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: Dr. Marc Gerdisch Franciscan Health, Indianapolis, IN Please Note:
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Last talk before, um, the lunch time. And I think this is the most important talk is a talk on and uh maximum credibility here. Mark is on that, uh, publication which is the clinical practice guidelines on, er, so the 10th is gonna be fantastic. But what I want you to take home from, uh, Mark as a speaker is he's passionate about everything he does. I think all of us should be extremely passionate about the therapies that we offer our patients because, you know, cardiologists are about theirs. So, um, let's, let's bring up Mark before lunch time. Looking forward to talk. Mark. Hi. Yeah, good morning. I have a video in here that I had to put some time marks on. I was doing on the airplane. So I have my tickets there. Um, so first of all, I'm gonna take offense because it, that wasn't the last surgical talk. This is the last surgical talk and this is the most, most surgical talk. So it's true that I love doing minimally invasive heart surgery, but it's really probably less than my third of my practice. I still have a couple of 100 people that I open their sternum every year. And so, well, why do you open their sternum? I open their sternum because uh for any A I, we approach A I as a repair like we do a for calcified mitr that we still want to repair in a young person. We do astronomy uh for people, you know, a particular body habitus or redo redo status or whatever, we're gonna go through the sternum again sometimes. So, uh I think that we need to talk about this kind of globally with respect to what is, what is the driving process in the program to achieve kind an equitable experience for everybody? Right? So that was kind of our goal when we set out for our program. So I gotta get to the beginning of my talk here. And do I just go to presentation mode? Thanks. Yeah, showing up there yet. OK, perfect. Thanks. So I listed my partners, I listed my ear, a nurse. Uh And I think that uh you know, this is height is I am highlighting ear ras here disclosures. So as mentioned, uh we published in Jama Surgery, the guidelines, at least as we saw them uh as the US Cardiac Society. The reason I laugh is because uh we received a little bit of scorn from some of the major societies and in fact, obviously didn't publish the Annals, although we will know I'm sure. Um Yeah, but we set up a great website if you ever you or your staff, ever wanna visit this website? I think it's one of the nicest websites there are with respect to anything in the realm of cardiac surgery and it gives you people data dates, information meetings and this is this is that publication, it became the most cited publication in the history of the journal. Um And uh he had a worldwide following. Uh So what do I like about minimally invasive surgery? Uh I get to teach courses with Mario Castillo saying where he does all the work. So if you do a course with Mario, his videos dominate and it's super fun. Uh it further confuses people about what I do for a living. So a cocktail party. Oh, you're a heart surgeon, you know, you put stents in. No, but you know, do you always do this? No. Do you do the trace? No. Yeah. So it gets a little confusing for people. I think it's kind of fun. Uh patients do love minimally invasive heart surgery, done well done, right? Gives them what they want. Uh It has preserved my valve surgery practice without question. Peter mentioned, you know, this, this uh creep into the younger folks or transcatheter valves. It has not happened in our practice at all. Thank God. Uh and it led to our es cardiac program. So I say that because we had so such great results with minimally invasive and I'll show you what we do with minimally invasive with our E program that was kind of focused on that, that we just moved it over to the entirety of the program. So everybody gets treated the same. It makes things simple because nurses don't actually look at the patients differently. Everybody gets managed exactly the same way. It doesn't matter where your incision is. So what I do not like about mentally invasive surgery, there's a learning curve means that somewhere somebody dies and that's some of what we've talked about here. So people uh embarking on the adventure, the adventure of minimally invasive surgery, somebody's gonna die because somebody's doing something they haven't done before. So I think this measured titratable approach where people take their time and they're cautious and they think a little bit that can be avoided. I think it can trap some surgeons into delivering something less. And I just mentioned a valve repair. I don't do a valve pair through a right anterior Thoro toy. I do all my isolated aid valves that way, pretty much. But if they want their valve repaired, I'm going to do a sternotomy or mini sternotomy and it can hurt, but we're going to fix that. So how do we smooth and accelerate recovery? We have the, this list of things here that you'll see that we're going to go through. One of them is minimally invasive approaches, includes cryo nerve block. This is kind of when we knew we were on to something. So these are gals. They came out on the same day, their best buds, they both had their micro valve repairs. They both went home day four. They both felt great. They're both moving fine. They both had cryo intercostal block. It's when we first kind of started doing it several years ago. And at the same time or shortly thereafter, this guy's son sent me a video of him, this 82 year old guy bowling, six weeks after he had had a cabbage, a VR. So how did that happen? He didn't have minimally invasive and we'll get to what we do for that guy, right? But his behavior is the same as the minimally invasive. So, er S is how we battle the surgical PTSD, how we conduct the surgical experience will affect the patient in obvious and subtle ways their entire lives. So sternotomies are bad things. We all agree on that because people suffer with them, they suffer with them for the rest of their lives. 20% of people have some issue with their sternotomy that was put together with bathing wire over the course of their lives. So we have to think a little bit about that. This is the, this is the daughter of one of those patients who came in to have her mitral valve done. Like six months later, she came from Wyoming because she wanted to have the same experience that her mom had. And then they send me pictures of their lives. And this is good because we know minimally invasive surgery is a good thing. We can do a durable repair. We can change the trajectory of somebody's life. They can be comfortable, but we have to do it for everybody. So we have this very aggressive, multidisciplinary team work mentality where everybody is involved. I don't know if you can do it in big institutions to tell you the truth. We're very much a boutique. I tell people we run a boutique. We don't run a department store. It's not a factory. We're not cranking cases out. We do 500 cases a year. I do more than half of them. So I get to have Dominion over much of what happens to the patients. But the reality of it is we have everybody involved, everybody invested and this is what our uh monthly get together looks like every month everybody is uh in this meeting. It used to be in person. Now we do it as a teams but we have respiratory therapy, physical therapy, pharmacy, uh administration, uh IC U nurses, step down nurses, everybody's there and everybody chips in. Everybody gives a response and everybody has a job to do. So if at the end of the meeting, it's somebody's job to come back with information on how we should change the way we use. Precedex or should we add ketamine for people who are narcotic