Dr. Kevin Hodges from Northwestern Medicine discusses the value of minimally invasive mitral valve surgery and shares a patient case study in which he performs a robotic mitral valve repair.
Thanks so much. Yeah, I just wanted to um spend the morning kind of looking at uh what has been our approach to robotic uh microvalve repair and sort of how we think about patient selection and, and what the role of this technology and approach uh you know, is, and, and this is an approach that, you know, mirrors a little bit of what we're doing in, in Clement clinic and then uh something that we're trying to build on at Northwestern. If we have time, we'll show a little bit of what we've been doing in the uh a FB ablation space with the robotic platform. Um So I wanted to start with the patient's story and this is a guy that uh is an enthusiastic patient of ours and has given his permission for us to use his story and his picture and all of that. Uh But this is a guy I saw shortly after uh joining a Northwestern, a 65 year old man with severe Mr uh who had a heart murmur detected on a physical exam by his PC P. Uh He was completely asymptomatic and had, in fact just come back from a hiking trip in Patagonia. Um His TT E which I'll show in a second, showed severe Mr due to posterior lea for prolapse with normal function and really no other pertinent findings. He actually saw another surgeon locally who had offered and was planning to do a mitra repair through a a median sternotomy. Um This is his uh surface echo which clearly shows, you know, posterior leaflet prolapse and uh eccentric severe jet of mitra regurgitation. Um And, you know, so this guy came in a lot of questions and, and, you know, this is obviously not a question for the group per se, but, you know, basically had been researching or had been told things related to all four of these sort of options. One was just to continue to follow him with ster echocardiograms because he's very asymptomatic. Um It had been proposed perhaps to do an exercise stress echo to see if his blood pressure went up or he decreased exercise tolerance. Um He had of course been referred to and, and was offered microvalve surgery already. And he had a lot of questions about the role of transcatheter therapies like MitraClip uh for a patient like him. And so I think we'll kind of go through and touch on how we navigate these questions because these are the ones that we always get uh when we see a patient like this. Um the guidelines I I think are reasonably clear um uh from major society guidelines and these are all sort of getting old. But um but were a big change from the previous guidelines. Um you know, of course, for patients who have uh severe r with symptoms or who have echocardiographic signs of uh LV systolic dysfunction. Uh micro surgery is clearly recommended and the big change in this iteration of the guidelines was this new uh class two a indication that replaced um some other sort of softer things like a FB and pulmonary hypertension. But essentially said that um in patients who are asymptomatic with preserved lb systolic function and dimensions, uh mitra repair is reasonable. Uh when the likelihood of a successful and durable repair is greater than 95% with the expected mortality rate of less than 1%. Um And they also mentioned this concept of a primary comprehensive valve center. Um And basically, um this comes from two sorts of, you know, reasoning. One is that um there's an increasing amount of evidence that patients who will refer to later in the symptom progression for microvalve repair actually do worse long term, we may be able to repair their valve with the same reliability. But if you look at this data from Northwestern, um the even 10 year survival for patients who present late with cluster for heart failure symptoms is significantly reduced compared to those who are referred earlier. And none of this is really that new. I mean, this is old data from Cleveland Clinic, uh with a lot of names that you may recognize. Um but basically showing the exact same thing. So 10 years before, I don't know, Doctor mccarthy here at Northwestern and her group published that data. Um We already sort of had the idea that patients that come late, um, do worse, uh, long term, they don't get back on their normal life expectancy curve. Um The other thing that goes along with this is that um the outcomes for Metro Repair have become really excellent at a number of high quality centers. And there have been a number of uh papers published. This is just a few uh that show that AAA high volume Expert Center for Metro Repair Repair rates for degenerative disease approach 100% and that the mortality rates are usually a half percent or less with uh similarly low stroke rates and rates of other major complications. Um from a patient perspective and, and from a, you know, referring provider perspective, one tool that has been helpful is the mitral uh foundation uh which is a joint effort with the American Heart Association. Um And you know, some key members of the AA TS that is basically used the same criteria um that are featured in those guidelines, which is um very high microvalve repair rate, greater than 95% with low complication rates to cert by centers of excellence reference centers as well