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.
Presenter: William Kent, MD University of Calgary, Canada Please Note:
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The next person I'd like to introduce is uh doctor. He's from Calgary and um proud to say that he spent a little bit of time with us in Northwestern, in Chicago. And um uh what makes me most proud is that uh the student is uh passed the teacher on this one. So I remember teaching him how to do minimally invasive uh aortic. And uh and uh he surpassed uh my numbers yearly on an annual basis. Uh Proud to see his success. Um Welcome Bill Ks. Thanks. Thanks. Well, I don't know about surpassing Chris. Uh um He taught me an awful lot in Chicago. So good discussion on that. At the first one, I think, um you know, the benefit of having a meeting like this is that you can, you know, have discussions throughout. And so, uh you're welcome to stop me at any point during this and if there's any questions or things that we need to talk about. So again, thanks to uh Artan uh Scott Rollins, especially for, for organizing this and for art and for being leaders and promoting and education related to minimally invasive surgery. Uh Pleasure to be part of uh the faculty here. Um Now, today I'm going to talk about right mini Thor approach for a VR you know, Catherine gave a great talk about upper heaty. We're gonna contrast that with the mini Thot approach. Um You know, and I'm, I'm not uh I don't claim to be an expert on this. I mean, many of you in the room are more of an more experts. I mean, the uh first one I saw was with Chris in Chicago. We did one together. Uh you were not using a core, that was a hand. It, I mean, it was a challenge. But uh you know, it's uh those are sort of the early days of using this approach and deny Bouchard and he's done way more of these than I have. He's uh he taught me most of the technique really. Um my colleague, Corey Adams here in the room, he does more of these now than I do. So it's um it's a, it's a, it's a great approach. Let's let's talk about um the technique. Uh what are the benefits? Uh And how do you achieve success with, with mini Thor economy? I think um the, the technical side of it is part of it, but uh equally important is uh you know, Mark is gonna talk about this later. But the, you know, the recovery afterwards and fast tracking these patients is, is key to the success and the benefit for the patients um this is a, uh as with any other minimum invasive procedure, I think team work is important. I want to highlight that. Um, well, every meeting I go to, there's a discussion of ver versus, and we all, you know, these are interesting conversations about, you know, especially the low risk cohort. What are you gonna do? Are you gonna put a ver in first and then you're gonna go to later, you're gonna go to a and then you're gonna use the VV Fit technology. And you know, all this is, um we're talking about low risk cohorts and young, young patients. So I, I think, you know, when all these discussions as fascinating as they are, we're talking about uh patients, you know, potentially bicuspid valves in their fifties, sixties, seventies. Um You know, we gotta remember that uh low risk cohorts in, in uh the partner trials were, you know, mean age of 70 you know, low seventies. Uh we got a lot of patients that are like younger than that. And so for them, it's about durability and sur and survival. And uh you know, you know, these discussions are about bioprosthetic valves. Uh We got to remember that bioprosthetic valves and, and how bioprosthetic valves are gonna be special tavy valve or valve and valve tay, uh long term durability. What are the results of that? Well, we don't know a lot about that and uh what we do know, uh when we look at long series of, of, of uh surgical stented valves like the Paramount Magnes, uh, you know, like this study, long, long experience with it is you get, uh, you know, SVD around 15 years, certainly earlier in younger cohorts. And, uh, you know, when you look at actual survival relative to expected, you know, you need a lot of years lost. And so I think when we, when we talk about young patients, low risk cohorts, and we're talking about bioprosthetic valves. We've got, we've got better options. And I think um as uh Ishmael has taught us all the ross perceives a real good option for young active patients. And we offer this in Calgary to the younger ones under 50 B A VA ory, no anti coagulation real benefit. And then the older ones, I think we really got to work as a uh as a surgical group to, you know, the uh onyx valve is just a great valve to offer this uh mid to older age cohort. Uh it offers uh lower inr less valve related complications, thrombolic complications over time, uh lower risk of future surgery. So this thing when I talk to patients and you know, what do you, what do you want here if you want, they say I really want to avoid future surgery. This is, this is what you do. And I think we can offer this in a, in a really invasive approach for the ram T and incision and get a really quick recovery. Um, now how calmly we offering Ram tea and, um, you know, I, I think I prefer to call this Ram t, a lot of people call it rat procedure, the rat procedure. I think it sounds better. Ram. T it goes over a little better, I think. Uh, so I'd advocate for that. How