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: Katherine Harrington, MD Baylor Scott & White Health, Plano TX Please Note:
The views expressed during this presentation are the speaker’s own and do not necessarily reflect those of Artivion, the speaker’s employer, organization, committee or other group or individual. Unattributed data, device selection, and procedural guidance is a matter of physician preference are presented on the basis of the individual speaker’s observations and experiences and should be treated accordingly. Federal law restricts the devices discussed herein to sale by or on the order of a physician. Refer to the Instructions for Use and other product insert documentation that accompanies each of these devices for indications, contraindications, warnings, precautions, possible complications, and instructions for use.
Products not available in all markets. The content of this presentation, including any copyrightable content included herein, is used with permission from the speaker. All products and indications are not available/approved in all markets. All trademarks are owned by Artivion, Inc. or its subsidiaries. On-X Life Technologies, Inc., Jotec GmbH, and Ascyrus Medical GmbH are wholly owned subsidiaries of Artivion, Inc. . © 2023 Artivion, Inc. All rights reserved.
First speaker I'd like to introduce is Doctor Harrington. Uh she's uh Stanford all the way through in her training, undergrad to med school to cardiothoracic surgery training. And uh what I like about Dr Harrington is she's a disease focused surgeon. So it's not just about the treatment, it's about the entire valve. Uh We have her speaking about mini sternotomy, a aortic valve replacement, but see, she, she certainly can do a tabby for the patient. A mini stern mini thot aortic valve repair ross procedure. So, uh this is an important talk to kick off on uh present to you, Doctor Kat Harrington. All right. Thanks for having me. Thank you to and thank you for everyone for coming. Am I hitting the wrong button? So clicker on or should I just say next slide or maybe we're just waiting to get it loaded, the actual power point. Uh Sure we can do the first question which is very similar to. So let's ask the first question. It's very similar to what Dr Malay asked, which is, how do you do your many A VRS? So, no, that's the second. Ok. We'll skip the second question because So what average has many A VR have been shown to have over full astronomy. So this is like the board question, I've actually seen this on the board. I tell my resident this question. Um, you know, maybe some things are true but this is what the board wants you to ask. So lower rates of blood transfusion, lower length of stay better mortality or lower rates of a fib I've seen this on the board several times. I know Doctor Malary did a Cochrane review of mini A VR versus sternotomy. I looked up in preparation for this talk like three years ago. Yeah. Ok. That's correct. Good job everyone. So this is if you're retaking your boards, that's what the, the answer. It's never been shown to have a better mortality or lower length of stay or, or even less pain medication or a higher quality of life. The one thing that has been somewhat reproducible shown is lower rates of blood transfusion. So kind of disappointing, but it's still a big seller, you know, marketing tool. Like, uh most of these patients I see in the ta clinic, they have their heart set on getting a TA, they have, you know, poor anatomy for a TA they, they have an aneurysm and they hear they have to have surgery and then you tell, but I can do it through am incision and they're like, oh, ok, great. You know, like it, it really does kind of soften the blow. Um, and it does make the patients, uh, a little more, uh, amenable to surgery and, uh, the cardiologist a little more amenable to sending them to you or letting you do it over. So this is gonna be a mini A VR through an upper hemi. So this is what I can do through an upper hemi astronomy. So I do obviously a VR and little R I do a VR with root enlargement. I do a VR A sendings, I do a VR sendings with a, a for like a Bicuspid if uh just the non sinus is blown out. I do redo through minis if they've had an A VR, I do it if after they've had a cabbage, even with a Paton Lima, I'll do a redo a VR if they've just had an A setting graft and now their bicuspid valve has gone down. I'll do a redo a VR after a David that's failed, never my failed David, but somebody else's failed David. Uh You can do a PFO through a mini if you go through the dome of the left atrium and then I'll do um for aortic program, I'll do a lot of uh aortic arch D branching beating for, for T bar. I'll do that through a mini as well. So there's a wider amount of things you can do. So for preoperative planning, uh all of these patients uh in our system and I recommend for all systems to kind of go through the aortic valve clinic. It's technically the Taber clinic, but they're, they're getting the full Taber protocol with the 40 CD heart, our radiologist slash cardiologists are very good at predicting the annular size. And if I look at like the, they say the annuus is 22 22 millimeters, that patient's gonna get a 21 valve, you know. So, uh if they say it's 25 it's gonna be 25. So I know going in if it's a 