as reference surgeons. Um and have sort of provided these research on their website. So, so there are, you know, the point of this map is not to highlight, you know, us or any particular center, but to say that there's a number of centers around the country who have um really tremendous outcomes and can do these sorts of operations reliably, which is why we approach patients like ours uh in the way that we do. So, um based on that alone, you know, we, we are thinking that we're gonna offer this guy an operation uh microvalve repair. Um And then the question, you know, sort of turns to, you know, how exactly do we go about doing that? Um So, um we've talked about this a bunch of times in different talks over the years, but there are basically four approaches that have been popularized for microvalve surgery. The first in the top left is the sort of tried and true median ster anomie, which is an excellent approach and affords us, you know, access to the microvalve as well as any other thing that we might need to deal with with the heart. Um The, the upper right number or letter B is a sort of upper heaty approach um that is less invasive and offers a, a smaller incision to patients. Um It is similarly limited um in terms of, you know, what you can access, you could do a double valve, aortic valve microvalve combination case uh through this um challenging to do coronary surgery and, and you could do a tricuspid valve as well, but um still is a, a sternal dividing approach that requires that 4 to 6 week time period for the, the sternal bone to heal uh before patients can kind of get back to their, their normal life. I would say, from a functional standpoint, the benefits are that it preserves some uh sternal integrity in the bottom half and, and preserves sort of dia attachments to the XY. Uh And so maybe a slightly better recovery, but it's still essentially a, a trans approach. Um Number C uh is what has traditionally been referred to as a mini micro operation, a mitral valve repair through a, a right, an inter lateral thot. Um We'll go over a little bit uh later from a technical standpoint, what the differences are um uh between this operation and robotic operation for the surgeon and why robotics might be a little bit better. Um But from a patient's standpoint, uh going from C to D generally results in a smaller thot with le less rib spreading. Um And uh somewhat enhanced recovery, I think I would make the argument in a little bit that the biggest difference between C and D is actually from the surgeon perspective and from a technical repair uh standpoint. Uh but patients want uh you know, one of the bottom ones for sure. Um And there's actually some demonstrated value to this. It's not just uh sort of marketing and small incisions. Um This is a large uh sts uh national cohort study, looking at um differences between uh conventional and less invasive microvalve surgery. And, you know, in this sort of propensity match large national study, you can see that the rates of wound infection, stroke, renal failure, pacemaker, uh post operative A FB and length of stay um are all substantially less in the, the robotic or I should say less invasive group because this included both. Um you know, but I think some have rightly said, well, you know, if these are centers that are metro centers of excellence that are doing these less invasive surgeries, you know, that may be a compounding factor. And so um I wanna also show um some data back from a Cleveland clinic looking at just single center data comparing that robotic operation to anatomy. So this is generally the same group of surgeons um who are highly experienced expert microvalve surgeons and some of the differences do sort of uh disappear. The the um repair quality is generally good in both groups. Um And reparation is low, but there's still a significant difference in rates of blood transfusion and atrial fibrillation as well as a uh statistically different uh length of stay. Although um what you see is that they become sort of closer. So we tell patients on average, uh you may stay one day or maybe a half a day less in the hospital with a robotic approach compared to a anatomy approach. Um but this kind of gets to sort of the benefit um of the robotic approach in terms of mitral valve repair and uh you know, technical advantage for the surgeons. And I wanna just highlight the bottom right here. Looking at comparing um sternotomy uh mini thot toy and robotic approaches. This is rates of conversion to microvalve replacement and you can see that of that group, this is again this sort of large uh national data. So there's gonna be some confounding for sure. That is the reason why the sterno replacement rate is so much higher than the other two. But specifically comparing um thoracotomy and robotic approaches, robotics has a much lower mitral valve replacement rate than uh a thot. And I think there's a good reason to explain this. Um And that is that uh when we do a robotic microvalve repair, we have the advantages of uh sort of two things. The first uh that we'll see when we see a surgical video in a moment um is the ability to use uh 10 times magnified binocular camera. So um on a, you know, screen, you know, via Microsoft teams here, we won't be able to demonstrate this. But