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: Denis Bouchard, MD, CM, MSc, Ph.D Montreal Heart Montreal, Quebec Please Note:
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OK. So um this is the last surgical talk. Uh Deny Bouchard is the chief of cardiac surgery at Montreal Heart Institute famous for many, many things. Um We asked the need to talk about another ski is the limit um procedure. Uh Not many of us are going to be doing minimally invasive double valve surgery. Uh So this is also pie in the sky for me. Let's bring up the well. Uh Thank you Chris and thank you to, to give me the opportunity to do uh what I like the most, you know, spending time with friends and spending time with colleagues and discussing heart surgery, stitches, cuts and, and all that. So, um the plan of the presentation that I'm gonna give to you is um when I start thinking of double valve surgery, uh I probably thought mainly about aortic and MIT combined, but I still wanted to go over uh the problematic with mit tricuspid surgery. Um There's also actually data that I want to share about burden of adding a second valve to to your micro surgery. Then uh bring forward uh some of the data that is being published about uh double valve, uh mis rep repair or replacement. And uh towards the end of the presentation show you um a case presentation and then a few words about the datas and techniques for uh triple uh valve uh mis surgery. So everybody I have seen that paper and no, uh now we were part of that study of, of uh randomizing no patients with moderate tr or diluted analyst to microvalve alone compared to microvalve plus tricuspid and lows. And um one of the uh composite endpoint outcome was actually progression of the tricuspid regurgitation. And the, the addition of the um analyst was actually uh effective at getting rid of. So this is two years follow up, but there's 6% of uh severe uh tricuspid um regurgitation when you just fix the mits compared to 0.6. Now, survival is the same, this, this is the two year survival of the two groups. Now, the mit and the ring being on top the red line and the blue line being the mit alone. And if you look um further down towards the right of that graph node, that is comparing microvalve surgery alone to microvalve surgery and tricuspid and low plasty, you can see that um that recur no, with the uh with the more yellowish part being moderate tr and the purple bar being a severe uh R now the uh NYHC functional class, no, at, at the different points in time were actually identical between the groups, however, not the surprise that which it was not a surprise. No, I could have any of us could have written before doing it that we might have more a V block. And it was the case with no percentage of patients having a complete a V block going from 0.5 to 7.6%. So a seven fold increase in the requirements of pacemakers, no 14% having pacemakers and groups. So that brings us to the idea now, well, there might be a burden then to do more than just a micro valve. And, and from this paper that got that look into the concomitant valve surgery. Uh from the Netherland Heart Registry looks exactly into that. They actually comparing it's a busy slide but just to show you the comparisons they look at. So Mapi M I and Tricuspid, there's probably um uh 1500 cases uh in that series, it was a bit older patient uh in the combined groups in both and uh and uh mis um the LV uh function was a bit um different being um more moderate dysfunctions in the toy Microvalve Tricuspid. Um and the pe pressure uh seems to be um actually a bit different with more um with a higher proportion of severely increased p pressures and the patients requiring trico valve surgery. Now, Microvalve also was not distributed equally. It was uh a bit less common in the mis microvalve and cu did surgery and as well as some changes between the use of mechanical valve and bio prosthesis. But most importantly, if you wanna look at the burden of doing the combined procedures, the mortality has been very, very low and both of in, in the four groups actually. So there was no advantage there. The um length of the hospital stay was a bit longer when you do the days of double valve surgery, nine days compared to seven. is it clinically significant, might or might not? But you're doing those surgeries for a very long time. And the new onset of arrhythmias here, they don't differentiate between new onset of a fib or uh a V block. But, but there was um quite a few more uh nuance set of arrhythmias and the double valve surgeries in both groups. Now, uh 44% for the double, compared to 16 and 36 for the, for the standard approach. So here's the survival curve. So you see in green that the mis mitr alone, the blue is the mis double valve and the red is the stary double valves. But once you um do um work to get the, the the group more similar, the the survival is actually the same between soy and mis. Now, what about my main idea of looking at what we know about Aorto and microvalve surgery, Conant surgery? Now, that's a paper from a Chinese group. They