The Minimally Invasive Valve Surgery Symposium is designed to provide an understanding of the various minimally invasive techniques used for treating the aortic and mitral valve, utilizing the On - X heart valve as the platform for valve implantation. The symposium will cover in detail the various approaches to minimally invasive techniques, with particular focus on the hemi - sternotomy, right anterior thoracotomy and video - assisted techniques. Additional areas of focus will include enhanced recovery after surgery (ERAS) protocols, keys to establishing a successful heart team, starting a minimally invasive program and patient outreach and aware ness.
Moderator: Dr. S. Chris Malaisrie Northwestern University, Chicago, IL
Katherine Harrington, MD Baylor Scott & White Health, Plano TX
William Kent, MD University of Calgary, Canada
Peter Knight, MD University of Rochester Rochester, NY
Mario Castillo-Sang, MD St. Elizabeth Healthcare Edgewood, KY
Denis Bouchard, MD, CM, MSc, Ph.D Montreal Heart Montreal, Quebec
Dr. Marc Gerdisch Franciscan Health, Indianapolis, IN Please Note:
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OK. So uh last topic of the day and we'll close up this uh symposium um tips on how to start a uh successful minimally invasive valve program. Let's start with the audience. What is this just like one by one? Just um what, what have you found to be, to be useful? What has been really helpful for you to start a minimally invasive program to get the other 30% of you up is giving me. So I think the most important and so spend with them three hours so that the whole have a plan and then he's gonna account come started. Yes. So Aah would add to that. No, that's what I had in mind, training the team and one step further, I would say, choosing the team and training the team because you need to take partners along with you which are willing to change and, and wants to participate in doing something new, right? Because the, because the people that you choose can have an impact. Now, if you have negative leaders among the team that might just make the whole building crumbled down, right? But it's, but it's a great point of not bringing a team along and, and, and then having the capacity within the team to um to, to share mistakes, share the good points and, and, and do uh after action, no uh report or discussions of what went well and what didn't went so well. I think, I think that's really important, the mentor before and after. So you're gonna go watch the whole team. That's great site visit and then you're gonna have the surgeon come up and look over your shoulder as well. Maybe you guys could, I don't know what, what it's like in Canada, but if you could scrub in with him, that would also be great. We can't do that in the United States. What else? You know, you, you definitely need buy in by every single team member, but also you have to go beyond just the team members, administration. I mean, you gotta have buy in at every level. You need to, to pick your team wisely. Um And training. Yes, mentors. Yes, but there's, you need to use it wisely as well. You train you do simulated cases. So you don't look, go look at it, do simulated cases either in a fake box model or a chest model. And you put a fake micro valve in there. If it's a micro valve or an aortic valve and do it in the operating room, you'd be surprised how many things you realize you can't, can't do in your current or, and you realize, uh, too late and, and you'll get, and if you have resistance it's fine. Just don't power through it. I'll do it anyway. Try to get whoever is, whoever is the cause or whatever service is the cause for the resistance. Get them in. Ask them to be part of the team and get the solution because you want your first cases to go smooth. Uh, anything that goes on in the 1st 10 cases could make or break the program. And I mean break I've seen programs where they do it. 1st 10 case don't go well. And it's like five years later and still have nothing zero. It's really important that it goes well. So it's not a, it's a marathon case selection is I said, you know, right now, like I see an A VR it's all right, anterior sternum this that if I could get into the chest, but that was not the case in the beginning. I mean, they were perfect male, skinny aortic stenosis zero. I I normally f aorta more than 50% towards the right side. I mean, there was the perfect, it took me a month to find that patient but you need to have the wins, you need to have cardiology buy in because if things go wrong because eventually they will that they are saying well, you know, sorry for sending you the bad case. Not why the hell what did you do to my patient? So that's what's really important because you want success and when there's failure it's everybody's together and it's not pointing the fingers and blaming or blaming the robot or blaming the, the scope. Yeah, you definitely need the cover because everyone's willing to share in the success. But when there's a failure, it's just you all of a sudden and you're like, where, where did everyone go? And uh, yeah, you're not going to do a minimum, minimally invasive valve replacement, some with endocarditis or ef of 15%. You look for a good case. Um What about this? What about the learning curve for the two procedures? A mini, sternotomy and a mini thy bill. And I are gonna look at our data and see, um, see what the learning curve is. Um What do you guys think the learning curve is for a mini stoy? How about that? Start with that one? Trying to remember? Yeah, it's not, I think that's the easiest of everything we've talked about today to pick up. Um, because