often, uh, is this done? Uh, well, you know, 23% of surgical A VRS are mixed according to the STS database and only 7% of those are uh Ram T so not real common. Uh low, low number overall, it brings us to our polling question. Um And this is the third time we're asking this. Uh So we, we can uh sort of go with the uh without the top one. Could we, could we put that up that uh polling slide or what I want to know is the second one. uh great. You sure. Yeah, I'll do it again. Yeah, totally. Uh OK. Yeah. Full Astronomy Ram Tea, upper upper Hammy. So, yeah, a lot of Ram Tea, a lot of people like, like I thought it's great. I mean, obviously very select group here, but that's uh that's interesting. And the next question, if you're not doing Ram, what's the, what's the reason? There's a lot of reasons for this. Uh you know, some would say, well, I don't know if it's any better. I mean, a small incision with uh, upper he astronomy, is it, uh, is there any advantage to it to doing a ram t, maybe more pain, some suggest or, or you don't have the supports to do it. So, I wondered what's been, what would hold you back from, from sort of transitioning from strey to upper ham astronomy to a ram t, if we can get that up. So, yeah, I don't believe it's a, yeah, not a training sport required. Yeah. Yeah, that's true. I mean, um, we, you know, one of the points with, uh, Catherine's talk is like you can use the instruments you have and right now, uh, and do it Monday, as Chris said, uh, with a Ram T, yeah, you need a couple of things. Not many though. Long shafted instruments. I think you need that. You need different kind of cross clamp. That's about it. So, I think it's not a big leap. Uh, and certainly there's ways to get the training and support. I don't think it's, I don't think it's much and I think anybody with some experience in valve surgery can certainly do it. I really do so. Ok. That's great. We'll move on. Um, now let's talk about, uh, we'll quickly go through the, uh, the technical side of things. So, sternum sparing. I think that's real important. You spare the sternum, no sternal precautions. How do you plan? I think they all need CTS. We do this for a lot of our patients anyway, uh mixed patients for sure. Um My colleague, Dan Holloway actually developed this little technique to decide which interspace he's gonna use. I, I've, I've always tended to go through the second um uh third in some cases though. So he suggested what we measure from the aortic valve annuus out five centimeters and then at five centimeters, look what interspace you're closest to. So he will sometimes go third interspace. And I, and I've started using this too. I think it's a great, it's a great idea. Sometimes your third interspace is better, better exposure. The other thing ct really important for identifying the hard ones. This is a hard one. Not many cases can't be done. Ram T but this is one of them if you've got the order right under the sternum, uh getting the cross clamp on and in this aorta is uh you're not gonna be able to do it. Uh So you want to know about those? Now, having said that in our series in Calgary had maybe two that had to be uh converted because for this reason. So it's not that common, but that's a problem. Uh Femorals. Uh We, we do no, some of us do percutaneous. Uh I do not, I did it for a while. I had a pseudoaneurysm issue. I just, I'm just safer with a little cut down uh in my hands. I'm not a Tavy expert. I'm not, I'm not so good at that. And uh so I use uh but knowing what the ferals look like, knowing if there's calcification, what you're going to get into how long the feral is, how deep it is. I think that's real important. So I do ac T with a reconstruction for that uh inter operative. Uh a picture of myself and uh doctor mccarthy during my fellowship. Um I think a single alumin et tube is all you need. Uh I don't, I don't think a double alumin tube is necessary. I can't really see the benefit in a ram t keeps it simple. I really believe you got to make this operation simple. Uh And a single lu et tube is, is what we use. Uh a small, a small, little cut down use um uh fem Venus and arterial cannulation. Uh Don't dissect those vessels at all, just sort of see them and put in some purse strings and, and I think we've been able to uh minimize uh complication related to that. I totally agree with Chris's point about the importance of the Venus cannula. So key um uh I think gave me this tip. Um It was, you know, both tons of experience in this, this procedure said advance that can up all the way till you feel some resistance. I used to put it in kind of be nervous, put in a couple of centimeters, it can get displaced. The drainage isn't so great. You got to get it all the way up there. And I got to say, out of all the sort of things I learned that may be the most important. It's just so important. Uh vacuum assist. You gotta have vacuum assist and your, your um you know, your perfusionist has to get a little comfortable with sort of being a minus 40 minus 50 sometimes. Um ours are because they do it all the time and there's, you know, there's no evidence of deleterious effects with uh with that much um VAC but your R A has got to look like this in every middle invasive case is gonna be a struggle if you, but you can do this on every single case, you can get your right atrium down to, you know, a deflated