21 valve and the patient's BS A is a certain amount, I am prepared to do a root enlargement if they have a very small route. You know, I know even before I make my mini astronomy that, you know, this person probably needs like a stentless route like a freestyle. And I'll tell that patient that ahead of time and we just agree to convert to a full astronomy. So knowing the size of the valve ahead of time is very helpful. And then obviously for minimally invasive work, it's very important for planning your operation and assessing for cannulation, which we'll get into in a little bit. I also uh specifically look at the left heart Cath because um you're gonna have to do a lot of handheld uh from this. You really need to know what size handheld Cannula you're using. You want to have them open right away. It's kind of, you know, you don't have the luxury of, of um protecting the heart in the way you do with a full astronomy. So I wanna already have the handheld uh size open that I need and ready to go. Ok. So this is for CT planning. So what I'll do is I'll go to the Coronals. I do almost all of mine through a um mini uh to the third. Uh You can't go through the fourth. I do probably 95% through the third. But in order to pick this, it's probably reasonable to start at the fourth when you're first learning. But um getting to the third is, is I think should be the goal. I'll look at this, I'll go to a Coronal and then I will scroll through to the sternum. You can see the angle of Louis right there. Then I'll find the second interspace, the third interspace and I'll put my pointer right there and then I'll roll back to the heart and you can say this is, this is an easy one. The valve is right there. And what I'm really looking forward to is the right atrium. If I can play it, can I play that again? Yeah. So what I I like to do all my cannulation in the chest, you can see the right atrial appendage is going to be easily visible. This, this is gonna be a beautiful exposure. My AAA auto or sorry, a can site is within the, the incision, the, the the um atrium. This is gonna be just, just so then this guy is a big just Yeah. No, let's go to the next slide. There we go. This is um like a 65 £350 Alaskan Ice Road Trucker. Not joking. He's on the show and this is his scan. So again, there's the angle of lo there's my pointer at the third interspace and then I scroll back and you can see his valve and his, I don't care so much about the valve. I can do pretty much whatever when the hearts arrested. But the cannulation side there, you know, this is gonna be really tucked under the sternum. It's gonna be really hard to get to. Now, you could just can through the groin, but I like to really try to do it through the chest. And this guy was such a big guy. This is someone that I'd maybe consider going, going through the fourth. But this is something to think about. So for anesthesia, so it used to be, this was the kind of the rate limiting step when we would travel around the country, teaching people how to do minimally invasive surgery. Anesthesia was the hardest buy in because they used to have to put these two fancy lines. And so the one in the middle is the uh endo vent, which goes in the pulmonary artery and was like your vent. It's basically that was the easiest thing for them was like floating a swan and then they hook it up to your um to one of your uh uh vents on the bypass machine. And that would be how you'd vent the heart. And then on the upper corner there is the uh pr nine endovascular coronary sinus catheter. These are no longer being manufactured. So when I started, we missed them. Uh when I started, we put these in every case, um it probably added 30 to 45 minutes of anesthesia time. And my anesthesia guys were really, really good at doing it. It when programs were first starting out, it would add maybe an hour or two. And that was the hardest kind of uh learning curve was getting anesthesia to place, especially the coronary sinus line into the catheter with, you know, echo guidance to E guidance. So these don't exist anymore. So it's easier for them, but it's harder for you because you don't have that backup of having a retrograde anymore. Um And you don't have um an end event anymore. So you have to vent it yourself and you have to be um be different with your cardio plegia. Um I use a standard et tube, I don't need a, a double lumen for this and then they just put in normal CV C lines, you know, corti and a triple lumen uh wherever they like to put it some like to double stick, some like to doesn't matter, they can do just normal anesthesia. Now, I do need them in the room, uh, to be more involved in te, at certain parts. You can't feel the heart to tell if it's descended or not. You can't see, you know, certain things. So I rely on them a lot more for uh echo guidance of, of watching the heart to stand and stuff like that. And then at my site we do a, a preoperative ultrasound guided uh local and regional block of the sternum. Um We have a paper and a protocol on that. Um It's not just local, but they actually do like a super scaling and a um a block to try to um uh increase our um mobility, less payments and, and decrease length of stay. OK. So here's my incision. What I do is I mark out the whole sternum. You want to have the whole