use same incision that we use in Montreal, it's a bit of a hybrid between an aortic and micro valve. They obviously have a bit of a longer CPP time. An aortic cross clamp, no, 100 and 46 compared to 91 minutes and 100 and 15 compared to 75 minutes doctor as well. Published his results um showing a bit of a faster surgery with aortic cross time of 104 minutes when they were aortic valve replacement and micro valve repair. But longer if that was replacement of both the aortic and micro valve. Now, this is the um a review paper of everything that has been published about the double valve approach. And obviously, there's all sort of incisions with all sort of surgeons. Uh But globally speaking, you know, if the um uh paramedial incision would be typical of the aortic and the would be further lateral. Uh usually something in the middle would be the best approach to address both valves. And obviously, he could uh give you access to all of the valves. So in that review, I not gonna go through all through all of it. But what's interesting is there are different exclusion criteria. So obviously, cabbage, you know, is a exclusion criteria. The um deep chest, the very superficial chest also comes back. Um I've seen respiratory disease in my practice, people with severe COPD or according to me, very, very good candidate for mis because we don't disrupt uh the, the chest anatomy as much. Um I think re operations or good cases in my mind, very, very severe. Mac would be part of the patients that I would hesitate, you know, at least early in the practice. Um What would be the inclusion criteria? Sometimes groups brought, you know, being less than 10 millimeter, 10 centimeter from, from the chest wall, 45 degrees uh of the, which is a value that I've never used. Now hearing that again, busy uh slides, you know, from one paper to the other, the mortality is extremely low. It goes from almost um there's 7% in one of the small series to zero, but most of the groups are very, very close to the mark of 0%. And um C PB time as we can expect are a bit on the side with around 100 and 30 140 minutes of uh of, of C PB time. So this is an image of, you know, looking at those inclusion criteria of looking at the depth of the ascending A, looking at the angles, the angles I think that pulling on the card, you pretty much always end up, you know, having the a exposure that uh that you want to do. So the clinical case that I want to bring to you is a 61 year old man. He's got a f he had rheumatic microvalve disease at balloon dila, you know, a couple of years ago, he is known as well for diabetes. This had a stroke with some uh form of uh a remaining uh left uh arm uh weakness as well as leg. He had craniotomy. Uh For the echocardiogram showed no MS with a gradient of nine aosis uh moderate no with a valve area of 1.1 and it's got 2 to 3 plus tricuspid regurge station with a pulmonary pressure of 50. He's got normal angiogram. His Euro score was calculated to be at 4.3. Um This, this is uh this is an echo of that patient has a 3d view of his valves or it goes super fast. Um So much valves. No, clearly the A valve is leaking a bit and uh there should be some view on the tricast side as well. And no, no. Ok. The I I know that never does chest ct, I do chest ct on everybody. Every single person leave my office with the prescriptions for a scan thorac abdomen and um and pelvis, I wanna know how I'm gonna those patients I don't do can on everybody but I like to do it if that can be done safely. I like to know where the aorta is gonna be located and try to pick up the best in space. Uh And that's trickier than if you just do the aortic or just do the because you need truly to find what would be on that doctor patient. The best approach for both valves. So here, if I stop it here, no, here is central, but it was a bit more right shifted when now it was higher. The left is huge, which is good. And um I don't know what's wrong with the color, but that's a 3d reconstruction that I do in Montreal where they keep, they keep for me, the left atrium and the aortic root. And with those two features in mind, I tried to figure out now here if I'm uh if the angle of Louis is here and I'm in second Tecos space, am I gonna be too high, too low? And usually if a bit like bill was saying for the for the aortic valve, the second Tecos space would be the most frequent for my case that would be between 4th and 3rd and for the double valve, most of it, most of them would be the third and uh somewhere you know, if the right uh dot or the and the blue dots are the mit, usually it's somewhere in, in between and we need to convince ourselves that we need to stay somewhat more lateral, that would be comfortable for the aortic valve. If not the angle of work for the is going to be quite a bit problematic. So here on the uh on that video, it does look like a ne valve incisions because it's too high at the third space to uh be able to dissect underneath the the the petrol muscle. So you go through the peal muscle. Um bill was super kind to say that I really uh displace