um the camera that we use for robotic surgery has two lenses that translate into the two eye pieces that we look through. And so we actually do get uh you know, 3d stereoscopic vision. Um And the other thing that we have is fully articulating instrument shown on the left of the screen here that allow us to really recreate the movements of our hands and wrists on the inside of the patient. Um in a way that enhances our ability to do sort of complex things. Um for repair techniques for a mini metro done, you know, the more traditional thar cottony based way, uh we use instruments like the one on the right, which are stiff, sort of straight shafted long instruments that you can imagine really restrict uh the degrees of freedom and the ability to manipulate needles at a distance or do complex things. There are certainly many expert surgeons who have mastered the use of these instruments, but I would say for the majority of us, uh the the trend has been that we can do a little more complex things a little more reproducibly uh through a robotic approach. Um So, you know, there's a lot of good reasons I think that a robotic approach is a good one. So the next question is, you know, who are the right patients for this? And the philosophy, you know, that we tell patients is that we want to do the least invasive operation that we can without compromising the quality of the valve repair or the the safety uh for the patient undergoing surgery. And, and we basically file this exact same algorithm which was developed over, you know, the course of 1000 or so cases at Cleveland Clinic, which is to basically use echo and CT parameters to screen patients. And um ultimately, it ends up being about 60 or 65% of patients um who qualify for a robotic approach of those presenting for isolated microvalve surgery. Um So just quickly to run through what these are. Um and we'll see some pictures and details in a second. But on the echo, we're looking first to see um the degree of aortic valve regurgitation. Uh the reason that we care so much about that, of course, if it's moderate or more, uh and we think we need to do an aortic valve repair or a aortic valve replacement, then it it no longer becomes an isolated uh mitral valve uh repair. And so those patients get a sterno to allow us to address both valves. Um But the more important thing in these patients who have, you know, a strong, mild or sort of 1 to 2 plus aortic fabric agitation that we might not need to address is that it affects our ability to effectively deliver cardioplegia and protect the heart uh during surgery. So, um for the sort of non, you know, surgeons in the audience when we do, um you know, any cardiac valve surgery that requires cardioplegic arrest of the heart, uh we have different options. One is to do what we call integrate cardioplegia where the blood is uh e cardioplegic solution is delivered uh sort of the normal path down the coronary arteries that uh blood normally goes. Um The limitations of that in a patient with the aortic regurgitation is that a lot of that is gonna go in the ventricle and especially once the heart stops or starts fibrillating. Then uh we're gonna have uh ineffective delivery of cardioplegia to the myocardium for an open case that would be immediate sterno. We have the option of doing retrograde cardioplegia where we give the cardioplegic solution through the coronary sinus, which then goes retrograde through the, you know, coronary circulation, but effectively cools the heart and delivers hypos solution regardless of um you know, things like coronary obstruction or uh aortic mouth disease. And so in people who have questions about effective uh myocardial protection, then we would do a sternotomy to have access to that uh approach patients with severe mitra annular calcification are often very complex uh repairs and often, you know, or maybe even more often mi about replacements. Um There's also, you know, questions about ability to, you know, debris, calcium effectively and control the calcium debris with the robot um that has made those traditionally non robotic approaches, sort of focal small areas of calcium are usually ok. But the, you know, patient that you see on the CT scan or the the cord with the circumferential bar of calcium are, are generally excluded from our approach. Um And then we look at people with the last are sort of in the same category, those with significant LV dysfunction or those with pulmonary hypertension are patients who typically are more advanced in the progression of their micro bowel disease. Um where we worry again that uh perfect myocardial protection um given with the anti grade and retrograde cardioplegia, uh may make a difference in terms of their myocardial recovery after their operation. Um and so a as sort of a conservative approach to this, those are often treated with the sternotomy. Now, if you look nationally and you said, you know, are the most aggressive uh robotic microbe surgeons doing some of these people robotic baby. And yes. Um and that's sort of um something that we talk about in meetings and things like that. Our approach is to be somewhat conservative uh to make sure that, you know, we never have a patient where we wish we would have done something uh you know, with better exposure. So