it's very similar. The view is the same. It's just less of the view. Um, yeah, the hardest part is figuring out how to close it. Yeah. Well, I would say what, what I have residents and so at the start I tell them they either get to, can it or they get to do the, they don't get to do both. Which one do you want to do today? And they, the, the can is the harder part of the two. especially if you do it through the chest. Like getting that aortic cannula in safely and getting the Venus in it for me is, is the harder part of the two once you're on pump and the aorta is open the valve for, for me for a heavy astronomy is almost exactly the same. Uh, my, my cross clip times are really no, no different person. Yeah, I'd venture to say mini sternotomy less than 10. You're, you're just gonna be totally fine with a mini stern harder one. Now, Bill, what do you think for a mini for a Ram TAVR? Yeah, I think it, it's gonna be longer, uh, you know, somewhere between 25 and 50. It's not crazy. It probably depends also on how quickly you do them, you know, 15 in, in two months versus 15 in six months is a big difference. If you're doing them once a week or twice a week, you get pretty good at it a lot faster. Yeah. And this, go ahead. Yeah. Um This may be a stupid question but we, we rarely do isolated a VR anymore. Everybody's a VR cabbage, a VR ascending a Vravr that like this is great if it's isolated A VR but a lot of isolated R is getting tapped that. Yeah, that's the whole point of doing mini A VR. No, I understand that. Like you're, you're 82% of 65 we're similar, we have a firm 65 cut-off if you're low risk of c but you're not getting a tavern no matter how much you want it. And that's well supported by the data. You just got to have a, a good options that you can push back against the cardiologists who are pushing that. Like my, my mini A BR mortality is like 0.3. Like, so I would like that by that has a risk of stroke and Taber at like 2.5%. The other thing is when you've got con common coronary disease, I mean, the uh once your program gets going, you'll have uh you know, proposals. Well, why don't I, why don't we stent the right and do the, do the right mini for the, that, that's, that's a real viable option. A lot of time. And you can, you can do a mini thot on dual, any platelets. No problem. And so, and so how often does that happen where they'll say? Well, look, it's an isolated PD A for example, you guys are the same, especially like ac or 100% especially if they are not symptomatic. They don't have symptomatic corner. I'll do mini on too. I don't, that doesn't bother me. Two vessel disease in an A VR and the right to chip shot maybe 50% sir. Yeah. Yeah, they brought it, but you brought it back to them. I, but, you know, stent and a graph to the right. That's equivalent in my mind. How long do you wait after they get stented, since they're, they'll be on dual antipla month. I, I actually do like stopping that. I do a month but I still, yeah, I do, I do them on, on dule plays or if it's not critical, you can do it first with a planned stent like that. Hospitalization depends on how tight it is and where depends on how tight it is. But ok, go ahead. The micro, they're all like you, sorry, like the learning curve the same question. But for a mini, how about how about a mini academy? So that data exist? I mean, Leipzig has published that before. Uh and it's uh about 75 mits for a mini Miron. We're talking about repairs, right? So if you do A P two through the right chest, that's about 75 I think that it's shorter. If you're, if you're tackling a replacement, that would be my first advice is that if you're going to to start a mini mito program, find yourself a nice traumatic disease valve that needs to be replaced, do it through the right chest, do it safely. That way you will focus on the set up on the can on the conduct of the Bipap machine and not on the operation because cutting a valve out is mindless and putting a valve in. But if it's a repair, you'll be focusing on everything. And on top of that, you have the repair to contend with, it gets diy starting out. II I would say more but, but, but, but, but just cross learning, right? What you have learned of doing can listen to the or uh exposure for neo valve. All that's gonna serve your microvalve practice, right? And if you have learned microvalve repair to anatomy, uh that also learn, learning uh knowledge that's gonna serve you in your mis. So when I say I have in mind around 100 cases, but that would include maybe uh 50 of them through anatomy, just learning microvalve repair and maybe 30 or 30 cases done for erotic valve replacement through uh right. Enter academy. But it is a longer course to learn the mits. Yeah, I mean, I think, you know, for someone like you all though, I mean, somebody who's, um experienced, you've done mitral surgery, you're in practice, you're comfortable with open mitr repairs. I mean, yeah, for you, it's, it's not, I don't think it's 75. Uh-huh. I mean, I, I will say like it's, it's, yeah. And what do you consider? Like, what do you want to get at that? 75? Like when are you like, you're good, you know. Um Yeah, I don't know. I mean, that's, that's hard to define too. I think it's tough at first. So I think morale with the team is important and that's why it's great when you brought your team and stuff. I think that's really important. They gotta feel like they're achieving something with you. That's of importance because the cases are longer at first, it's a little tougher. You don't want people saying why are we doing this? Why are we staying late to do this, you know, and you