the ribs. Uh I tried to be as less invasive in terms of moving around chest uh structures as I can. However, for those double valves, I would say the great majority, unless the space is very, very generous, the great majority of the cases would have a displacement of one of uh of one of the cartilage at the junction with the sternum. And I usually look up through the womb first, figure out where are my structures do I suit? So I open up the pericardium, but I've not decided which which of the two ribs above and below the incisions that I'm gonna uh mobilize here. I'm mobilizing the superior ribs and uh to uh have the difficult access uh of uh of having proper exposure for both valves. Now, I'm gonna speed this up a bit. I like the Edward soft tissue retractor because of the radial force that they can apply, you know, forcing open the intercostal space as much as we can. And um that usually gives quite favorable results if I can have nothing metallic into the incision is by far my first choice. And um once in a while I would use um a gil retractor, just a tiny metal retractor to increase the size of it. Here, we can see, I'm trying to bring the camera through the incision so that you can see the aorta, I do see it a bit myself. We don't see much of the, of the right is here and here you see the gil which has been used for the um for the incision. So now that we are inside um with those, no, you have seen it on the scan, the left atrium was huge. Uh So these are not the most difficult cases because you can always end up putting a long enough um left retractor blade to expose yourself the micro valve uh quite nicely. Um But, but if you don't spend enough time exposing yourself properly for the microvalve, you're gonna find that uh that through that incision, the view is a bit more coming from above than let's see the video that the beautiful video that showed us where he had the complete lateral uh view into the, into the left atrium. So here now it's a very, very rheumatic valve. It's as disease as we have seen on the echo. I like to be very, very progressive in the way that I um that I cut the anterior leaflets, I just cut a small part, start putting my stitches. Um And as we go along, you know, I I tend to uh to open progressively more and more on the uh an interior microvalve leaflets. No, I don't want to show you all my tricks knowing for the interest of time and try to move to move on. Um II I truly like no uh mechanical valve. No, this great great prosthesis. I like to keep the enter in the leaflets most of the time. And I like the fact that the casing is go deep into the ventricle and cannot have uh entanglements of cords. Uh keeping the whole apparatus that way I think is um is safer here. The valve is down and uh obviously for those uh for those double or triple valve case, uh uh I like using to save time. Um Bill told me that it is cheap in Canada and I believe them the uh I want to move II, I would, at this point, I would close the uh I would close the army. That's what I'm doing and uh leave the uh leave it um sections into DLV. Uh Here, I'm finishing the closure of the left atrium. And uh well, there's something happening here. OK. So now I'm uh I, I've exposed the Arctic valve. The most difficult part is truly doing the nitro once the mit is done, uh the Arctic valve is very, very, very similar to what we have seen with a regular right, enter interior omy incision. Um Here measuring with a top I, I like using as a second no, at the MIT aortic continuity because it's coming above the annuus. And I think it makes uh less competition for space. Um This is a case uh that I've used a, so we don't see cardio plegia. We don't see, you can work no for your two valves. Uh without having to worry. Uh if you go uh at a decent pace about reducing uh the cardio plegia, um it's figure of eight stitches because that's how uh I like putting the, the top hat. Um Let's see if we can have the valve down. It's about to come down then again. Now you see the incision with the, the rib mobilized and just the soft tissue, it's known it's space is generous enough to be able to bring down uh, the prosthesis between the ribs without too much problem. I find that when I, whenever I, I lower down the prosthesis and that's more true for the TIC valve than the micro valve, the smaller my incisions, the more I take time making sure it's properly well seated because you don't see as well. You cannot know forego that step. You know, you need to take all the views that you need to make sure before time that you are exactly sitting the valve the way you want it to be seated. And, um, and it usually takes no more than a few minutes for that, making sure that the valve is all the way down. And, uh, let's see what we can see on our Yeah. Ok. Um, you not, you have not seen the Tricuspid, but it doesn't matter. It was pretty much straightforward. It's usually sort of low down into the right chest and you would see it a bit in diagonal when you come up. And, uh and there's so little to do usually by just putting a ring that whatever