sternum marked out. God forbid if anything happens, you can just zip it open. Um And then I feel the second innerspace and then I mark the third interspace. You want your incision to air, lower one that's better for a cosmesis for the patient. But the skin and fat there is very nonmobile, the top up at the notch, you can, you know, yank it up and make a flap lovely. So I put my bottom of the incision in the middle of the third interspace and then I go up, you know, a nice amount uh maybe 34 centimeters. And you can see my two little marks there. Um For where I make my incision, you can see the little what I like to call the chupacabra, uh bites where the anesthesia has done. Uh the block. OK. And uh we talked about the uh J shaped uh third interspace uh mini Astronomy. I use two saws. I use a regular oscillating saw to go down and um or the regular saw to go down and then the there's the small um redo blade to do the thing. I got some partners that kind of do it in one swoop. I'm I'm more of a controlled right angle kind of girl. When you make your um your J off at the bottom of the third interspace, you really want to go at the very bottom. Don't do do it right in the middle of the third interspace at the top, go at the very, very bottom. So you can maximize the amount of space you're gonna get. So these are my opinions uh for the benefits of Mini Astronomy. Again, I like all my cans in the chest arterial and Venus. Um You know, there's definitely papers that have shown that femoral arterial cannulation has slightly worse outcomes than central. You have a higher risk of dissection. You've got some flow issues with watershed. I know, I mean, I do it for mini mits. It's, it's, it's a thing, it's, it's fine. But um if I can do it in the chest, I think it's better for the patient. Uh, in the same way. I also almost always like to do my Venus in the chest. You know, when their, when their crit drops late at night, I sleep, the deep sleep of someone who does not have a retro hematoma. I know it 100%. I don't even have to worry about it. So that, that's worth it to me. But it, if it's tough or in some of my redo, you know, I'll do a Perk Venus. It's, but I really like to keep it in the chest and you can do that, uh, more easily with a snoy than, than in some other approaches. I find that bone heals very well. Taking out the cartilage for the right, uh, interior. Sometimes it doesn't heal so well. Um, and I, I personally think a mini astronomy hurts less than a thot toy. Muscle hurts. Bone does not, the, the lifting restrictions are certainly quicker and better for a throaty than the bone. I think it hurts less. Again, this is also easier to convert. If you have problems, you, you know, you can just extend your astronomy to what you're used to doing. Um, and then I can really do any aortic position or anatomy. I don't care where the aorta is left, right in the chest. It's gonna be, you know, relatively under the sternum, no matter how leftwards it is, you can get to it through a mini astronomy. This is a possible retractor. So we used to the coolie actually is probably most of you have is a nice one. It fits in a mini incision and it, it almost acts like an Alexis. It flattens the um the fat down. Um This is hard to get in. Uh You really have to have a good P A you can because of the lip of the retractor and some people, if they have a tight chest, that's what um I used to use. If it um kind of the easiest thing you guys could use to start on the right is my baby. The genesis, my favorite tractor. I had a girl, I would call her Genesis. Um I'm not joking. So when I, when I got hired at my place, they're like, what do you want? I'm like, I need the Genesee Retractor and they're like, it's like $20,000. I was like, I don't care. This is the one thing I want. So I use it for everything. Uh You can see on the top, all the tools, all the mitr tools, there's a nice uh Ankeny retractor for when you're doing cabbage for Lima things. Um It has a curved um articulator. So with the minis, you know, it's normal that one side will kind of pop up over the other. This curved part of their tractor really keeps it. Um uh stable, especially, or if you're taking a Lima and you put it in, it keeps the chest nice and, um, uh, flat. Um, and then, uh, on the bottom there, you can see there's uh, many different types of blades, there's long, thin blades, there's long fat blades and then there's short, um, thin and fat blades for minis. So I really, I do every case with this. Ok. So when you, after you've done your J Astronomy, you get your, your gene with your uh mini blades in. Um, this is how I go and pump. Uh the midline is not the middle. Um You start to buy the pericardial flat at the corner of the J not in the middle. Um because really the, the right has moved towards, you do not get into the plural space. If you, if you start in the middle, you'll get into the right plural space. It's really hard to put two chest tubes in through the, the rib incision. Um And so I hate it. If there's a hole into the plea that blood can just sleep into overnight, you don't know about it. So I, I get really pissed when the residents get in the pl uh remove the thymic fat. If bulky. If you have a lot of thymic fat, it will really give you a lot more room and just take it out. And