that's sort of our, our disclaimer is that this is not a, a universal approach, but it's our uh conservative and what we think is very reproducible both approach um from the CT scan, I'll show you pictures of the next slide. But the main things that we love for the the diameter of the femoral arteries um and presence of significant ado aortoiliac atherosclerosis and calcification because these operations robotically require peripheral cannulation for cardiopulmonary bypass. Similar like what you might see for femoral ECMO. Um And we have retrograde flow of blood through the aortoiliac system. Um We'll go there some data actually about stroke risk and embolic risk related to that in people, uh who may have a significant calcification. But to look at some uh pictures that kind of see what we're talking about. The top left are uh from patients that ended up being good robotic uh microvalve surgery candidates. Um You see somebody with a 11 millimeter femoral artery, um, typically we're using seven or eight. All right, I should say 21 French or 24 French equating to seven or eight millimeter uh arterial cannulas. Um And so those are sort of the, the limits of what we can, can get away with. Um, and a very small patient, uh you know, we maybe use a 18 French cannula that sometimes you can, you know, squeak by with, you know, 6.5 7. Uh But we really want to see sort of in that range. Um And then on the sort of uh other view here, what we want to get a sense is that this patient is one who had minimal, you see a couple of specks of white calcium, but essentially minimal burden of ether sclerosis. And uh what we see, you know, a lot of these people are young asymptomatic people, uh like ours who are very clean in. Whereas when people come in there in their mid to late, you know, seventies or eighties. Um just, you know, demographically speaking, our patients tend to have accumulated some aorta aortoiliac uh disease. And so we're a little bit skeptical in terms of promising the rub up before we've seen these images. Uh the bottom, right, are examples of patients that were not such good candidates. One with the 6.3 millimeter uh femoral artery, um and you know, average size or larger patient that's generally insufficient. And then you see a cross section of an aorta with this sort of uh shadow of uh sort of, you know, radio opaque kind of shaggy stuff with some calcium burn. And this is an aorta that uh we would not want to retrograde, perfuse for risk of embolization and stroke. Um and actually some patients will, will bring this up uh very astutely and, and when people looked at early uh outcomes of minimally invasive uh micro surgery, this is that same uh paper we talked about before. Um in the unadjusted data, there's a uh a significant difference in stroke risk uh with a higher stroke risk actually, uh and less invasive versus conventional surgery. Um And even when they adjust for uh risk factors, there was an odds ratio of 1.96 for higher stroke risk and less invasive micro surgery. Now, this is sort of relatively old data that uh we don't think matches, you know, current practice in high volume centers and um you know, but this was a big concern early on in the sort of learning curve for this nationally. And if you look at um sort of the approach in Cleveland when this was being developed, um they went and they analyzed the 1st 1000 robotic metro valve surgeries and they noticed this inflection point in the stroke risk. Um And interestingly what this corresponded to was discussions about risk of stroke and embolic events during retrograde perfusion in these patients. And a conscious effort to make ct scanning a routine part of the preoperative evaluation. So it's a little bit single center anecdotal data. Um but at least some, some kind of story that being careful about, you know, perfusion technique and selection specifically related to stroke risk can make a difference. And uh in the the modern era, you see that the stroke risk is uh less than 1% over the last, you know, 500 patients or so. Um So I just wanna briefly take a moment and kind of talk about, well, what happens? Uh you know, this is a fair amount of, you know, screening Algo algorithm and we said maybe 40% of patients will not be good candidates for robot for one reason or another. And so how do we kind of approach a patient like this? And, and you know, what do we do? Because a lot of patients come to us specifically for a robotic approach um and are often disappointed that they may not be a good candidate or that we have some intraoperative decision making to do um and navigating that to make sure patients understand that they're getting a good operation and a safe operation is really important. So I wanna just briefly touch on this other patient. A 64 year old guy who had mild Parkinson's but otherwise uh asymptomatic. Um he had bili the paralysis, Severe Mr, he talked about mild to moderate tricuspid regurgitation, which we could do a concomitant, uh tricuspid Avenel plasty with uh without an issue. Um He had mild aortic regurgitation, normal function, no coronary disease and AC T was fine patients like this. What we uh talked to them about uh is that um there are some red flags, you know, he has mild to moderate tr but, you know, we can handle that