the exposure that's not as difficult. Uh It's not easy when you do just the, and the, the you're always well exposed in tracker, not always so much, but for that uh triple valve approach. I don't think that the tricuspid is harder than it would be in just regular combined. Now, uh I move a bit my technique of, of uh thermal can uh just like to do a little uh quiz here of who's doing that and who's doing what in terms of uh can for mis cases. Now, these are you're going to write academy, what would you choose? So the answer so far uh thermal cut down or that we have seen from the presentations trans trans approach. No, probably with those who have more um uh experience central, I never decide that I'm not gonna do an mis case because there is per vascular disease. But I would definitely not hesitate to change my can site. If I want to do central can I would do a small incision higher than my incisions. And through that separate incision, just the size of the cannula, I would can lead straight into the ascending aorta. If that's a redo open graphs, I would sometimes dissect the Cleon. And if the, the thermal vessels uh are fine. Uh My choice of incisions is um is usually trans and and I'm super, super pleased with the results. Now, this is a little small footage. Uh I had the chance to dive um off San Luca in a gorgeous, gorgeous, yeah, in the gorgeous, gorgeous places and every single dive we would see those giant giant mentor rays like 12 ft in diameter is not just amazing and pretty much at the same time, I started using the system for uh for, for dealing with my and it is 10 times better than when I use the device. It makes it so much, so much um simpler, more eic eic and with less chances of compromising the femoral artery. So here, you know, that's the anesthesiologist asked them to put some grand when they're putting their lines so that it's eco guided. And uh with the mental device, once I have the, the wire in place, the first step would be to bring a measure that is just not the depth of the can. So if that's a feral condition can, that I would do for, I would just do that step of um of bringing the measurements and once is ready to come out, I would do the rest of the um of the of the man. So this is the measures it would come down on the groin and then you would have a little blood gush when it is within the femoral artery let's say uh the blood gush comes at four centimeters. Uh you would want to bring the mental device one centimeter deeper. So from 4 to 5 here, probably the blood gush is about to come. Yes. Ok. So then I pull out a bit and I redo it to have the proper marking. So when it's, when it's done, it just no feral can as you would do percutaneous. Now with, with one dilators and then the cannula and at the very, very end of the procedures, I would stick a needle into my, into my fem cannula and uh bring a very, very uh lipophilic uh wires because there's gonna be a lot of friction within the tubings. And then um and then you bring the device into your femoral artery at the same side as the can obviously. And so that's the second part of it. And once the device is deployed, you just, you know, remove the wire, cut the small cord and um the device has been removed like for two or three seconds and you remove your hands and that's it. There's no, there's no compression, there's nothing II I thought it was miraculous. I am, I am even considering doing my partner of microvalve surgery doctor uh does open, open uh grid can and, and I think I get better results with that in terms of not compromising the of the vessels because the plug comes on top of the vessels and there's never any form of construction. So the um so on, on, on that patient's ingredient was a bit high in the top act. Even though it was a 25 gradients on the microvalve was fine, worked well. The patient that uh as a good post up echoes. No, this is the no, the aortic was was similar a bit of delirium, a bit of a f uh this has been our experience at the Heart Institute. Um I have not convinced my colleagues yet. So these all, all my cases, no, around 150 were MIT aortic. I've got 20 or something uh triple valve, uh a, a couple of cases and a couple of cases of myomectomies and MIT which are cases where the myectomy is done through the aortic approach. Like if it would be a VR that's why I joined them within that experience. We've discussed the cardopa choices uh earlier. You know, I'm a big fan of for those double triple valves if you don't want to rush yourself and be concerned about cardio, I think has been very, very good for us. Um For the Tricuspid, I don't, I don't put uh a Jaguar Venus. Can I like to have no, some are done done by Tronics. This one is from Nova Can that got holes into the IVC and holes into the SVC part and you just need to loops around the, the, the uh I think that the drainage is very very good and it is simpler. I like it simple, especially when there's a lot of work um here to finish. Now, that's one of the only publications on the tri triple valve. Uh mis no, that's from the group of uh of uh and they