balloon kind of look. Uh The operative set up an Great Del Needto cardio plegia drop sucker, you know, use some CO2. Uh You can get a good access here to uh put an event if you want to five centimeter incision, second interspace cross clamp. So this is the one thing you gotta have a little different. You can't just pick a DeBakey clamp off the shelf. You're gonna need a uh that's a sign clamp. Uh A um uh The other one was a Glauber glauber clamp which you'll see here in a sec or um uh uh not Cosgrove Chitwood. Um Most, most centers have Chitwood uh clamps. So let's let's go this through the I sent him an incision. I filmed this video when I was dabbling in the percutaneous. Um, and, uh, you know, the, uh incision here going down into the inner space preservation, the right internal thoracic artery. Uh This is something I used to take the rib off at the, at the cartilage. Um, used to do that in all the cases. And then I went and spent some time with deny and he was like, yeah, I don't do that bill. You don't need to do that. So I don't touch the, the rib on the car. It's totally intact. I don't touch the re put in the soft tissue retractor. Um It, it gives you fine exposure. Uh I don't think, you know, rarely in a really obese patient would it help to, to take the rib off the sternum? But it's pretty infrequent. This is a huge move here, big, big move. Uh If you put the uh traction on that pa cardi and bring it over to the side, you're gonna bring the order right, right into position. Um And you can see here the exposure through that incision is, you know, very good. There's a glauber cross clamp goes off, then detaches. So it's out, it's out of your way, um making an incision. Um And, you know, depending on what valve you're gonna use. Certainly, if you're using an onyx valve, you're gonna, you know, I'll cut right down in the non sinus to uh get really nice exposure. Uh I think that's important. If you're using a, uh a suture, you stay a little higher for the cage. Uh Certainly. Um, and I mean, is a good one. I think when you start doing this, it might be good to use rapid deployment and suture as you get more comfortable. Certainly, you don't need to do that. I'm not showing this case just to, uh this is uh like a root enlargement, but I wanna make the point that you can, you can do this um kind of work uh through this incision because this, this part and I mean, Peter Knight is gonna tell us what you can really do through this incision. Like this is child's play compared to what he's gonna show us in a few minutes. But um you know, you, you can do complex uh work in the, in the proximal um aorta do uh root enlargement and even bent all procedures, right? So your exposure in this area, um you know, putting an event, the right for pulmonary veins right there. Like you, you've got really good access to this. Uh in this case, an on valve. Um you know, he wanted to get a 23 couldn't quite get a 23. So did a a root enlargement with a patch just to be able, this is a young, young patient and you really don't want a prosthesis, mismatch in somebody that age. Uh I totally agree. You can tie these, you can use a knot pusher but is just so superior in, in this kind of setting. So, um and then of course, uh closing your ay with, with bovine per card. So, uh I really think as you get comfortable there with this uh approach, you can accomplish a heck of a lot even more than just an isolated a VR but certainly it takes some time before you before you get there. Um ok, so really what the question is, are there benefits? So why should I uh transition over to doing RMT? Um Well, kind of tough because these are all like cohort studies, you can look at the literature and you think, well, ok, they did a great job in single center with uh you know, you know, 50 cases. Well, so I think the best thing we can do is do me analysis and this was 19 studies and looking well. So what, what can ram T versus conventional A VR um you know, longer pump and cross clamp times. Now, I think that's could be mitigated with, with experience and with using things like um but it may be a little bit longer, it's a bit more challenging. Uh But you do see consistently the, the less A F and shorter length of stay and that's becoming we're seeing that more and more often in studies. I mean, this is good, right? So this, this is uh this came out uh 2021. This is sts. So this is uh sts data, uh 6600 patients with right anterior um again, longer pump and cross clamp times. But this is sort of like real world experience. Uh it's safe, this is a safe. So those of us who think, you know, I don't know, it's not uh as safe. Potentially, it is less a fib seems to be a thing. And uh I think uh so our, our experience in Calgary has shown that as well, less transfusion, uh definitely less renal failure, shorter length of stay. So these are the things. And I think whenever you start doing something, you got to evaluate how you're doing, we're up to 267 ish uh at our center of Ram T uh approach. Uh We looked at the 1st 100 you know, no conversions transfusion rate rate really low. Uh I think that's maybe the biggest benefit of Ram T just, they don't bleed um low risk pacemakers less a fib uh five day meeting length of stay. And you know, these incisions aren't painful in contrast to the mini, uh those hurt, those hurt a lot. These, these really don't. It's, it's