if it was severe. We maybe rethink our plan and he has mild aortic valve regurgitation. Um that should be fine, but uh we're gonna take a close look at the tee. So we got in the or, and we see a valve that looks like this one has severe bileaflet prolapse and, and, you know, sort of classic Barlow's disease with severe Mr on the 3D views. It looks something like this. Um uh we see on the left he has, you know, probably the same out to moderator because of regurgitation that we would address. But then we kind of tuned into the aortic valve, um and said, you know, this is probably not moderate, it doesn't need to be addressed surgically. But we're worried that, you know, as we described before, we're not gonna really get a great uh protection of the myocardium and decided that it probably was safer to do a sternotomy for that reason, in particular. Uh And you kind of put all the together, you say this is gonna be a complex metro repair. It's gonna take a while. Uh We're gonna do a tricuspid repair at the same time. So a long operation, question about myocardial protection, you know, for us, that's a ster case. And so we had talked about it pre op, we told the patient, ehe this was a possibility. Um And so we called his wife from the operating room and said, you know, we did our tee as we discussed and based on these factors, you know, we think it's safer to do a, a sternotomy. And so that's what we did have a sternotomy of mitra valve repair. That was a complex repair with multiple components. Uh We did a tricuspid valve repair and got a really nice result. Um And I think the key is that, you know, the patient was repaired or prepared for this possibility. Um And so I was really pleased that he got a great micro repair instead of um what, you know, the situation you don't wanna get in where uh you've sort of promised a, a robotic approach and you either do something that's less safe or you have to uh explain it after the fact. So, so that's kind of our approach in these sort of borderline cases. Um The last part of uh sort of the, the questions that the, you know, this, our patient asked before we get to his operation was, you know, what about transcatheter options? And, you know, I think most of us that see a lot of these patients aren't enthusiastic about uh transcatheter edge to edge repair for low risk patients. Um But uh I think patients here that some things uh transcatheter are less invasive. Um and they wanna know about it. And uh I think what you see, this is a, a big sort of real world um paper that probably a lot of people saw from a couple of years ago, I looking at Real World World Practice of Tar. Um And you see that although, you know, the total population is 17,000 or so, um But about 1600 so approaching 10% were in the low surgical risk category and a huge number of patients were in the intermediate surgical risk category. So intermediate, you know, from an S CS standpoint is 2 to 6% less than 2% is low risk. So in the real world, although we sort of view tier as a a, you know, a modality for high risk patients. Um or you know, people who are enrolled in clinical trials, you know, the majority of patients that are getting this technology are, are low and intermediate risk. And so it there is some, you know what we would call indication creep or, or some reason to think that, you know, this is something that's gonna be the part of the conversation for patients like ours who, you know, historically would have been clearly surgical. Um But I think looking at the outcomes, again, these are real world outcomes from, you know, almost 18,000 patients. Uh when we compare, you know, surgical results versus tier results. Again, this is I'm not, I'm not a tier uh hater or basher by any sense, I think it's a great technology. But for a low risk patient, I think when we look at um the outcomes that have been achieved by tier and what percent of them are sort of what we would consider to be surgery like outcomes, which is sort of the box on the bottom left, you know, mild or less Mr and a a gradient less than five when we leave the operating room is actually a uh a majority, I guess, but barely of um of these patients. And uh you know, a fair amount um have sort of less ideal outcomes than that. And we don't know for sure what the the durability of these are going to be. I think, you know, some of us have seen some of these patients go back, you know, an anecdotal data shouldn't drive your practice. But one thing that I think is also powerful is when you look at uh rates of mitra valve repair after failed mitral valve clip. Uh nationally, those rates are only about 6%. Um And so with patients where they're low risk for surgery and likely to have a good repair and get them into this purple box up front with good proven durability. Um You know that I think is clearly still the answer in low risk patients. And we talk to patients about that, you know, very uh bluntly uh because often people say, well, why can't I just have the the less invasive thing? Um You know, the other question I think is, you know, clinically, what's the importance of some residual Mr after um mitro valve clip and mitro valve surgery? And you know, in this showing essentially uh mortality and then also um heart failure readmissions, there seems