uh dependent people coming into the hospital. They come back with that information at the next meeting, short loop feedback all the time. If we change something, we look at it at six weeks, three months, six months and a year to see if we're doing the right thing. If we're spending money, we gather that data, we tell the hospital what we found. So some stuff we're gonna do that's gonna cost more money. And then when we see it didn't do anything, we get rid of it. But if it does something, then we get to keep it. So trauma and pain, trauma and pain, right? This is what happens to people, right? They have pain, they get the side effects, they have the opioids, they get it changes how they get exhibited. They get delirious, the medications effect on their sleep that experiences the pain that leads to or that comes from the trauma that can change our trajectory. So let's talk a little bit about intercostal nerve block. I'm not going to dwell too much on the, on these images that show the anatomy. We kind of all know them the neurovascular bundle. Uh we do use uh in the chest wall blocks for every single patient that gets either astronomy or mini. They get an erect spiny block. It takes our anesthesiologist literally only 10 minutes and if we're doing just a mini throaty, then they'll get it on one side. If they're getting sternotomy, they get it on both sides and that really does diminish the overall achy discomfort around the entirety of the chest. Very effective for that. Uh All patients in the operating room get that erect, spin a block. All patients get IV acetaminophen. We've been using it for years. I know it was expensive and it probably still is. But I fought that fight a long time ago and I got it and we used it for 72 hours and everybody we use Precedex really liberally. And I know there's been some negative press about it, but it's in the context of not using narcotics. And I think Precedex without narcotics is really benign. But if they overlap, then you can have some issues we use in the operating room a lot of times that gets discontinued soon after surgery. But if we look at it, we were talking about this earlier thot is hurt and this is kind of like best data. People looking at how, what their outcomes are like. And it really takes about a month for people after any type of thot to feel 80% better. 80% not 100% right. We're after 100% and with vats, it's a little bit better but not a lot better. So this is our cry intercostal block. This in my opinion is the golden ticket. When you talk about a Thor, this is a lady, I think this was a Tricuspid maze. It's a bigger incision. Uh We've got plenty of access there. You can see, I put my whole hand in there and it's a big, you could probably do a little toy through that. It's an old video. It's probably five years, six years old and the block goes in right into the inner space and then we're gonna look from the inside and you'll see where the crow probe is. So the crowd probe is snaking along there outside the plora on the intercostal nerve bundle and then pressing against it. And then we freeze for two minutes. That seems pretty aggressive, right? Because trauma, we're putting that thing in there. We've had, I've done this hundreds of times now. Many, hundreds of times now, I think, and we've had no ill consequences. So the Alaia, the chronic problems, I do tell people that they're gonna be numb there. I show them where they're gonna be numb. They're gonna be numb for 8 to 12 weeks as it comes back, they'll feel a little pin prick, a little odd sensation. Uh, but it always comes back and they do, well, we'll freeze the inner space and then one above and one below, we also will freeze where the chest tube goes in. So that was kind of the last barrier, right? They, we'd have no pain at their thy incision, but they would hurt where their chest tube was going in the, in intercostal space. So we freeze directly on the nerve there where the chest tube goes in uh some conversation here, just kind of about chronic postero pain. We just haven't seen it if we had, we would have backed off of this process. Uh what happens when we cry on nerve, when we cry on a nerve. As I think most of you know, the outer layers of excuse me, of the nerve of the nerve remain intact and it allows for first degeneration, then regeneration within the track of the preserved uh external component of the nerve. And as a result, we're able to kind of get away with this, it will regenerate the axon, we're not killing the cell, right? We're killing, we're, we're hitting the dendrite and that, that dendrite, that limb of the cell will regenerate through that channel. As long as you haven't disrupted channel, you got to get cold enough, you got to stay there long enough, you can't go too cold. Uh And I think the sweet spot is right around negative 60. Uh And because there is some data that when you get down to like a negative negative 100 you can get a permanent and non reversible scenario. Some of the things that people complain about, but we haven't seen it. So I'm just saying that we don't, we don't live with this. It's not something that's been an issue for us. We had some people with odd sensations within the first couple of months. But then that's it. We just show we just saw percutaneous access. I didn't know somebody was going to show it. Uh We do this routinely. So every mini uh most of my redos uh whether they're thor or we will do uh percutaneous cannulation. I think it's a game changer. Um No matter what you do, you're gonna get a cerro cmas are a nightmare. I actually picked this up a few years ago after a patient had come to me uh from the east coast to have his minimum invasive microvalve surgery. He's a very vain guy. He did through a tiny little incision. He loved that. He went home. He had a horrible cerro. I had to deal with a surgeon that was fixing it for like six months. And after that, we switched to this and never looked back. So uh this is, of course, as you can see, we're using PC closes. Uh and we use it uh routinely, uh we use two of them on the artery, two on the vein. Uh It is approved for the vein now as well. Uh And basically we set the two PLOS in and then through that, we're going to introduce our uh cannula eventually through a smaller sheet. So we'll drop a smaller sheath in there and, and advance a super stiff wire up into the proximal, descending the order. And then we will have that as our guide to put the canal in and that's through a nine front sheath. I always put a nine front sheet in the artery just because I know I'm gonna put something bigger in there later and I won't leak around it on the vein. Same process, ultrasound, guided, see where we're putting the, the needle. We never go above the e on a ligament, especially on the vein, right? Because you got big vein there. You don't have to worry about it. Uh So don't go crazy trying to get high there. Uh Make sure you can see the structure, make sure on the artery, of course, that you can see the bifurcation so that you're on the common common thermal artery, uh two per close devices on that side as well. Uh rewire on this side, we'll put an eight front sheath and just so I can remember which is the artery, which is the vein and then uh on this side, we'll run an uh uh So there's a super stiff wire going up on the artery. Now, I actually put that through uh through another catheter because that's a little bold and then on the vein, uh an extra stiff wire going up to the right IJ. We also cannulate the right IJ on everybody. So I don't like to do anything different case to case. Basically, I don't wanna have to remember things. So I have this eight French put in the right internal ju vein ahead of time. And through that, I'll run an extra stiff wire down into the below the diaphragm. Uh And so