALL COMBINATIONS OF VALVE REPAIRS AND REPLACEMENTS NOW PERFOMING THE MAZE PROCEDURE FOR ATRIAL FIBRILLATION

39.  AORTIC VALVE REPLACEMENT  MITRAL VALVE REPAIR  MITRAL VALVE REPLACEMENT  AORTIC VALVE REPLACEMENT/MITRAL VALVE REPAIR  MITRAL VALVE REPAIR/TRICUSPID VALVE REPAIR  AORTIC VALVE REPLACEMENT/MITRAL VALVE REPAIR/TRICUSPID VALVE REPAIR

40.  AORTIC VALVE REPLACEMENT/ROOT REPLACEMENT  RESECTION/GRAFTING ASCENDING AORTIC/ARCH ANEURYSMS  AORTIC VALVE REPLACEMENT/CORONARY ARTERY BYPASS GRAFTING  LEFT ATRIAL MYXOMA  MITRAL VALVE REPAIR/MAZE PROCEDURE