remarkable that difference uh in space is, is so profound. So, you know, less bleeding. We're talking about a uh a um and pain is there science behind all this? Well, our resident Ali, whose picture was on the previous slide looked at, well, ok, let's see what's going on in the Perri space. After many versus conventional astronomy, looked at the perc cardial uh drainage and effluent, uh looked at inflammatory meters mediators in the perc cardial space. And um found not surprisingly parac cardial drain outputs when you leave a drain in there in addition to the, uh, you know, uh put it on a little bulb and, and check the output, it's less. And when you look at inflammatory mediators, um all of these are less after a right anti mini thoro compared to astronomy approach. So uh what's the, what's the, what does this tell us? Well, maybe, you know, what are the consequences of pericardial inflammation? Post op A fib, maybe that's maybe that's what uh lessens the incidence of it, pericarditis, uh effusions, adhesion formation down the line, uh re operating these patients. There's really no adhesions. Uh I shouldn't say no, but it's very minimal, uh less pain and uh potentially less RV dysfunction. So I think this is, this is something, this is something that connects uh why we're seeing the clinical results that we are so looking uh postoperatively. Um Paul feedback, I think who's here today? Um You know, he and I talked a lot about, you know, it's the um the operation is one thing in the operating room, but it's what happens afterwards. The, the, the uh post op care, the quality of life and, and the qualitative me metrics or what's, what's really important in evaluating these operations. So we developed a protocol think of this as like er for mentally invasive. Uh and uh we instituted this uh just in December. Um This was developed with the whole team, with the physiotherapist, with the NPS uh anesthesia. This program is every patient is put on this protocol. Uh We want to evaluate well, how we doing real early. This is super early results. We just started this in December, we said, OK, so if we look at a composite outcome and Corey Adams did a lot of work on this, putting this together, um what's what's the composite outcome if we uh look? So we want people discharged from IC U and post op day number one intubated for less than eight hours discharged home and on or before day four, how many were meeting that before we instituted the protocol? 25%. How many are achieving that afterwards? 40%. So showing we're having an impact and is that impact at a cost? Well, no, it's not, there's no, no, we're not seeing more readmissions, not seeing more plural effusions, a fib all this uh adverse events was equivalent between the two. So we'll see as, as we go forward with this, but really, really encouraging, I think um Paul feed has been, you know, very innovative in looking at options for, you know, not everybody can have a mini, mini approach, not everybody can have a mini thoro. So when you're having to do full strey, is there a way to sort of uh help patients in their recovery and enhance the sternal closure? So he looked at some of the minimally invasive cases that we've done and compared those to enhanced internal closure with uh montage. And I think uh you know, he demonstrated some exciting. Again, this is really super early data looked uh done by one of our residents vishnu viant showing that um you know, time to discharge is reduced both when you do an enhanced internal closure and with uh mis with a ram and in physical disability, when you're looking at in index of the hack index of physical disability at week two, you're seeing a real benefit with both enhanced internal closure and with mis and when you get out to six weeks, it's even more significant with the mil invasive over the enhanced internal closure, but both superior to, you know, conventional astronomy. So I think these are important findings. I think it's really important that we look at this stuff. I think uh the qualitative metrics are really important when we evaluate how we're dealing with invasive surgery. And uh you know, final thing here as I end here is that the the the team work. So it's it's super important, I mean, could learn from our colleagues take advantage of training opportunities like this meeting, peer to peer trainings, available, meetings, collaboration, and mentoring uh young surgeons I think is, is the way to uh advance mental invasive surgery. And, and in, in Calgary, we there's four of us to do this operation. 203 7 case since we started doing this a lot in, in 2018. So it's, it's a good group. I think that's the way to do it. And there's lots of support. I mean, in this room, tons of expertise. So I think rat can be a preferred technique for isolated a VR. Uh I think really, really, really there are benefits, less bleeding and a fib shorter length to stay improved quality of life, less pain. These incisions don't hurt much. It's remarkable um better mobility afterwards. I think you realize the full potential of this with a post up protocol and a committed team and mark is going to talk more about the, you know, the post up protocol sort of er structure things uh in a bit. But um so thanks, appreciate it. Great talk bills here. Stay right up there. There's, there's a lot to unpack here and I just want to make sure