everybody gets this kind of bike val Cand to make sure we have an empty right heart all the time. Uh And then we, we watch all the wires go up, we confirm their position. Uh And then I make my decision to do the operation. And um and then at the end, uh I think this was a troll and at the end or this is actually getting on pump, right? So going on pump, then after I, I do put my per cardial in ahead of time, but I understand doing it with while you're on pump and this is the IJ line going in. So now and this is just a 16 French uh pediatric. Can you of some sort? And we use the same one for everybody. Uh Note to everybody if you're gonna, if you have the opportunity to cross clamp high, cross clamp high because it gives you plenty of play in the order and lets you get through the transfer sinus to close the appendage if you want to. And this is not important. And then at the end, as mentioned before, when we take that thermal artery candle out, we will put a wire through it first, it's just AJ wire that we use. So then we pull the thermal candle out. We still have access. We want access still to the thermal artery in case you have to put another perclose in or something uh to manage the artery, so never lose control of the artery. Always keep a wire in it and that'll keep you out of trouble. Uh For redos, I always do an Antegrade stick. And that's because I had the bad experience of a compartment syndrome. For fortunately, the kid got better. He's a young man with a red or valve repair and uh his limb did get better, but it scared the hell out of me. And since then I've always done an Antegrade stick. I hate that I had to learn something the hard way. Um So, and then this, I'm gonna leap through this pretty quickly. This is one of our VRS, but I think it's kind of worth looking at because this is actually several years old. This is early in our experience. Uh It's kind of a regular person kind of a, you know, a heavy woman. Uh And we're kind of figuring out, you know, uh the orientation of things. You'll see, we use some clunky stuff here. We've kind of slimmed down, but there's a couple of like important points I think that are worth looking at here. So, uh you can see we did free that lower rib. So a third rib is off. Uh I do still routinely divide, divide the right into because that's how I learned how to do it. I don't know, I don't think there's a, I don't think there's a big fight to be had there. I don't think it makes that big a difference. You want to divide it, do if you don't, don't. But you can see, I got pretty good exposure in this kind of heavy person. And one of the things that we'll do, uh kind of purposefully is when we put our pericardial on, so we'll situate them where we can attach them directly to the skin, obviously. But then also, as was mentioned before, we'll pull them out laterally to pull the heart over. But for us, I think the most important thing is we still marsupialize, which is Joe showed me that like 15 years ago, I think basically taking the per cardi and we'll take this retractor out and then we'll take those per cardial stitches through the, through the skin and pull the whole thing up to the incision. So it we don't have a soft tissue retractor in there ever. We just do this and then these stitches are gonna get pulled through um and tie down to marsupialize the entire thing so that this all gets pulled up basically into your face. So in this kind of heavy set lady, uh it's still a pretty small, nice, small incision, I'm gonna have this aorta right there right where I can work on it and I can change the orientation if I want to by slacking on any of those sutures any time I want. So peripheral cannulation. And then, as I mentioned earlier, I think it's important to dissect out high on the aorta. We go up above the pulmonary artery. Now, not everybody's gonna agree with this, but this, I think just makes it infinitely easier because you have all this real estate on the order. Um And then we will put a vent in routinely. Uh You can see we just use a sponge stick to pull over there. I've got carbon dioxide being inflated and then we'll put the vent in through the right superior form vein on the rare instance where we can't do that. We have this kind of small kind of pediatric can that we can drop through a valve. But in general, we like to have that vent in there. Uh It's just nicer to have all the blood out of the chest when we do it. And that's the vent going in. That's the big clunky one. I now have a smaller vent. I also use smaller rams and, you know, fabulous exposure of a valve. We've seen this already. So when the valve goes in though, um and I think somebody mentioned this earlier, you always have to remember that you should take it off of the holder and uh turn it sideways. I try to show you that, but it's, it's really important, turn the valve sideways. Uh So, you know, you make your air to me any time you any way you want, I tend to head down toward the valve a little bit in the non corny, but not much. It's mostly transverse, turn the valve sideways and then plop it in there like uh like, you know, you, you're fitting a shoe on a, on a foot. And then the other thing that I just wanted to mention here and I think it'll show up here is uh well, that's the um is that we will use these little els at the nature of each sinus. Uh There's one going down there. So this really gets an onyx valve seated all the way. So you get the three reels in there and then you can use the poker, look through the valve and you'll see that it's always seated. Now with impunity, you just fire your sutures off, right. You don't have to worry about anything getting un seated because you know, the skirt of the valve, which is one of the beautiful things about the ony valve is that skirt is going through the anus and then you can just fire it off with the, with the uh uh Cornell. Um So anyway, we, you know, we went back to, we took this idea that we could first, we manage the pain in the minis, we get them mobilized and then maybe we could spread this across the entirety of the practice. So, you know, our postoperative mobility program to call is aggressive, but it's aggressive because we don't use a lot of stuff that slows people down and we give them the ability you'll see to use their arms right away. So, with minimally invasive, obviously, you can use your arms right away for sternotomy. In our practice, you can use your arms right away too because everybody gets rid external fixation. But post operatively, everybody gets I acetaminophen for every six hours for eight doses, we use Precedex pretty liberally. The li is on and off depending on uh if the patient is having, you know, if the patient is not waking up right away, a lot of times they'll take it, get rid of it. Now, here's the key thing, fentaNYL is available for only the first eight hours and about half of the patients never get any narcotics. The whole hospitalization that includes sternotomies, zero narcotics. They don't even get any Fenty the first eight hours. So it's, but it's available to the nurses. They can use it as much as they want. Uh Everybody's on a although we stopped it now for 75 year olds and older because we're a little bit worried that it could make them a little bit foggy and they just don't seem to have any pain anyway. For the vowels, we still use some tool. Uh and a lot of key passes, pressure points and ice packs. So ice packs, right? If somebody's sore, put an ice pack on it, don't give them drugs that systemically dull their senses, give them a localized treatment. Uh Nurses will tell you I walk in a room. Somebody tells me they have a pain somewhere. I rub it myself. You do that too, huh? Yeah. Right. Right. So, I'm like, let me see if I can fix this and because you don't wanna give somebody systemic medications