then I put six para cardios in, I only put four of my full astronomy. But what I tell them is, you know, you need, you need even better exposure for minimally invasive. So I'm, I'm even more uh hemostatic on the bone. You want like no blood leaking down from above. You already are having trouble seeing, you want it like spotless. So we're more, more hemostatic, more retraction, six protocols. When you put the two bottom pair cardios in and yank up, um it'll pull the, you know, right atrium towards you. But in some people, especially these people have stenosis that can cause almost like a a pseudo tao kinking of the IVC and their blood pressure can drop. So I always tell anesthesia when I'm doing it rarely, maybe one in 100 times, they can't support them through it. And I'll just cut those two para cardios down and the pressure comes right back up and then I'll cannulate and then put them back in after I'm cannulated. That's rare, but it's just something to be aware of. So then I identify the appendage. Like we talked about looking at the coronals. Can I get to the appendage or not? 95% of the time? I can, I always want to the chest at that point. I tell them to give Heparin if not, you know, I'm waiting to stick the right common femoral vein with ultrasound and then I'll give Heparin right. I don't get the clamp side out until after I'm cannulated. So I just cannulate both of them. I go on and then I do all getting out the clamp side and putting in vents and stuff like that. OK. For cannulation, I do the standard arterial cannula of your choice. I use uh um what are we using now? They, they switch it every like 20 seconds on me. Um I can't remember it. It's a 21 French, you know, standard cannulation if you feel more comfortable um using Selner, that's fine. I just do it standard, but I have very small hands so I can get my hands in there and cannulate with my hand on almost all many. Um some of my residents with bigger hands have to use um you know, different techniques but normal place, normal purse strings, whatever cannula of your choice for the Venus Cannula. This one is the best. Uh It's the bottom of the two. It's called the Sco Venus Cannula the VC two. It's a Metronic Cannula. You can see the oval, it's flattened into an oval. Um There's two sizes a 34 38 and a 34 48. I have never put the 34 48 and even my big ice road trucker guy, I did the 34 38 excellent drainage and it lays really, I mean, like really nice and flat over the retractor you, you barely notice it's there. And then after I put it in, I pull it back and I tie it to the retractor with a silk that kind of pins it down and pulls the atrium uh out of your way. So you go on, uh you dissect out the clamp site. Like I said, after you go on and then for cardio plegia, you know, we used to have this lovely retrograde pr nine, we don't have that anymore. Um Honestly, like I said, it makes things quicker and, and you would always be worried the anesthesia would perf the coronary sinus. It happened maybe 3% of the time. So now we don't have to worry about that anymore, but it makes the cardle a little more stressful for you. So it has to be all antegrade. No retrograde. Like we talked about identify which balloon tip you need. Uh from imaging. It's almost always a six for the left, but it'll either be a six or a four for the right. You know, if they're right or dominant or not, I like anesthesia in the room because I want them to be, you can't feel the LV to feel if it's descending. So I want them to look at the te while we're arresting. Um You can also see how much the main P A is descending through the incision. If the P A starts to blow up, it's too much distension and I'll, I'll stop. They integrated and I'll switch to handheld. I do place a slush on the free wall. You can't just like push slush in there. You have to, like, make it a hard nugget. I call them, I call, call them Turds. They give them to me and then we push them in. Um, and that gets the, the free wall of the RV, uh, protected too. So I'll give a, a grade basically until if they have no a, I, I'll give a whole leader 12 50 if they have some A I, um, or, or, or a lot of A I, then we'll just give, you know, till they fibrillate or rest and then they'll switch to, to handheld. So for venting, I put a standard integra root vent and I place an LV vent through the rice prayer, pulmonary vein. I use my normal LV vent, the LV. Uh the rice prayer, pulmonary vein is very easy to see through a mini astronomy, even third or fourth interspace. Your in uh assistant just uses like the um cell saver and the uh uh cardio plegia sucker and shows it to you. It's, it's no harder. Um I place an LV vent obviously, if they have significant A I or if you're placing mechanical valve because you can't put a drop sucker through the mechanical valve. So I like to have a vent. Um Also if I'm doing maybe a root enlargement or a sending, I'll put the LV vent in. If I'm just doing like a straightforward tissue valve, I'll generally forego that and just stick a drop sucker through the annul while I'm working just to save time. But so for the A VR I make my ay, a little higher than normal. I would rather struggle with the valve when the hearts are arrested and then when the heart is beating and the AOT is bleeding, I'd like it closer