have five cases. Um And uh the incision is a bit larger than mine. They use retraction and the large enough to do uh central, but that's the same concept. So one valve for mis that's truly the way to begin. And uh and it's nice, you can have the perfect, perfect incisions, either for the or for the mits. When you move into double valves, you're moving into something that's going to be a bit of a compromise, compro compromise more strongly for the. So think of it when you choose the incisions, be a bit more lateral than what you would like. And, and Tricuspid is just adding not much to the complexity of the procedures. So, thank you. And uh maybe before we take questions, uh I would have another uh little poll. I don't know if you can put the, the poll slide forward and we'll see whether you are good students or not. We have the results having a chance to answer yet. Let's see. Yeah. Well, I think that we only have the perfect students. Well, thank you very much for your attention. OK. Right. That's um I just wanna clarify on how you do the double aortic So you said it's in between? Does it look more like a or does it look like a more, more like a ram? It looks a bit more like a ram? It does because you got no, I, I would never do a here. Right? As I learned it, I've, I've learned my miss with was doing them like for space quite and, and, and the more that I've done it, the, the, the more lateral I end up and you know, Mario's incision was super lateral. That's the same place as our robotic incision, right? But working on the aortic valve through that perfect microvalve incisions would be very difficult. So you need to compromise. So, so the compromise is looking a bit like in the aortic valve, which would be maybe a bit lower, but sometimes my s are at the third and definitely more lateral. Ok. So it looks more like a ram T I thought I saw an atrial lift re tractor for the Yeah. So where are you bringing that thing out? So that thing is coming, usually there's not much space. If there's a bit of space between the sternum, I would, I would do a transitions, bring the, the, the shaft of the retractor truly against the sternum and, and uh then you pedal uh within the left atrium and sometimes it would only hold between the ring of the sub tissue retractor would be the one holding that shaft. But that's not the difficult part. Now you end up having quite a stable shaft to do your left retraction. The difficult part is that you're gonna be looking at the micro alphabet from higher up, right. And, and you're gonna need to try to tilt a bit the left atrium to be able to see the microvalve unless you got one of those nice 3D camera where you would actually all being on videos guidance. But if you don't have, if you don't have 3D view, like we have on the robot, just looking at the image on the two D image is, is very hard to do. It's hard to, to have the proper feel for, for the depth of, of your stitches, right? So, so, so I like to be able to visualize it given the fact that I'm not using a 3D camera. Well, there's no arguing with 100 and 40 cases. What, what other, what do other people think about? Um the, the approach to double valves, Aortic and Marshall Mario, I think you said you had a couple of double vows as well. Yeah, so I I've done uh I've done also triple vowels. Uh It is AAA, I usually go to the fourth space for the mitro, but I go to the third space when it's combined. Truly third space, I put a scope in the second space uh really comes in handy when you're looking at the aortic valve, uh retraction stitches and the that pull the aorta to make it look at the incision to see the Shafter, the, you see on the pipe of the aorta, you see very well. I shy away from doing a heavy, heavy er, that way because the instruments are not good enough to really get that calcium out safely. Uh The run jus are not as strong as the regular run jurors, et cetera um uh unless you use, but then again, it's another cost but for A I uh for a s that has modern classification, not very, very heavy um with the microvalve that you're replacing or a simple repair. Sure, go for it. Um That your doesn't fail. And the third space is, is no different. So if you're fourth space, the March, you do third space for combining with Marshall Kat. What do you think? Yeah, we, we do most of our, you know, robotic or sorry, our martial track with robotic and then I do that but we went and I went and watch any bad war a couple of months ago. And so that was where robotic ra was most exciting for me because that, I think if you could do a robotic triple valve, you get the best of both worlds. If the robotic A VR is really reproducible, I don't think you have to, you know, suffer on one or the other because you're getting pretty good views of both. So we're planning on doing starting robot a VRS next month. And then we're hoping to move into, you know, develop that way. Any questions on the approach. Because I'd like to talk, I'd like to talk next about the, uh, because you're, you're the first one to talk about, uh, percutaneous femoral arterial