so minimally invasive. So, if we look at our data, uh, our postoperative stay are, uh, are, are actually our post operative pain scores don't change much, but the use of opioids goes away, It goes essentially to zero. So basically low scores the whole time. But early on we're using the drugs later on, we're not using the drugs at all. So something changed, right. And got rid of the pain because before they were using the pain medicine for the pain, post out length of stays kind of stayed the same about four days. Sometimes we send people home day two now just to show off. But it's, we're not in a race. Uh mentally invasive folks going home on average of four days, I think still respectable new narcotics. Nobody uh discharged to home, everybody. And that's important, of course, but minimally invasive, you kind of expect it. But everybody goes home, nobody goes to an extended care facility. This is a guy, 64 years old, two days after his I call it a parasternal but right through economy, uh 64 years old never wants to have another procedure. Takes care of his uh his family member at home, goes home post up day two, let him do whatever he wants. He can lift his mom up now and put her in her wheelchair and can do anything he wants. Uh, and he's not petite. Right. So we got that operation done for him. Quickly. Went, I went home quickly and he's back in action. So not every patient can or should have minimally invasive surgery. Right. So why do we do minimally invasive surgery? It's about the trauma and here we can see a way to address the trauma more aggressively. Uh You know, I always say if you were in a car accident, you split your sternum right down the middle and you went into the hospital and the surgeon put you back together with some wires and sent you home. Would you think that was ok? Or would you not want an orthopedic repair of the bone that was fractured in your accident? I mean, it's orthopedics. So we're the only discipline that doesn't put a bone back together the way you're supposed to, we do uh average anatomy narcotic usage for the entire state entire hospitalization. As we shifted. First, we went to play fixation and kind of left their narcotics on the table any time they had a little glitch or a little pain, we gave it to them and then we just kind of just said, oh, they're not using them, let's start taking them away and we took them away and now we're down to the average narcotics for the entire stay is about four codeine pills for the whole stay that includes their fentaNYL at the beginning. So, sternotomy, narcotics and status at discharge. So this is sternotomies. 6% of the people go home with a, with a new, with a new narcotic prescription. 6% that includes traMADol. TraMADol is a narcotic and probably most importantly to this whole thing. And because we did bundle, we did a bundle car, the bundle car experiment with the government and we rocked it. The most important thing was we went from 30% of people going to extended care facilities to 9% of people. I think we've got it down to a little bit lower now going to extended care facilities of any type because that's where you spend money, that's where people get sick, that's where they get wound infections and they don't have to go there anymore. Well, how do we do that? We just let them use their arms because they have rigid fixation. We let them be active. This is a guy right after astronomy comfortable, you know, excavated in the operating room, one arm over his head, you can put his arms any place he wants. This is a guy who goes home post out day two. And I didn't do him minimally invasively because he had this really broad base tumor. Uh And I did a anatomy on the guy and went home post up day two. A week later he's driving. Now we tell people they can drive five days after they leave. If they're not gonna have a visiting nurse, they can drive themselves home as far as I'm concerned. But the visiting nurse won't come see the patient if they're mobile. So, and we have had patients. I had a guy come from North Carolina got in his car and drove home right after surgery. This is a good example of the power. So, uh a VRM, er, post update four, he's going home. He's got a BM I of, I don't remember what it was. 60 58 using his arms to get up and down leaving the hospital now. Yeah, it'd be great if I could have done that operation through a little incision, but I'm not going to nor neither are you. So what do you do for this guy? How do you make his experience the same as the middle me invasive? Can it be done? It can, it can be done? So, how did that affect? Ok. You guys are doing all this fancy stuff. Uh, your front end loading, everything it's experienced in the hospital is much better. What does it look like in the long run? And what do we see? We saw a steady decline. It's not dramatic but it's a reasonable decline. These are six month windows and these are just Anatomies. Uh, but 6.5% re admission in 30 days is pretty damn good if you're not sending anybody to extended care facility. And perhaps more importantly, in 90 days is not going up much. So now we're down to like three additional percent from 31 to 90 days. Our job is to send people home and keep them there back in their families, back in their communities. And you think that our sty really makes that much difference to them. I actually beg to differ. I think that you can have a discussion with somebody to say, do you want your valve repair or replace? Do you, do you want, should we do the triple valve maze or should we just do the double valve? Should we, what are we talking about? There are choices to be made that impact the person for the entirety of their life and we shouldn't let the incision make the difference 90 day readmissions overall 9.4% for the entire cohort. So in the IC U, everybody gets seated at the edge of the bed within four hours excavation, most of my patients are excavated in the operating room. My partners are moving toward that, but it, it's not a big deal. Everybody's excavated really within six hours and most importantly, four hours within, within the time from their time they're excavated, they are up at the edge of their bed and most of them are standing and we try to get them walking right away if they happen to have a swan we don't really use those anymore, but we do when we have people that for a reason, we need them, we still get them up and we walk them. If they're in an effort and fed, they're out for a walk as long as their index is. Ok. Uh, mobility, everybody gets out of bed and doesn't go back. So the day after surgery and I tell patients ahead of time, you won't be in bed. You're gonna be up at seven o'clock in the morning and get you out of bed. You're gonna take your first walk. You can have some breakfast, sit in your chair and you'll never go back to bed that day. You will stay in your beautiful recliner that we spent a quarter million dollars on acquiring after I beg their hospital sterile precautions, you know, red green, we don't have red anymore. Uh, and we have aggressively stepped this up. So, uh, at the time of their operation, we pretty much will let them lift £15 in each arm, uh, in a week and a month after. We'll tell them, you know, £40 overall, they, a lot of them disregard it. Uh, they send me videos of themselves doing crazy things. Uh, but it is because of the fact that we've done sternal fixation and they have a sternum, they can't move, you have to do it right. Uh, we do use different versions of it depending on the osteoporosis of the bone. And uh in BM I over 40 is surgeon specific, but my partners are, are the same as me now, which is everybody gets to do whatever they want. Uh And then the activities, you know, we try to give them guidelines but basically they can get back in action pretty quickly. We let