to be a clear correlation in terms of the success in eliminating retro valve regurgitation without a significant gradient and the the clinical outcomes at least over the first year. Um And so we talked to patients about that. Um some of this remains to be seen if you look at, you know, the limited data from the surgical literature about the impact of uh residual mitral regurgitation or recurrent uh Mitrovic regurgitation after Mitrovic repair that now, these are obviously you don't have to go through the whole abstracts. But uh on the left, uh is a paper by Rick surgery that's relatively old when he was at Mayo Clinic looking at uh the occurrence of residual um moderate mi or I should say recurrent moderate miric education that was correlated with increased uh long term mortality. So I think moderate miration is clearly an important uh outcome. And um then on the right is from our group looking at the effect of mild um residual or or recurrent regurgitation and it didn't seem to have a major impact. Um That question in particular is a hot topic in the design of two ongoing randomized control trials. Um The repair Mr trial uh and the primary trial that are looking at uh the effects of uh mitra valve uh clip in lower risk patient cohorts and younger patient cohorts. Um So we should have some more data coming on that. But I think uh there'll be some very interesting conversations and debates in our, our meetings in cardiology and cardiac surgery about uh sort of the end points of these and, and how to interpret it. Um There's, you know, potential for conflicting uh findings and it'll be interesting to see how the field evolves. But we would say for now in a patient like ours who's a healthy guy and low surgical risk with a highly repairable doubt, we would probably steer him away. Um from MitraClip and, and stick with a minimally invasive mitral valve surgery. Um So here's what we actually did. Um So this is gonna be the patient's uh surgical uh video here. Uh So, intraoperative tee, let's see. There we go shows uh the same as the, the surface echo, which is P two paralyzed with severe micro regurgitation, a very eccentric uh jet at the P uh 3D shows the same. And so this is sort of a classic uh anatomy that we see a very tall redundant P two scallop. What we do in these cases, especially when we see these cleft like indentations is check that there's gonna be sufficient tissue for cleft closure. If not, then uh you know, this might be a case that we would think about uh repair with artificial ptfe neo cords um versus our more standard approach of a, a resection which is shown here, but this guy had plenty of tissue on either side. So we do a triangular resection to eliminate the majority of the redundant and prolapsing tissue. Um And as we do that pay attention to not just the zoomed in view but the articulating uh certain nature of the robotic instruments. As we go ahead and start sewing this resection close, um notice that we can really, you know, turn and point this needle any which way um which allows us to sort of do some of these nuanced sort of folding sutures and things like that. Um When we think about the resection closure, one of the things we always think about in much about surgery is the risk of developing c in the post operative setting. Um And so you notice what we did there when we closed, it was to do a slight fold of the free edge to sort of subtly reduce the, um the height of that P two segment. Um This is essentially the exact same operation that I would do through a median ster anatomy with a couple of minor technical modifications. One is that uh we do interrupted uh sort of sutures here that we then tie on the inside of the patient with a robot. Um The reason being is that uh to have assistants sort of follow the stitches and tie from the outside uh becomes kind of a cumbersome process with a lot of uh possibility for suture entanglement and things like that. This has just proven to be, although it's a little more tedious um an ultimately faster approach to doing this. So what you're seeing now is essentially the resection closure going all the way down to the level of the, the Annulus. Uh One nice thing about these robotic operations uh for things like this is that all of the operations are recorded. And so from a, you know, quality assurance and, you know, debriefing education standpoint, um but also, you know, from uh you know, dissemination, this is a a really helpful technology. And we actually this guy, he was so enthusiastic about having had his mi valve repaired in this way that he kept asking to see the video. And so we actually just did a little like promo thing with this particular patient where we sat down and went through his video with them and he had to ask all sorts of questions and it was pretty cool. Um This last stitch, this is something that we, oh this is the closure here. So, um so that's this is these like cleft like indications that we see uh between P one and P two. And um you know, if you looked at the guy's echo, you would not have said that you expect a significant leak from a cleft. Um Typically, those jets are more centrally directed and, and distinct from the, the jet from just the, the prolapse that we see. Um But when we do a resection of repair like this, we