approach. So there are there any other tricks that, um, you can apply from other field, other parts of cardiac surgery when you have a small femoral artery and you're worried about, uh, leg ischemia. Yeah. So small. First of all, I don't shy away from using small candlers. Right. That, that's a discussion that I'm having for every single case with the perfusionist. No, that tiny little lady I, I would, I would do it with a 16 French can. Do. They have any problems with that and, and the smaller I go in my canon, the more I need to be in the mindset that I know exactly what I'm gonna do. And that's gonna be a short surgery, right. If you wanna do a two hours and a half surgery, now, that's where, no, not being perfused at a high enough flow might be more problematic. Right. So, so, so I don't shy away from using small can, if, you know, the are small, uh, if they're calcified and they might be still, can you possible to ate them? Those that would do a cut down. I'd rather see them. You know, if there's a bit of disease, I wanna see where is the plaque? Where is the soft spot spot? Are we gonna truly use that? But most of the time when I'm in that mindset, very, very small s or uh uh the access, I rather just switch to central can and making sure that the aspect of the surgery is not gonna be a problem. Anybody else have matrix for small femoral arteries. I, I got an answer in mind. I want someone else to say it though. Was that actually bilateral? What about, what about our heart failure specialists? What can we, what can we bring in DPC? Yeah. So if you got a small femoral artery, this is, this is why we're cardiac surgeons, all of our ECMO cases. Uh Almost one, I'd say 100% of our ECMO cases will get a DPC. And now I'm not just using it for small femoral arteries for thermal arter. I'm using them for all of them. Why even, why even worry about it at this point? So I just put a DPC in. Go ahead. I got a five French sheath that's braided. That's, that flows really, really well. Yeah. Yeah. But, but you would be worried for the duration of the surgery of, of ischemia because not with the DPC. No, no, but, but that's why you're putting the DPC because we would put a DPC on every single case of the, because they're there for a week, right? But for, for the two hours of your surgery. I don't think it matter much whether it's tight or not tight. And, um, it's, uh, I sort of view a dead leg as a never event because it's gonna be an automatic, um, settlement for you. If that happens, you're not gonna go to court on that one. You're just gonna settle that case. I have a question for the, the, uh, any, any concerns about the size of the candidate, Is there a limit to like if you use a 25 arterial? What's this? I have not the, the larger Cannula that I've used is 22. I I don't, I never go above 22 of the can I don't use it for the Venus site. So, so, so I usually use the 25 for the Venus site, just put a big stitch and take the, the stitch out to three days after. So, so they decide I want to save money and I wanted to make it simple and, and the thermal uh arterial side, the larger one that I use is the 22 and it works perfectly fine. I would say my average can size is more in the 18 to 20 in cost of a comparative say, per close or it's, it is a tiny bit more expensive than two per clothes. So, so to give you an idea per clothes in Canada is probably uh 120 per device, no Canadian dollars. And uh and the man would be like 2 80. That must, that must be because they're charging us 2 50. Yeah, you, you need to use more. And then to say, Dani said, yeah, yeah, we were part of the trial and we use, we use it for our tas and our tea bars. There's multiple sizes like the small size works almost 100% of the time. The larger size I find fails but a larger percentage of the time, maybe 30% of the time. So I, I think it's fine in the small but II, I have not had the failure of the man yet. Uh It has been very, very reproducible. I always uh I, I do like preparations all the way to the toes so I can do, you know, peripheral pulses and just to make sure that, you know, because we don't do angiogram, no controls that, that the pulses are still in place. Uh But with the I had so far no uh worries about distal perfusion and uh no worries whatsoever about bleeding from the sites. But compared to the probably that those vessels are in better shape, you know, because the patients are not that old and they're not that sick. Now, most of my practice is microvalve surgery which is very, very different from the right. So we have, we have a couple of questions. One, she, I thought she had a question is 25 French. It supposed to supposed to close 25. Usually competitively priced at about the same size of, depends on what your reps doing out there. We don't use it. So they, I mean, they offered it to us, we just think it's too much material inside the vessel. Like you don't have an issue with that. No, I think there's almost nothing within the vessel. That's what I like about it because the plug is coming outside. Well, there, there, there, there's