them drive, like I said, five days after they leave, unless they aren't having a home nurse and they can drive immediately. So you got these two guys, one's got this pretty nice swing. This one's got this pretty nice swing. Which one had astronomy three weeks ago? No, the guy on the right hitting fast pitch. The golfer had a mini mit. So the menu right now, let's see. You got the patient walks into the room. He's 66 year old male physician. His son's a doc. He comes for a ver uh he has severe bicuspid valve stenosis with a deep left so he can have a Taber. He's got good anatomy for a Taber. Actually got normal coronate has proxy atrial fibrillation for which he is symptomatic. He's a little cardiometabolic, you know, a little diabetes, hypertension, uh didn't measure his inflammatory markers, but I'm sure they were up a little bit. His ace is 43 millimeters, not an indication, right? They're supposed to leave that alone. So, what do we do? We could do a ver you could do a parasternal uh saver and closes appendage. Uh We do a mini sternotomy closes the age possible root larger if we need to, right. Get a big valve in there. If we're gonna put a tissue in, that's a whole, that's a whole other debate, right? Whether, whether we're even supposed to put a, anything less than a 23 in any human being, we can duke that out. But in general, it has to do with their body surface area and the architecture of their root, which like Chris said, we should get a scan on every human being before we operate on them. So we know after we do what we do with that finished product, it's gonna look like and what their opportunities are for the rest of our lives. And then the last thing we could do is astronomy saver maze aorta. Maybe we do the route if we need to. Who's gonna, who's gonna take this guy's AORTA? I'm just curious say Chris Blaser says, no, I took his aorta. So the way I put that to people is I tell you, I know you're a couple of millimeters below. You're 64. Let's talk about how long you think you're gonna live? Uh How do you want to monitor your AORTA? Because we have to monitor his aorta. Don't we have to monitor his AORTA, Chris if he's 43 millimeters? Yeah. So I really don't want to get scans on him. Yeah, you still need to monitor after surgery. Sorry, you still need to monitor it after surgery, whether you replace it or not. So, no, you don't. No, no, not if you've gotten, you've gotten all the way up to, you know, uh, to the a and then, yeah. And then after that you don't have to follow it. But somebody does. Yeah. But if it's by cut, but it's only to the para cardial reflection, you take everything out the roots easily, see it on echo. I don't think he needs four CT scans after a year. So we can do that later. But I, but I like the debate and uh and but the reality of it is I like kind of let the patient decide because I think you're gonna have to scan them. You're gonna have to follow them somehow. If you leave it, I don't think you have to follow it as aggressively. Obviously, if you take it, I thought you had 15 minutes of the operation. I was already doing astronomy. Uh So it came out. Um I think that it's important that we, you know, we pay attention to what we're promising people, right? I just mentioned that a minute ago. We have technology now, we have scans, we have interpretation of data with respect to the durability of vowels. We have an understanding of aero Annuar architecture that we can predict whether somebody can have a valve valve later. We can't just slap a valve, we can't do that anymore. It's over. So you know, be the intellectual in the room even challenge the cardiologist, which is what we do. You know, I'm like, uh, you know, if we do the, and what's next and if I do the, I gotta do this. So, because when you're finished, you have to be able to predict what this is gonna look like later. This is actually a patient who has a high risk of coronary obstruction later and it's kind of moderately high risk is moderately high risk. Ok. I don't actually don't know the answer to that if that's what you're gonna leave somebody with. So why do you do a limo? Why do you do multiple arterial graphs? Why do you do a cox maze repair type three V mit regurgitation? Do mam invasive surgery? It's not because of randomized control studies is because we know what we're supposed to do for people, how we're supposed to take care of them. And we refine that based on the human being in front of us, their age, their comorbidities, their personal expectations for their lives and their long conversations. Unfortunately, my clinics last forever. So can we survive in the value based care environment that's coming our way? Don't think for seconds that it's not coming. And I can tell you who the winners and losers are. This data exists and the winners are the ones who don't send people to extended care facilities. So not only do those people not do as well. And they're miserable because they're not home with their families, but it's very expensive. So, if you want to save a couple of bucks with whatever suture you're using or picking a valve or whatever, fine, but try to save the money on the long end where the patient gets to go home and be active and not be restricted and not have to live in one of those places for any period of time because that's where you're gonna be paying the money. So things to think about safety, life, brain kidneys, right? So the first thing we're doing is we're deciding if we're gonna hurt the patient. What are the goals of the surgery? Valve size later? Valve, valve, what's the ro geometry look like a complete operation? We don't walk away from atrial fibrillation. It's a class one indication with the sts. You will fix the A fib if you don't know how to, you need to learn how try customer regurgitation. We saw that earlier. We treat that does the patient generally understand their condition, their life journey computation. So I have another talk where I actually like do uh actuarial tables on a patient under different conditions. And I, you know, it's different, you know, if the patients slovenly and uninterested in their care and they don't have any chance any interest in changing, it's a different patient than somebody who's, you know, maybe a little sloppy on the edges. But it's trying to figure things out and wants to get involved. It's a different patient. Does the patient generally understand what they want from the operation? What are the goals to finish product, the operation? So you should be able to sleep well every night, knowing that our goal maximal days of quality of life home in their community, working and living not coming back to the hospital. And that's the end of that. Oh, this is a guy uh who sent me a pic. This is a, this is an, an actually uh Minnie, he went skiing in the Alps, uh a month after surgery. So that's kind of cool. Thanks. Do you have any questions from the audience? So, there you go. Yeah. Good, Mike. Yeah, Mark. We used to use a lot to Yeah. You, yeah. So it's really, you're right. This is a drug that you have to use in a very nuanced way. Uh Certainly as age goes up toward all use goes down. But fortunately older people don't hurt as much. Um And at the first sign of the, of a bump and, and you have to stop it. Um We haven't had, having kind of been more rigorous about that and using less of it. We've only seen the occasional bump, but I do think there's still a price that you pay for the use of the drug. I'll admit that and I know that places that use it kind of more ubiquitously just had to stop period so that they would have to deal with that. So are you using 15 or 30? It depends on the size of the person, but the data says 15 is fine. But if it's a big person, I usually use 30. Is anyone else you do? What are, what are the people doing to reduce the