that we don't, we didn't get some questions earlier uh because people came up. So can you uh go back and just kind of touch on the non um you don't dis articulate the ribs, you said? And uh have you had issues with the valve insertion? Have you had to do that after the fact or how often does that happen? Yeah. Um, the, uh, I started doing the disarticulated the rib. Uh, I was just sort of taught that way. Um, if you're gonna get bleeding, that's the spot, you're gonna get bleeding. So it always took a little bit more time to be sure it was dry in that area. Uh, and then really, when I saw Denny Bouchard, we did a few cases in Montreal and he said, yeah, Bill, you don't need to do that. I said, really, you don't, he says no, really, you don't. So uh I just stopped and really exposure is fine. Crank that retractor open when Dany does it even without a retractor a lot of the time, I think. But uh uh you know, you let the, you let those rib space open up a little bit and crank it a few more notches and your, your exposure is fine without it. So I think even when you're starting, I wouldn't do it. Make a comment mark. Yeah. So, uh yeah, I actually I agree. There's a lot to unpack such fantastic talks so far. Um A few comments first, you pointed out the aorta close to the sternum. And I think for folks who don't do a lot of either, maybe to start it, whatever this is a key matter, right? So, you know, I don't think people should be timid about kind of choosing their access based on what they're gonna be super comfortable with um you know, I have had people for whom I'm doing redos that were done at, you know, very uh high end shops that were told the patient, the patient told them they, they had a minimally invasive operation. Yeah, the skin incision was kind of small, but the whole sternum been split and patient was perfectly happy with that. And, you know, when I redid them, their whole sternum was split and I re split their sternum. My point is that uh you know, our driving impetus shouldn't be the small incision. Our driving impetus should be to scale down the approach to be comfortable with how we're getting there. Um And I think your point about where the order is, is absolutely crucial. People cannot get into a situation where they're struggling to see what they're doing. Um Going back. Uh Also, I would mention for those who don't get a, a pulmonary vent in pulmonary uh vein vent in uh they do make a small like pediatric tube that we will drop through a mechanical valve as well. And it's super handy when you just can't get that vent in. So, uh people should have that ready to go, you know, because you do want to get the ventricle emptied out. The other thing is on the redoes, um We will just put a catheter in the left main and gently inflate that and then you don't have that blood getting into the space around the valve where you're working. Uh The last thing I would add is that we use a, we regularly use a second pump suction now. So we really don't use cell saver anymore. Uh And our perfusionist who's a brilliant dude, kind of sorted out all the mechanics of that and blood damage, et cetera. And now we have this kind of high speed pump sucker that we can use instead of a cell saver, which I think is important. Um, and also with many sternotomies, I would add that we've never done AJ, we always do an I, I call it an I people say, isn't that just a sternotomy? But I did pediatric surgery, uh, with, um, with Michelle very early in my career and he would just like split part of the sternum. So I did that on adults and it will crack a little bit down there, but it never fully separates and it doesn't bleed. And if you do have to extend, you just zip the rest of the sternum open. So I think it's kind of an interesting way to do it for folks who are just getting started. If you don't want to jay off, you can just split the sternum as far as you want to go. Third, space is fine. It's what we use and then just get your retractor in there. Um, so I'll leave it at that. Thank you. Yeah, those are all great points. The, the peds drop sucker. Yeah. Really when I found that thing, I didn't ever put a vent in the right group on my van anymore. It's beautiful. Yeah. Yeah. Thank you for the presentation. A couple of questions about your regional uh block if you use any for the ram T approach. Um and any complications with lung herniation after the procedure if you don't. Uh Yeah, two real good questions. Uh The, the, the pain control strategy for the mini mits we uh those hurt. And so yeah, it's a, it's a battle. I put uh regional um intercostal blocks inter operatively in those and then we do an ESP block as well. Um I know Mark does uh cryo nerve blocks. I mean, that's a strategy that you have to have these, it, you really don't need, I, I'm being honest, you don't need much for pain control, put a little local in incision, that's it. And, and they often have almost no pain. Uh It is, it's a really funny thing. I'm not sure. I understand why this incision is so different to this incision for pain. Um Yes, her is I have, yeah, I've seen it. Uh have. Yeah. So um I would say, I don't know what the answers would be. Maybe 2 to 3%. I it's not that common but it will, it's usually a thin person. So when you take that intercostal muscle, they cough and they've got like this. So it's not a, it's a cosmetic issue. It's