essentially always have to close clefts because you take tissue out from the center of the valve and pull things in from the sides, um which essentially results in these clefts being slightly pulled apart from what they would be in their physiologic state. Um I don't know that anyone can say for certain why these clips exist, but they may help the valve sort of open in the normally functioning valve. Um And they coop with each other, you know, just like the anterior and posterior leaflets would um but when you do the resection in the middle of the valve and pull things together, then uh you disrupt that. And so you end up having to close them to make sure you don't get a leak. Uh in the, after the repair, we do that essentially in the exact same way as we close the resection. Now, we do try to do sort of a, you know, a focused tailored repair. So we, you know, we knew that there was P two prolapse and flail. Uh We close that up and then we go ahead and, and do this cleft closure, which was clearly uh sort of in our face. Um We're always sort of cognitive of the fact that there could be other little things that have small jets and we'll test that in a second. Uh But once we think we've done the, you know, the important part, then we'll go ahead and put our um annuloplasty in and, and every patient gets a annuloplasty uh robotically. And actually, for open cases too, uh my practice is to do a posterior flexible anoplasty band. Um It doesn't really matter what ring or band you uh put in. Um As long as you do something that will do a sort of modest reduction of the interior posterior diameter of the valve. This one is made by Metronic. It's sort of like the oldest cheapest uh one on the market, but it works really well because you can do this running suture technique that saves you a lot of time and headache uh putting in your annual plastic band. But again, it's the exact same uh one I would do and same approach, uh it was asteron. So we try to make sure that we're doing, you know, a as much as possible, the exact same operation, you know, and it, so once we tie this in, the next thing is the static saline test. And um you can see there's a little tiny jet of uh residual micro ari that we'd have to deal with. So uh we look in and that sort of cleft like init on the other side of the P two, looks like is the culprit. And so we'll go in and uh and close that up. It's always amazing when we have cases like this that it didn't really look like there was much of a clip there to start after you do a test and there's a leak, you look back and say like, you know, I was always gonna have to close this. I'm not sure why I didn't do it the first time, but uh that's why we do the, the water test uh before we come off to make sure that we've dealt with any possible site of uh of residual regurgitation. Um So we do the same thing here and then once we get that tied up, we'll do another um saline test and we'll see what we get. So we do the same test again, that little jet is gone. Uh We see a nice, you know, uh ratio of interior posterior leaflet. So we know we're not gonna get S AM and then we take the clamp off, we look at the tee and we see this, which is sort of exactly what we want to see following a uh microvalve repair. Um That was the bad part at the beginning. Uh So let's go to the next slide. Um And so the, this patient essentially did great. This was him four weeks after his operation, he sent us this photo, um and said that he feels great. He's practically pain free. He walked uh seven miles ahead a bucket of golf balls at the driving range. Um And so he, he really had a, you know, sort of, you know, poster outcome for what we hope this uh to be. Um which is fantastic. Um So that's essentially kind of how we approach the, the MIB thing. I want to uh briefly show you guys one other thing because we're excited about it and it looks like we've got a couple of minutes to do that. Um Which is that, you know, we, we always think about how can we sort of use our technology to do bigger and better things. And so, uh one thing that, you know, we've started doing here, which a few other centers are doing as well. But using the same approach, uh which is essentially a, you know, right chest approach to the left atrium to start uh doing stand alone atrial fibrillation procedures. Um Obviously, there's a huge overlap in patients with micro regurgitation and, and A F. Um But what we're finding is that uh as the technology for a fib ablation and things like that have evolved, there's P FA and, you know, a lot more can be done in the Cath lab. We asked our electrophysiology colleagues, you know, where are the gaps, you know, what is it that we can offer? And they basically, you know, came to us and said, well, you know, there's lesions that we can't get to, there's lesions that aren't part of hybrid things like convergent or, or totally docos scopic maze approaches. And so we came back and said, well, let's do a, you know, full biatrial mase procedure uh through a less invasive approach with robotic assistance. Um And it's really worked out pretty well. So, um just to kind of highlight, you know, what this approach and technology offers this video, we're presenting this at the upcoming STS uh meeting. Uh But uh so, so basically this, you