to me personally. I, I do a very transverse aot. I don't go down uh towards the annuus. Um That's my normal um, procedure for fulls too, but it also helps it. Uh when you're done to, to, with hemostasis, it's easier to do repair stitches and stuff like that, make the minimum aot you need to make so that you deal with, you know, less bleeding and, and getting to the, the corners later I remove and to breed the valve as normal. Uh Both of your, your heads cannot fit through the incision at the same time. So, um I'll like to breed and then I'll pull my head back while I'm handing it off to the nurse. My assistant will suck. So you kind of have to get a, a routine with them. Um And then I place my stitches as normal. The only thing that's a little different is for a very horizontal aorta um uh or really uh most of the right cuts for all of them, you have to hook them because sometimes you can't even see the right. So if you stick your needle into the right and then you pull it towards you with a hook and then push it through. That's generally how I do most of the oops, sorry, most of the right um, annuus then seat the valve and uh I tie them with the corno device, you know, manually tying these or doing it with not pushers. It just can add just too much time personally for me. Oh, can we go back? So, this is my setup. Um So we've got, do I have a um, no, we've got up at the head. You've got the arterial cannula under a regular cross clamp. You've got the antegrade root vent. You've got the sco flat Venus Cannula at the bottom at uh six o'clock, you've got the LV vent coming out at five o'clock and then I've got my drop in the hole. This is a mechanical valve. Um And he had really good anatomy. So this is, this is one of my smaller incisions definitely showing off here. They're not all this bad. Um But I can only get two fingers in. Um And he got a mechanical valve, but the Venus Canyon really does lay nicely uh out of the um out of the way. For example, that's, I always joke about that. That's the hardest part is getting the valve through the incision once we get that in and it goes in the uh in if it's, it's, I mean, I'll show you the end result. It's not as small as it looks there's just a lot of stuff in the hole. Um, and those are obviously all the stitches coming out, uh, in the Gabby there. Ok. Coming off, I put, uh, pacing wires on the anti free wall when the heart's arrested. If there's any bleeding at that point, you have to fix it, then once the heart starts beating, you're never seeing those again. Ever. Um, it's much harder to DEA than a full astro. So you really need to de air um a lot uh before you take the clamp off. So I'll have them put the head up um and really fill the heart and DEA, you know, while the clamp is still on to really try to get that a air out. Um Head up again. Anesthesia needs to be kind of more involved here. Um And then when you go put the heart down, you got to make the heart, make sure the heart is fully empty before taking the clamp off. Because if the heart is descended at all, you can't um you know, decompress it with your hand like you normally can and you can get to this real bad cycle of not being able to fibrillate it if it's um if it's uh descended, so gotta be really, really flat. And then I always place an extra Venus oopsy per string stitch. So I just place one, you know, uh three Os H on the uh appendage to start. I place another one around it. Um, because when you're pulling out the Venus, if that were to tear that kind of flops down underneath the sternum and you'll never see it again. So I do that separately. Um, and then once you're off, uh, you know, normally, you know, you come off, you take the Venus canal out, they're taking some air, they fibrillate, you can just pop it back in. It's, it's much harder to get the, um, to get the, the Venus canal in. So I'll clamp it, I'll leave it in there until we're absolutely sure that they're gonna be fine because in a, um, you know, emergency situation, if you crash back on, it's a lot harder to get it in. So, I mean, I'll clamp it so I can get protamine, but it's not coming out until we're sure then closing. Um, you always want to check the rema if you, when you've attracted the right he part of the sternum, you can rip the, the rema there. So take, specifically make sure you, you haven't done that if you have, then obviously clip it off. That happens rarely, but it's definitely something to check to. I put the third, uh, put the tube through the peck muscle and then you're not actually making a separate hole through the intercostal. You're just putting it through your peck muscle flap and then flopping it in the little, um, space you made, uh, with your astronomy. I use the full chest tube, I put it along the right atrium and then over the tip over the P A so that you're draining the um right place for the tamp it on and also the poster uh per card. And then I do four wires if I go through the third interspace. So I still do three in the manubrium, like you would normally do it. And then I do one figure of eight, it's percos through the second interspace and then it's through the bone um at the uh at the j of the sternum and that brings it back together really nicely. One, it's more stable. Two, it bleeds less if you have like a gap there