not a, it's not a problem otherwise, but I have put mesh, gone back and put mesh in two patients because they didn't like the cosmetic look of it. I don't know. Do you? Yeah. You know, you're probably being high at two or 3% but it's, it does happen, uh, like you said, you going back, I remember. Yeah. And, uh, what I have gone to though is, first of all, I'm trying to not aggressively, they can all hear me but uh trying to not aggressively split the muscle going laterally, right? So we kind of stay away from that, especially like you say, in that incision, it doesn't hurt as much. So you can put the tension on the muscle there and it just doesn't seem to give you the any real trouble. The other thing is uh you know, I'll put two good figure, we rib stitches in and it's not because I need to reapproximate the ribs so much as it's, I just want to close that space off better. So it's kind of taking those two precautions. We haven't seen it again, but it, it may still come. So it is, it's irritating. The vaccine patient comes in and things popping out if anybody else has any ideas. So I, I do the same thing. Um First of all, I agree with you don't go too far laterally with the intercostal incision and you don't need it. And then I use a uh fiber wire because uh fiber wire is not absorbable through the rib, not around the rib right in the middle of the space. Because if you go around, you'll have rib pain. But if you go through the rib, you probably won't have rib pain. I do that routinely. Peter is that the Arthrex fiber tape, it's a fiber wire. It's orthopedic, uh um uh suture for approximating 10. It's called the fiber wire. It's called the, I used, um, I used, um, a initially and you think that that would be a good enough because after two or three months, you know, you shouldn't really need it. And then I had a patient maybe nine months post op cough and develop a lung hernia and then went to the non absorbable and I do it on the, on my as well. What about, what about the rest of the panel lung herniation? I, I have, I have not seen it for, I have had two for me for my, you know, spite of approximating the ribs and I had to go back and fix them. Um, I did put mesh on both of these. Yeah. Yeah. The, the patients are very symptomatic when they have it. Yeah, I think, yeah, I think some, I mean, thin, thin person, they'll, they'll have a little bit, uh, you know, and so I almost say that, you know, that may be something. What's your, well, I, I've seen it. No, questions. I, I didn't thought that I've seen it often enough to worth closing the space and give maybe intercostal pain, extra intercostal pain, those two cases that, that I've taken back, I closed them with sort of the, the medical th wraps. I can't remember the name because it's broader than the stitch. I would think it crushes less on the nerve. Yeah. Yeah. The, yeah. Yeah. Yeah. And, um, and I've seen it only, I do my aortic valve and my, my Amy with that incisions and I've seen much more of them than to the incision. And usually because I think that the were mobilizing the petrol muscles and go underneath and then petrol muscle goes back and, and, and pull the holes and we cannot do that higher up. But I didn't sit often enough to work doing it unless the space was super wide. But I like Peter's idea that if I go within the rib rather than compressing from the outside might be better, I wanna ask you another question. Have you seen um pectoral muscle necrosis? Uh when you close it, uh do you, do you close? Just the fashion on the top of the? That's a good point. I try, I try to, yeah, I haven't seen uh issues with necrosis and very thin woman who has a very significant cosmetic defect now. And I believe it's because uh we went full thickness basically on the peck. So from that experience, I've gone. Uh, I split the picture, Alice, uh, on the way in and then just close the fashion on the way out. That's a good point. So, these are all costs of doing a mini Thoro, which we should, we're going to stop talking about that right now. So that's the cost you have these sort of issues. But what, what is the benefit of a mini Thoro? I'm always interested to know what is your exercise restrictions after a mini ram TAVR for your patients? What? Because, uh, cat said eight weeks for her mini sternotomy? Yeah, I usually, um, when they leave the hospital I told them that the only place that they've been operated is on the right arm, right? So that they can, they can carry bags on the left arm and they can walk whatever they want. And, um, and, and the, uh, patient wants to play golf. Yeah. So, so, so, so those I would tell them to wait a month. So you usually says be for the first month, not working out too hard with the right arm and, uh, and obviously not cough too much, don't cough that long out. It's a one month, Mario, what, what, um, what is in your protocol? It's a, it's a month but I've had, I've had patients come back to the clinic and tell me I went hunting because it's Kentucky. So they go, and they shoulder arrived for like two weeks and they did Ok, not happy about it, but, yeah, 44 weeks is that's not exercise that's hunting, that's hunting. Uh, just, just shoot from the other side, shoot from the left side. Right. Peter. What, what do you tell your patients after a minute to narcotic? I tell them basically, they can do whatever they want as soon as they want to. I, I think pain is the only thing that's gonna restrict them and that usually tells them what to do. Uh, we have a policy that our patients are not supposed to drive till three weeks after they go home. But I tell the patients again, if they have essentially none of them go home on narcotics. So, uh they can't drive home from the uh ramp garage, but they can drive as soon as they feel safe enough. That's awesome. Peter Bill. The protocol. I'm with Peter. I think I tell him the same thing you would do whatever you want. Yeah. Yeah. Ok. Yeah, I used to, I used to tell them no restrictions but I had a patient decide to bench press. 