risk of renal failure? Post op? So I heard some comments earlier about using the using small cannula. I cringe a little bit with that because the smaller can mean higher flow, more turbulence, more hemolysis and which means more renal failure. So um another way to combat that is don't go up the femoral artery Denise said it just can like centrally with a large, yeah, just can central with a large cannula. And you know, there some literature that mis cases have a bit less acute renal failure. And it's true among red. It's true among patients that start with higher Ethan. And uh and I've looked at it in my practice and for the, for my three big groups, the mits, the aortic and the septal myectomy. Each single of them have a decrease in uh a renal failure. And I don't know whether it's related to inflammation. I don't know whether it's related to being perfuse no to the lower body with higher pressure going into the kidneys. And if it is coming from, from the aorta, my my feeling it is about inflammation, but mis even though it is longer on the procedures. They are a bit longer on pump and they have a bit longer cru time time and that should not give us those good results. It seems to be something related to the trauma that is actually good for acute injury. I don't know if you have seen the same thing. Now, I, I agree. I concur with that. I think that, uh, I have seen less renown sufficiency even in those who come in with a baseline GF that's already altered, significantly altered. Um I have not yet seen somebody go into needing C RT or something like that post up. Um Yeah. Yeah. The um the most convincing um experience I have is with T primary pr cases for some reason when I do a sternotomy and do a TV replacement or repair for isolated tr these are sick patients, SDS is like 8 to 9% operative mortality. They do a lot worse than if I do a mini thoro tricuspid valve repair cats, cats institution does a whole bunch of these. Are there any more tricks to taking care of isolated tr cases? We, we do a lot of what we like to call pre so we bring them in 23 days ahead of time, put them on a Mione drip, las drip, basically try to get them as optimized as possible. Maybe in a right heart cath. Our, our heart failure guys are very excited about doing those repeatedly but so we, we if for most of our tricot patients and then any of our mit patients that have significant pulmonary hypertension, we bring them in and do pre Yeah, I think, I think that's so important because it also gives you the option of canceling that case because they're on a really slippery slope. You may have seen them like three months ago and all of a sudden they're in the toilet so you can, you can test them a little bit of dopamine if they don't look like they've got any contract to re there, just cancel that case, what you got? No, I'm just intrigued by that. The whole pre business. Um What are you looking for specifically to decide whether this is getting better or this is working, is not working? I mean, most of the time, the problem is their volume status which you can, you know, do you know physical exam and track their BNP, but most of it is right heart dysfunction. And so, you know, if you bring them in and you put them on Miller, no, and you dry them out and you get an echo when they are admitted and then two days later you get an echo and their right heart looks a lot snappier, then it's a much nicer operation obviously. So, and if it's not, we'll cancel it for how long forever. I mean, as much as it takes, but I, I'd like to add something to that. Uh the amazingly important people and there's a two or three good series out there talking about hypertension and mini uh nitric oxide is a great, we, we use it like water. So anybody who goes to sleep gets a swan and the P A for the maps of the, the P A maps are above 25 30 30 to 40 will call in for nitric oxide. We will use it 20 parts of a million or so. And then we'll take it off once we come off bypass and the peer pressures are better after you treated the pathology. That's really important. Uh Are we still on the questions part for Mark? Yeah, we get starts. Yeah. Yeah. Go ahead. Yeah, go ahead. I, I had a question for Mark and, and for the panel is extubation in EOR versus none. That was one. Yeah. So we've, we've steadily, you know, we don't do things overnight and that when they're protocol like that. So, meaning direct patient management, that kind of shifts things. So we kind of made steady steps where uh first we just did it with the like beautiful minis and then we slowly progressed in my patients toward doing almost everybody that's reasonably stable at the end of the case, even if they're on a little bit or whatever, we still activate them in the operating room. Um Now why do we do that? We do that because our nurses are so regimented about what they're going to do next. So, a patient hits the unit, they get their numbers and within four hours, no matter what their situation is, if they're not bleeding and they're human stable, even on their drips, they stand them at the side of the bed. So what our goal is and I don't know if I mentioned this earlier, but, uh, and I, I talked about this last night, but there's a study, there's a study done by a woman who had a chronic disease and she was being repeatedly admitted to the hospital and she was somewhere in health care. I think she was a CFO or something of a hospital. And she looked at the amount of time she spent actually being treated for what she was in the hospital and it was like, it was less than 1% of the time. It's not, it's obviously not true about heart surgery or surgery in general, but it's true that we spend so much time not doing anything for the patient. So our focus became the condensation of all of the events to push them as far as approximate as we could safely. So that's kind of, it's part of the philosophy of the excavation in the operating room. It's not like we don't wear it as a badge. We just recognize that the patient seemed to do better. It was a question. Yeah. Thank you doctor. So I had a question about the, your eras program. I think it's fascinating. We have a lot of patients that complain about not being able to rest, not being able to get sleep. Is there any component of your eras that addresses sleep timing of vital signs, interruption of labs? Chest x-rays melatonin, anything like that. So this is such a great topic uh because they're sick of hearing it from me at the hospital. It's one of those things that I harp on because you slip after time. But number one, as soon as we have the opportunity to not wake people up, we do it. So we put the order in basically on rounds. We'll say, ok, this patient, we need to let them sleep. You're not going to draw any blood, you're not going to get a chest X ray before 6 a.m. You know, these kinds of things. It's a little bit hard still to get that done. The other is that I talked about Precedex earlier, we really use it, but they're not getting any narcotics. So if somebody doesn't sleep one night and we will make Benadryl available to everybody, it's not great because it has a little bit of a hangover. If you've ever used it, it does leave you a little foggy, but I don't have anything better yet. So they have Benadryl. We don't use any of the other powerful sleep aids, but you can use, Precedex. Precedex. People will sleep. They'll get like a great night's sleep. And the nurses are very comfortable with it now. So it doesn't depress respirations. It is a continuous intravenous medication. It's not expensive but patients get a great night's sleep on it. That's kind of the, that's the button that we push when we really need to get somebody to get sleep. Yeah, that's, I think that's really important. Yeah. And giving las twice a day do, like, eight and 12 rather