know, and taking them through it and having people proud and understanding why they're doing it and the reasons and the benefits is super important. I think not for just minimally invasive, but like we do a lot of type a staff has to come in at like two in the morning, we have a program where we bring them up to the floor afterwards. You know, you saw this person was practically dead and now look at them and same with the minimally invasive you go up, you see this tiny little incision, the patient's walking around. So I can't remember what we call it, but we have a thing where we like rotate the nurses up on the floor and see the patients afterwards. That really helps. I think in terms of the mini micro learning curve to it depends on somewhat on what technology you're gonna use during that case. Are you going to employ an endoscope for instance and do it on the camera completely? Are you gonna look through the wound? Are you gonna use the endo clamp versus the directly with a cross clamp? Because the endo clamp alone is a technology that has a serious learning curve. It cannot be overstated how careful you have to be as an entire team. Anesthesiologist, perfusionist and surgeon that alone is a complicating factor. Hard core technology. Talk about another technology that's been around for 30 years. So we've been throwing around a lot of numbers now. So 25 for 25 for mini, maybe 50 or 75 for a mini. What I suggest is if you're gonna embark on a mixed program, you have to have a clear line of sight on these cases. So perhaps you're already a big open mit practice. You've got a line of sight of line of side on these cases. Another way to take a look at it is take a look at your tavy volume. If your site is doing 200 tay, you've got the patients, you've got the patients in there. So, um, because you gotta think, well, how long is it gonna take me to get 100 mits? That's, that's, you talk about several years there. You're not gonna get there. You're only doing five mits per year. Ok. Well, let's, let's close it out here. Everyone gets, um, a, a two liner and then we'll, uh, call it a day. So we go, um, go to the gym, go to the pool, play some craps, enjoy ourselves the rest of the day. Then you go, you, you're first, you know what I didn't mind? Maybe to complete the questions of ALI is doing it as a team of surgeon. You, you actually um it, it helps you out going through difficult cases and you're doubling your exposure in your learning curve, right? If you're there one day as an assistant and next day as a surgeon, you're still learning both ways. And um uh you know, Bill has done that with Corey, we've done that with Michelle in Montreal III. I think it's very, very useful rather than try to do that alone on your side, right? And you're more also open to critics that, that we, I mean, I following up on that, I was gonna say similar, right? I mean, I think uh you know, we're trained to be uh independent and to sort of this competitive sort of this, this is the, this is a field where you really benefit from working together with your colleagues and uh uh do it starting these operations together on your own. It's a heck of a lot easier. And really, I think you should, you really should have a, have a colleague to uh do this kind of thing with. Yep. I agree. I think that uh in the panel and in the audience, you have a lot of talent that you can go watch. Um I would recommend you do a pilgrimage every year, make it a point no matter how far you have to go travel and see high volume centers with good outcomes. And make notes and if you want to take with you a partner or a, an assistant do that, it is worth it. It will change your life and those resources are available. Peter. Yeah, I would agree with that. Don't let it end here. Don't let it end today and learn a new operation every year because it's always changing. Very true. Yeah. Yeah. I, I agree that you shouldn't compromise the surgeon surgery just for a smaller incision. Don't, don't do it half, half as like if you're going to do the incision, you're going to have to struggle to do the same operation you did. But don't just like, you know, make compromises when you're in there to get it over with because it's so struggling, you have to sit in the struggle to do it like you would do it open all, all in, all in Mark. I know you have something. So, um I think uh I would reiterate in a little bit different form in the sense that uh it is a journey for different people at different paces. And I mentioned earlier that I went to visit NYU and Colvin and Galloway were working there together and I remember walking in that operating room and uh they would open the chest like the, the hood of a car. It was completely open thot and you could put your head in there and they can directly and then I'm leaning over Colvin's shoulder and he's operating, he's cussing, he's moving tissue around. And I learned some great moves from him at that time. I also learned that and because they didn't keep doing that big thoro they got down to a very small incision, you know, uh uh Galloway is a good buddy of mine. I know what he does and did, I think he's retired now. But uh point being that you can start out with a little bit bigger incision and use the cry in intercostal block if you're up for it. And that will really change that for you. But make sure you can see what you're doing so that you have these great results and then your incision just shrinks over time. Great. Well, thank everyone. I thank everyone for being here and thank you for being great participants. I had a great time here. Please help me give these speakers a big round of applause.