know, a patient with long-standing persistent atrial fibrillation and otherwise normal echo. Um This guy actually was fairly asymptomatic but uh was sort of insistent on getting out of a fib who was one of these guys that was like, you know, he, he, he was sort of debilitated by being so worried about his A FB we always wanna manage the left atrial appendage. And so this has been discussed a couple of different ways. Um with the robotic approach, some people do endocardial suture, ablation or suture closure of the appendage, which uh we have concerns about whether or not that's gonna be a long term uh durable option. So we actually just do a quick left thoracoscopic uh but the appendages with a clip. So before we, you know, sort of go in earnest to the, the robotic maze component, we actually will just use port AIS only on the left side and uh do this uh this clip closure, which is, you know, 20 minute really sort of easily reproducible option uh for appendage closure. Um We sort of painstakingly tease the appendage through because at this point, the heart is still full and beating. So if you grab this thing and it starts bleeding, you turn, turn this into a, you know, totally different operation, which is never our, our goal. So we get the appendage to kind of pop through, we close it, um close the clip and then we check on tee, which we'll show in a second essentially to show that uh we've completely obliterated this thing. Um Make sure that we get all those little sort of nooks and crannies in there. So we've obliterated the appendage. We look for a stump less than a centimeter. Uh That one was like, you know, 0.15 millimeters. So that looks really good and we released the thing. Um And now we know that we have 100% reproducible appendix closure. Uh We then go to the left side, we arrest the heart uh like we would for a metro repair. Um And then we go into our lesion. So we do a epicardial coronary sinus lesion for reference that, but this is the cryoprobe that's freezing the uh the coronary sinus. Um Now we're inside the atrium and essentially marking where that is so that we can overlap that and, and get the mitra isis line uh that goes to the, the annulus and also overlaps that sort of coronary sinus lesion. Uh We'll come back to that once it's thawed. So then we do a box around the uh pulmonary vein starting with the so called floor line. You see the slit of the occluded appendage up there, which will be important in a moment. Um Is when we come from the, the top to do our, our roof line here. Um What we wanna do is make sure that we overlap the, the floor line completely. Uh But also hit that um based of that left a your appendage slit so that we freeze to the, the clip on the other side and are sure that we're gonna get the sort of Coumadin ridge line uh as well, so we overlap this one. You see, it goes right exactly up against that uh the slit like uh residual opening of the elect atrial appendage. So that'll get uh a box on the pulmonary veins as well as the Coumadin ridge uh to the base of the left atrial appendage clip. And then now that the coronary sinus thing has thought we go back and we look for our little purple mark and do our Milius line going to the Annulus and making sure that we overlap where we did the coronary sinus. So that we know we're transmural all the way there. We actually really see these lesions a lot better with this approach and we can't even through a sterno at one time. So I, I've been impressed that uh I, I think the competence in this being a perfect maze lesion set has been really high. Um So then uh we do this is a bi a procedure which has been something that we think we add to the way we used to approach a sort of so called totally Thos copic maze or hybrid maze approach. So we do this is the Tricusp annular line. Um A lesion to the superior Vena cava that will be part of our uh SVC to I BC connection line. Um taking great care to spare the sinus node, which is up here. I don't know if you can see my mouse hopefully, but uh it's sort of at the junction of the SVC and the right atrium, we do a line up into the right atrial appendage and then down into the IVC. So this is relatively new for us. I think we've done like seven of these and one was in combination of the mitral valve repair, but uh we've had a lot of interest in it and I, I think it's a good um example of sort of applying our uh same approach uh with a robotic uh you know, transthoracic approach to cardiac surgery and looking for good ways to do it with a similar sort of selection criteria. Um And, and basically offering less invasive uh options for patients that, you know, may otherwise have not been interested in having surgery if that devay. Um So that's been kind of our approach to sort of step wise building this uh robotic program here in Northwestern, kind of starting with the, the foundations of, of what we've done with Mills and then just sort of going uh step by step. But um we're really excited about this and uh I'm glad we had a couple of minutes to sort of look at that, but um it's been about 45 minutes and uh happy to sort of just pause there and uh and take any questions or talk about uh robotics or microsurgery or, or what the future looks like.
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