than, uh, eight and eight. So they're not having to go to the bathroom at midnight. We do use Melatonin but it doesn't do anything. You agree 11 more point about the right side where you're talking about and then Weak RV is that when we in our time out, uh my time out has a profusion part that I'll ask him to do. Cool to this degree. Um These are the cannula and take off a liter and a half volume ultra filtrate a liter and a half off. So that I think impacts dramatically the way the RV returns, taking the clamp off if you're doing a cross clamps. Uh Yeah, absolutely. Well, great. Um I wanted to shift a little bit to atrial fibrillation because one of your slides mark is um doing a ram tabr with a left atrial appendage closure. There's a lot of Canadians here and I thought one of the biggest trials that came out last year was the Laos three trial showing that everyone, everyone with a F coming into cardiac surgery should get a left atrial appendage exclusion. I think it's just a slam dunk. I don't have to repeat a randomized clinical trial. But, um, I've yet to see a video with a left pend closure underneath the aorta three transfers that actually looks, looks like, looks like it's easy. So, uh, for the, for the right interior throaty, it is a little more challenging. Uh, and I don't have a video for that. I have it for the, of course, everybody's got those. I got plenty. I can show you one of the videos. I got three or four of those, but I use actually the short flex V, not the long one for mits and for aortic, whether it's or right anterior throaty on the right anterior thor economy, it's very dependent on the patient's uh particular architecture with respect to their heart, the aorta and the size of their chest. So if when you go through underneath the and I have pictures, I don't have video. If you go underneath the aorta though, you have to have, I have a very nice long like egg beater that's narrow and long and stiff that I can put underneath the aorta and you can see the, you can see the pend there buying right into your throat, but some people you actually can't see it well. And then to be honest, what I'll do is heart fully empty, make sure that there's no volume on the right side at all. Make sure that, you know, that your LV vent is in a comfortable position and then I'll take a sponge stick over to the other side of the heart. Rotate it toward me enough and the pend will pop up and put it on over the top. So, I've done it both ways. Uh, when it's dicey, I don't do it. So, if I am on a mission to close that appendage, I'm not gonna do it. I'm not gonna run into, I'll do as if I am on a mission to close the appendage. Yeah, Chris, one of the things I found specifically for this is that I think I get like uh I hook the pump sucker under the ear to lift it up low near the root and then um I push down, I use two. So uh forceps to push down, grab the appendage, but also push down the dome of the left atrium because I think what you're doing with a, with a sponge stick and it rotates it. All right. And I use the long one personally and I use it kind of upside down. I, I find it better for me to kind of go like this rather than like this. And I put it in and it's, I'm gonna say 95% achievable, not in a redo but on a primary case, I, I'll send you the video. Yeah, I like to see the video this um you, you know, this area is gonna continue to explode when other companies start coming out with devices. Medtronic hasn't said it to us, but they've made the announcement to their, um, to their investors that they're gonna have a left at pend closure device coming out. So it's not just gonna be here. Metronic is gonna have a device out for left at elo. So keep an eye out for that. Um, I have no, I have disclosures for that as well. All right. Well, there was a, there was a good, it was a good question from the audience. Is Corey, Corey still here. Core you wanna ask, you wanna ask that question we're already on, I guess it's just the fear of compromising is my fear. You know, we do, you, you want to make sure if you can do the right side, minimally invasive surgery, can you offer everything? So you got to offer based on the data class, one indication to do microvalve surgery right and left side and then you got to take off the left at pend. I'd just like to hear everyone's thoughts about that and how aggressive they are on the right side with keeping your incision small, keeping the morbidity down at a hospital. Where do we value that compromise? Is there no compromise in ghost to anatomy or do we really push and say, ok, let's do the whole thing from the right side and it does take time I mean, it ups your pump time, your clamp time. And are we ok with that? Yes. So the specific case would be a S plus A F. Are you gonna do a Ram T and skip the maze or are you gonna do a full stoy and then knock out both? What do you, what do you guys think for, for a case or my hearings? 34. Well, for, for, for the aortic case, I do exactly like I've described the double valve, it becomes for me, a double valve, open up the left atrium and I do the full set of lesions, you cry. Uh If the approach is nice, I rather close the left appendage now with a clip. Uh If the approach is not good, I would close it from the inside and double layer closure. Um And, and for the, I would, I would try to do the same as that preferentially clipping the left appendage and if not closing it from the inside, uh I don't um I don't do right lesion sets unless uh I'm working on the Tricuspid as well. Um It's uh it depends how much you want to push and how much better you believe the results are. I don't know if you remember, but when we have done the NIH randomized study for the maze, uh even the uh uh even the pulmonary vein isolated alone give the same results as the full set maze. We weren't doing a maze. That was not amazed. That was amazing. Let's just establish that. It was not amazed. I'm sorry. But this is something I'm very passionate about. The paper is important. But if you look at the appendix, you see what the lesion set was that they called a maze. It was not a maze. And they used the monopolar unipolar RF for a lot of the lesions which we know does not work. So this is an important paper but it's not for that reason. The reason is because like you said, if you do something, it's better than nothing, that's the answer that we get. But uh I, I think, you know, we have to be scientists. If someone has persistent longstanding atrial fibrillation and they're not 85 years old, you owe them a biatrial mas. I mean, if you're not going to do it, then tell them, look, you know, I think that your a fib isn't all that important and I can't really fix it that well. So I'm just gonna not do it, but the patient has to be part of the conversation. If you genuinely believe, genuinely believe that you're not gonna help them, they're fine. Tell them it won't help you. So that I'm not doing it. Let me ask you this. What about atrial size? I know that. Yeah. Yeah. So it's important, right? So we know that once you get past six centimeters, the outcomes diminish and you get close to 78, it becomes 50%. 