253 £100 broke the suit shirt and come out with a lung herniation. So I say you could do whatever you want, but you can't bench press a lot of weight and you shouldn't shoot. And I'm in Texas now. So I also tell them to put the gun on the other side. So those are two restrictions I give them a, a couple, a couple of points. I think one of the things that people struggle with, with the many A VRS, whether you divide a rib disarticulated it, what have you is the exposure of the, the valve itself. And I think putting three sutures in the top of the commas and suspending the whole valve, bringing the valve up into the field, delivering it up into the incision itself is critical, especially if you're doing like a myomectomy or a root enlargement. What have you? I, I think that is absolutely imperative. And I see many surgeons sitting there and they, they struggle and they put their, you know, sutures in for the valve and they, they only partially pulled it up and then, you know, you pull it up and it's a big deal. I mean, I, I think the long hernia thing as, as Mark was alluding to earlier is very real. And, oh, probably 15 years ago, I went to a permanent suture, an eon suture for my, um, uh Percos. And since I've had that again, I don't know if it's so much, I'm pulling the ribs together or I'm just preventing the lung from herniating through it. And I just use two, maybe three if it's a bigger thot if I'm doing like multiple valves. But I've, I've almost had none since they've done that. And I think that what happens when you use the traditional Percos sutures, which are vir you said three months later they dissolve, they cough and you know, there's nothing there. So how long for excise restrictions? I'm gonna talk about that later anyway. But we have the same precautions basically for everybody no matter what operation they had. So we'll, we'll get into that a little bit later. Two things I wanted to mention. Uh one is the point was made earlier about when to put the pacing wire on and where I think this is crucial for folks who haven't been spending a lot of time doing minis, right? So you gotta decide where you're gonna put it and then you gotta be able to test for bleeding, which was mentioned before. So you put the wire and you gotta give some blood or cardio at that point to know if there's gonna be some bleeding, if there's any bleeding, right? You gotta get that wire out. So you alluded to, you mentioned it. But I think it's important for people to actually know this is a concrete absolute detail. And I made show in my video that you know, we put it in and then we tested it and then we clip, we actually clip the pacing lead to the P cardi until the end of the case just so I won't pull it out because I clumsy in there and I sometimes pull it out. So, but that's something to remember also that you needed to be positioned because you don't want to go back to it later. So do you all put it in at the beginning of the case or at the end of the case of the, of the cross time? I put it at the end, I don't use them, don't use them at all. No, not unless they have heart block. Well, you don't, you don't put them in for tabbies and they have a higher pacemaker, right? So, so another question, correlating to that is how many, how many of you use a swan against catheter A P A capital? For these cases? We use a lot of cases. There's some costs associated with it. Um Not much. A lot of centers don't use A P A catheter for any of these operations. We stop using it for most things. I think that the information you get from it is very small at the area of echo and DV function, the RV function, you can have no estimate of the P pressure, just an extra, extra catheter and extra complication. Sometimes the last thing I just wanted to add really briefly is Mike had mentioned the transverse sternotomy, which is a real thing and you can really get amazing exposure and it's a bailout, right? So people shouldn't, you know, you're looking at it, you're deciding if you wanna go and split the whole sternum when you have a right answer your thoro I've done it twice and I worked perfectly both times go all the way across to sternum. You do have to be able to put it back together, which I can explain to people. Both of those patients really didn't even know we had done that to them was extended, their incision a little bit. And that's all. Uh So it's worth knowing how to do that with plates, how to get the approximation. Once you get the bone approximated and then using a plate properly, you'll be able to get a, a good result that won't, the patient won't even know their sternum is divided. So this approach I think is uh the sweet spot for surgeons or Ram Tabr. I, I'm using that