a anchor, there's a small anchor within the vessel and, and, and a plug outside and, and uh and, and I would, my guess is that if I do an end to end comparisons with what I usually do when I do a cut down, right? I uh I do a five purse string and then I can lay through my purse string and then I tie it at the end. I, I think that I'm compromising more in the open technique this, the, the of the femoral arteries than I do with, with the technology. And, um and I don't know that that's something that I've started using, you know, uh probably eight months ago and it has been just super favorable. That's why I wanted to spend a bit of time with it, you know, for those interested in and in Pakistan relations. There's no questions that when I was doing the cut down, the complication rate was low, I didn't have much problem with the cut down, but I would have the odd, no, lymphoma II, I would have the odd, you know, little fluid collections sometimes in obese patients. Now where there's a lot of humidity, I would have a small wound infections. But with this, no, it, it, it becomes a complete non issue. And I think that if you do it safe, you know, you have seen the feral scan of that patient, you know what kind of vessels you can leading you feel they are appropriate. Uh I think it increased the level of the quality of the care. Well, great, thanks. Oh yeah, I, yeah, I can't see it because there's so many bright lights here. Yeah, go ahead as uh you know, for an advice for someone who's embarking on minimal invasive surgery. Why not recommend to the surgeon to uh have just the hybrid incision as opposed to a second in costal space for gray or, or more lateral uh you know, fourth tecos space for your, why not tell the surgeon like myself, do it all through the third in space and more lateral. So a universal incision is to make it reproducible. Yeah, for, for all the cases, the to do the same incision if you're doing your then your module for all the cases. Um I would, I would not suggest that I, I think it's better to be perfectly set up for what you want to do. So if you wanna do a and that's the only thing that you want to do. I think it's nice to be a bit lower and a bit more later. And if you want to work on the Arctic valve alone, I think it's super nice to be almost flush against the border of the sternum. Um And, and then I, I might suggest that for, to build a learning curve, uh maybe start by just one of the two. Uh I, I used to have, I, I have people in Montreal that comes now all the time for, for mis training and, and, and if they're coming for both, I usually tell them do the a first, do the a first because it's super reproducible because that's a replacement 99% of the time. And uh everybody, well, that was before area maybe. But everybody, a lot of aortic valve, you know, it takes time to build up a microvalve practice, but aortic valve, they were, they used to be all over the place. So, so, so I think it's a good idea to start with one, do it repetitively, you know, weeks after weeks after weeks, get it down all the details. And then that's your set of procedures for the aortic valve and then move into the mits. And I, I was saying, move into the mits second because most of the time when they call me and said, I would like to come and learn mis mit. I said, OK, how many are you doing? Well, I'm doing uh five a year. Well, I said, well, maybe not because it's gonna be hard to learn all the tricks on the very low volume. You need to be doing that often enough. Often, often enough, maybe b we can pull the group. How many cases would that be? I would say that would be 30 a year, something like that. Yeah, we should, we, we'll talk about that in the uh in the uh discussion section. So, Chuck, I'm gonna answer that with this simple thing. Get the CT angiogram on every single one of these cases. You have to be able to tailor your approach to that patient. 2023 everyone's getting ac T ta you don't understand how much minutes and hours your reps are going through those CT vers to make sure you got the right valve and there's no coronary problems. All that sort of bullshit. You gotta be the same way for your open cases. Get that CT Tavy, you gotta get good at it. There's a one click on our packs right now and I get that 3D rendering. It doesn't look as French and artistic as yours because yours is purple, but it's a one clicker now on packs and you can rotate it yourself. It does not take any more time. Um Who asked more questions? Yeah. Thank you so much for your talk. I I'm thinking about this because of the more lateral um in incision that you talked about here in the, in your case, any comment on how to manage breast tissue with women and take that a little further are implants a total hard stop. I mean, how do you manage that? The implants for women with implants that come for isolated microvalve surgery? I, I do that almost every, every month. Right. There's enough that it, it is coming all the time and they are super willing to undergo mis surgery. Right. And, uh, and, and I told them, first of