50% is still pretty good. You know what I mean? If you've got some stenosis usually have atrium and no calcium in the atrial wall. Even though I'll do the ones with the calcium. Uh, then, then you should pursue that, but you have to pursue it rigorously with transmural lesions, the complete lesion set and you have to do the right side unless they are newly persistent or proxy, they don't have an enlarged right heart. They don't have tr they don't have pulmonary hypertension where you don't think that right atrium is going to come back into play and haunt you with nuance at a fib because remember once you get rid of the a fib, if there's any part of the atrium that's still vulnerable, you're going to have a fib again. So, you know, just have to be intellectually honest about it. You can't just shave things off because it's convenient for you. That's not right. But the patient's preference has to go into it as well because I mean, there will be patients who will decide I don't want astronomy with that full maze II, I want a thoro fix my micro or fix my aortic or whatever it be and not have that therapy. I think, I think if you do a fixation, you can, you can convince them that they're gonna feel the same either way. You can't tell that. Like I said, I can't tell the difference between my patients where they had a mini astronomy. We walk in a room if they have a gown on. So most of the time I just say, look this, you know, there's pretty good data that says it's gonna extend your life. You don't have to deal with the A fib anymore. Your age is not getting any bigger. There's just a pathologic data that shows that even under rate control, there's damage to the left ventricle, even with rate controlled a fib. So, you know, it's, I'm just changing your incision and I get to fix the A but, you know, we, as I was telling somebody earlier, we follow every human being. We do amaze to, we follow them their entire lives. We do. So I have one week of continuous monitoring on every patient every year forever. So I know when they go back in. So it's important to us because we're good at it. I mean, if, if you're not really good at it then maybe you don't go after it. I don't know, actually know the answer to that. But that's tough. Those are tough points. And I mean, not to be controversial but you talked about a 4.3 centimeter ace aortic aneurysm. Yeah. Yeah. I was probably off base there. I'm probably not gonna do that anymore. Yeah. But I mean, you know, but that was after a conversation with a physician where I, I asked him, you know, do you want, we're gonna have to follow you. It's gonna have, you know, it's about 15 minutes of the operation and it was very straightforward as it turned out. He had a little bulge in there, but I guess I wouldn't have known that. Uh, and so, but, yeah, I understand what you're saying. It's, if that is more nuanced than this is, this is not nuanced. Yeah. And I, and I get that and, and I wanna go down that road too. I wanna say to patients, if I take your appendage off, you're less likely to have a stroke. I think I'm confident to say that is the room confident to say that like shown. I think the data shows that if I, if I do the maze on the left side, I'm gonna impact your, your life span. I don't know. I think if I do a left and a right, I'm gonna keep you out of heart failure, which should keep you alive longer. That's, is that what you say to patients or how do we, you say if I do a left and right on you, it's gonna be successful 80% of the time and you're gonna live longer. I, I struggle with this and maybe it's just, I don't know enough. I don't need to read closer literature, but I tough, I struggled with the consent form and I don't want to do sternotomies on an 80 year old or a 75 year old. But I don't want to compromise on that healthy, 70 year old either. I want to do the both sets, you know? Yeah. Right. And you don't want to compromise, do you? You just said it, you don't want to compromise, so, don't compromise. But if you, if, if you, if you put the sternum back together with properly, uh, you don't really compromise on the patient's recovery. Yeah. I think you have to have astronomy now, but you know, not with wires, wires really isn't a good way to put a sternum back together. I know I'm talking about sternums though. I'm talking about, you're talking about sternums. I'm talking about sternums, wiring a sternum is not a proper way to fix a sternum. It's just not, we do it fine, fine. We've been doing it the same way for 30 years. 50 years. Right. I got quoted uh forward earlier. He said, if you've been doing something the same way for 30 years, you're probably doing it wrong by now, we should have changed how we do that. Just like we should have changed a lot of things. So just mentioned closing the appendage from the inside. 60% efficacy. 65% efficacy. Don't do that. Don't close the appendage from the inside with a double layer, even though you're a good surgeon, you're gonna get a great stitch in there. We know from follow up data. It doesn't work well. So put a clip on clip 98% effective. So, you know, II I OK, you don't want to astronomy, you don't wanna do ASY. But as far as the, as far as the data for a fib in managing a fib and people who are going to live a few years, whether you look at the 30,000 ft view of the SDS data where their survival is better at two years, or you look at the more granular data of centers of excellence where clearly their longevity is impacted. For example, the data coming out of Northwestern. So if you don't want to do it, you're not gonna do it right. No. How will they do it? I think he thinks it's worth it. Not have every you could do it. You should close it better though. Yeah. Yeah, Mike Tuckerman is here. I operated on his dad when he was in his eighties and replaced the valve did bypasses for him. Mike knows what the experience is like, how different it is. The only thing his father complained about was a little pain in his leg where he took his endoscopic vein. So, uh and he was back, you know, being himself again pretty darn quickly. So I'm not gonna argue this forever. It's not what this meeting is about, but, but the astronomy shouldn't be the thing that stands in the way of giving you a complete operation. So there's, there's a discrepancy between what we recommend surgeons to do for our patients. And what actually happens is a class one recommendation to abate A F if there is a F but only about 30% of us actually do that in real practice will get a full maze. But it's because I do so many of them. This group here is a zealot of a F ablation. I am one of them as well. So we'll try to blade it when the A F exists. Um There is a survival benefit for a F ablation and it is about probably about 10 to 20% at five years. And to give that number a little bit of perspective. Do you guys remember what um Floyd loop showed the benefit for a lema to L AD was for cabbage, it was about 10 to 20%. So if you think that lem to L AD is really important for your patient, you should also think that a ablation is also important for your patient. OK. Well, how do we get people to do more Aib then? Uh so many, so many is not gonna help, is it mm Like steers you away from a are there? You can do a maze with cryo, you definitely can. Uh In in those cases, I would argue by right, put an catheter, put a thermal catheter, get, getting uh the cryo probe shaped in different forms. And in the left maze, it's not difficult uh managing the appendage. You'll have to, you're gonna have to clip it like I don't have a video of that. Uh, Mark does it really well, clipping the appendage with a B clip through the transfer sinus and uh and going to the right side and to do the right side of lesions which are not difficult through the right chest. I actually have a great video of a tricuspid full maze that I'm glad, you know, happy to share with people minimally invasive tricuspid full maze. But I do think though to be intellectually honest again, if somebody is not persistent, like genuinely persistent and you do a good left sided maze and Northwestern is going to have data to confirm this. I'm sure soon if they haven't already, that that's ok too. A full cryo left atrial full lesion set, including the coronary sinus with closer the appendage using a clip or whatever definitive device you want and somebody who is not persistent, uh that's perfectly acceptable operation. Well, good, good to Corey. Thanks for asking that question.