more as well that term. Uh but it comes as a package. So you're all in, you got to be all in on this one. This is not like you're gonna do this month. You're not gonna do this Monday. This is not a one course thing. Um uh You, you gotta figure out exactly what package you want. You like, Bill Kent's package, just talk to Bill do it exactly like that Peter Knight or deny Bouchard. I'll be glad to tell you how I do it. Same with Mike Marant, but you have to have everything here and uh we didn't unpack it all but everything from CT A to arterial cannulation to what Cannula you use where you put the Cannulas del Nido versus no, you know exactly the type of cross clamp you want to use um how you want to deal with the rib if you want to disconnect it or don't the regional anesthesia. This is a package. So if you're going to start doing Ram tavrs, uh pick your favorite person up here and just connect with that person and take them out to drinks and maybe invite them to your hometown. But this is, this is a sweet spot, but you got to be all, all in on this one. Uh Can I add something? I think a lot of the anxiety when starting to do this operation through a tiny little hole is not knowing what the heart is doing is not having control and vision over the. And the only way you get rid of that is by visiting somebody and saying, oh, you can get away with that. I did, I didn't know that and you see like them do cases over and over and you see what things can do, right? So you can give cardio plegic, get a good rest and you're not looking at the heart, but the heart is safe, right? And you, you get that by proxy understanding of what you can do or not do? Great, great, great point. Can, can I ask a quick question? Um I think Bill kind of mentioned about the uh pericardial sutures and using that as a retraction. Can you comment on the shape of your pericardiotomy and and how that might assist in the retraction? And then also Dr Harrington mentioned that she tried to avoid going towards a commissure uh on Bill's uh video there. He kind of extends that into a hockey stick incision. Um kind of if you guys can compare what, you know, pitfalls and what, you know, how you can use these retraction sutures. I know that Dr Moran mentioned about the suspension sutures. What have, what have been your difference in incisions and perot incisions and suspension sutures been like, OK, I'm gonna answer that for everyone if, if you don't mind. So there's two questions there, the uh parac cardy, uh the pericardiotomy, I've gone from not taking the thymus out to taking half the thymus out, just take half the thymus out. So you're looking straight at the uh pericardium, um go straight down to stay sutures. I prefer to bring them out lower to the right. So you're gonna need an instrument called a Carter Thomason suture retriever. And then you could bring them right out the skin, they're invisible just to make sure they're not bleeding and that pulls it either up or down. It brings everything closer to you. You could ask anesthesia to give you a little bit of peep on the other side. If you've got double lung, if you don't, you can't do that obviously for the aortotomy. Um absolutely have to go in the non coronary sinus. Otherwise, it's a pain in the ass closing a bio prosthetic valve because the posts are gonna be in your way. You're not gonna have that problem with the mechanical valve. Yeah. Go ahead. Yeah, like I said, I, I don't like extending it down. I mean, I'll do it for root obviously, but I like to keep as much of the bleeding up towards me as possible. Uh, that's when the heart is beating. It's hard to get to when the hearts are rested. I don't, I don't use retraction stitches at the, I just, I can see the valve. I, I don't have a problem. Yeah, we used to, we used to call that, uh, cut all the way down the road to a coffin corner. That's what's gonna box the patient. If you lose control, when you're pushing the valve in, it can extend even further. So I like to, I don't hockey stick at all, but that's just my personal preference. And I think that's the big difference really between the upper, uh, he and the right door economy. I think in the right door economy you do need to go down lower. But when you're coming from a different angle, I can see that without, I mean, the beauty of the, of the upper sternotomy, it's the exact same operation as a full sternotomy only. You can't see the right ventricle. You had something. Yeah, I, I do my ahoy quite differently through those, through those right approach. I make it right in the middle of the incision I want it to be easy to close and I want it to be easy to add extra stitches. So now when I was younger, I was doing sort of low ery and then you put this type of and you do it a bit differently for the righty. My ery is mirror is, is the continuity of the rat itself. So, so, so it's right there in the middle, in front of me. So easy to close and even if I do it lower, I don't see that part of the world because there's the rest of the, of the rib cage, right? So, so you have to work a bit more in the tunnel, but that's the name of the game, right? Yeah, it's about the view. Not about how far it is. So this, this brings up the next couple talks here. We're getting into, we're on, save it, save. Yeah, because we're gonna, we're gonna run behind here. We're gonna miss a break and lunch.