all, I told them all that they might be damaged. I've damaged three in my life. Only one was through an mis incision. Uh, because they are, they are at risk given to anatomy. And I told them it is a risk for tsunami. There were cases that they were so big that, uh I told them that I would remove them during the time of surgery. So I've done that maybe three times. Take the prosthesis completely out, put them in the seal and cover it. So it doesn't get infected. And then I played the plastic surgeons at the end and I, and, and, and, and I woke up something nice. Uh, most of the time I rather not touch them and usually they're not that big and you can be a bit lower and your microvalve incisions to do that for the aortic valve incision. I'm usually above it where you need to be careful and that's the only case through mis that have ruptured, the prosthesis is putting a chest tube at the end of the case, but my chest tube at the end of the case and, and, and there was adherence between the prosthesis and the tecos space and I broke the back of it. Uh But usually for the Arctic, you're high enough for the, you're low enough and I've not done it with a double valve case, but the double valve case, unless the prosthesis hangs quite a bit low, it might be quite difficult one quick follow up for many trolls. I, I, we, I come in from Scottsdale, we have an awful lot of this but um, the incision has not been a problem so much in terms of disrupting the implants, but any tips or comments on how to get a good placement of your atrial lift when you have a large implant in the way. Yeah. So, so, so the atrial lift, um I probably push it a bit more again, close to the sternum, taking a bit more risk with the uh with the, with IME damage, right? Uh Because you're almost there where the, the bundle would be. Uh But I'd rather take a risk with the IME than take a risk with the prosthesis, you know. And um, but, but usually that's not that difficult. But when I do the wrapping, when I, when I prepare the skins, I use, uh I use rapes and, and I make sure that I lift the breast and the prosthesis upwards and naturally. So that, so that there's a nice space for the lift and, and that I'm away from uh from the incision. I have a comment on the breast implants. Um So I universally have them see their plastic surgeon or our plastic surgeon. Um If the, if the incision is in, you know, not a but inferior, I use that same incision, we use the same incision, they open it up, take the implants out. It's remarkable how many want both of their breasts done at the same time. So, so most of them get that implant out, it doesn't go back in, they get a new implant and that the other breast is also done. Um And that they're happy because there's no added scar. It's the original scar and you don't have the liability of the implant or a ruptured implant in a case. And then you have to try to find a plastic surgeon, but a large, about 80% of them want both breast done. Uh Iii I could write a book on Adventures and breast implants. I uh unfortunately, perforated a silicon implant unwillingly unknowingly and my re tractor is going in the stick and I just see that silicone dripping drip, drip, drip with the left hr mo, that's a scary moment. Ouch. So if you ever have that, uh my P A was a former plastics, uh P A you obviously need to take the implant out and you take the tummy syringe, you know, the big bulb syringe, you take the bulb out and you invert it. You put the big part against the implant and, or the incision and you put the sucker on it and incredibly, and in one second everything goes in just like that. It's amazing. So that's one way to salvage that. So you don't get, you know, silicon in the, in the heart. Second thing is I do the opposite in the I, I use Ioban and in patients with implants, I will do the I to first I move the breast before prepping and I make marks to where I want it to lay and I use the Ioban after prepping to position the breast in that position. I make my mini thy try to stay away from the lateral edge of the implant. And then at the end, well, in the middle of the case, when I need to put the stick, I take that Ioban off and I move the breast the other way. Here's the part that I think will help you get a camera, put it in the insertion and look up and you'll be able to see the memory and just go to the memory to the sternum, right? And now you're in a lot better place. I've also done in patients who are lactating and you wanna avoid the breast, you know, uh that's, that's come in handy. It is surprising how rarely we actually hit the, the memory, don't you think? II, I usually know, make a space with, uh, with an instrument, a vital, like with a blunt instrument. And usually I think that it's pushing away the I MA it's very, very rare that they needed to, um, sacrifice the DME. But when you do, you never forget it. Yeah. Yeah. So, for you, I just, uh, take the implant out. That's what I do as well. I was doing things with Ramsey and your plastic surgeon will make more money than you will, by the way. A lot more money.