at that, that jay that part of the bone will keep bleeding. So, and I really like them to really touch. I want the bone to oppose at the bottom. So your assistant will reach over and grab the shoulder and push the shoulder towards the feet. You'd be surprised it'll come like a full another inch or two. And I really want that angle together and um that cuts down a lot on bleeding. Here's the end result. This is the guy you saw before you can see the uh angle uh of the storm up there. So it's maybe about four centimeters. Um And then this is what the x-ray looks like with the chest, with the chest tube down around the atrium and over the top. And then the wires, post op care is the same as our regular sternotomies. Uh We're already kind of team e which we hear more about team, um, you know, accelerated pathway. Uh Our average length of stays for isolated many VR is 4.1 days. We probably could get a little bit better on that. I still do sternum precautions for eight weeks because the manubrium is a load bearing portion of the sternum. So people think like, you know, I mean, maybe I'll say like six, but um I mean, they can drive a little earlier, but I, I still feel they don't really gain that much in terms of like going back to heavy lifting or like, um you know, if we have some people who do like baggage claim for American Airlines, I'll still make them wait the full time. Um because the manubrium is the load bearing portion and that's been split like normal. And then I've got um special considerations. So for ascending, uh I find that the valve exposure is actually easier because you've cut out the whole ascending and doing the valve is a lot easier because there's nothing in your way. But then the, the main reason it's harder is uh that proximal suture line is really hard to get to and do repairs. You know, once you're, you're beating. So, what I'll do is I'll do my proximal suture line and then I'll look from the inside and anything that looks like it might need a repair stitch, do it from the inside before you, you, so the, um, so if, if I have to do a pair of stitch down there, I'm upset with myself. So I, I put them all, anything that I'm very like, uh, maybe that could be a dog here. Maybe that could bleed. I'll put a stitch in it. It's much easier to take care of it from the inside when they're arrested. And then for red, I, I find redos easier through a minute. You don't have to dissect out the right ventricle at all. That's, you know, kind of the hard part, the fatty part you get into, that's annoying. You just have to dissect out the order. That's an easier redo. Uh, what I'll do is once you just do the regular j with the oscillating saw top, right, dissect off then bottom, right, because that's the mobile kind just put a, a bone hook in it and go underneath and then I'll do the left side and the bottom left, get the retractor in, just dissect out the aorta and the right at appendage. And then once you go on and arrest, you can dissect out a little bit more of the RV to get the wires on. Um, I still like to cannulate to the chest on redo if I can, but I have probably a higher threshold to go to Perk Venus. A red is nice too. You've only dissected out the aorta, they can't tamp it on, you know, their right bell and their right atrium are still, you know, stuck. It's like you don't have to worry about a lot less stuff. Uh Just a redo valve is pretty easy if they're a red with a pay and Lima. Um then obviously, uh we, we still just cool the 32. Uh We don't go down to like 20 or 28 like we did it where I trained. Um And there, I've never had a problem. Um We have experiment, we used to have the retrograde in and we would just give low continuous retrograde cardio plegia just to keep them fibrillating. We don't have that anymore. So we've started to um experiment with doing systemic high K for kind of a total body. Um rest of the heart. Uh I've done that maybe five times now since we lost the um pr nine and it's worked fine. Um Or you can just do frequent handheld doses as long as the heart is fibrillating, it's fine. Um The only annoying thing is that the lema, you know, if it's patent, obviously will keep coming out the left main and the back flow. So it makes it harder to see the valves. So you kind of have to have your assistant just like sit there with the tip of the sucker, which is one annoying and two you have to pretty much use a cell saver for that. So, perfusion needs to be aware and just constantly recycle that volume of blood into the pump because it's not a small amount. And then if you're going to do a PFO, um, uh you go through the dome of the left atrium once you've, I don't just do this, I don't just do a PFO through an astronomy, but if I'm doing an A VR and they have a PFO, um, you, you know, once you have your ay done, pull the out of the way the dome is right there. If you just make a horizontal dome incision through Bachman's bundle, the PFO is right there and it's pretty easy to just do like a running, you know, double air prolene and close it. So those are the kind of the special considerations. I think that's it. Any questions? I have a, I have a question. Uh Do you use any CO2 or anything? I do? I, I use uh CO2, we put it on two liters just for um just to reduce air but it's not inflation. Yeah, there's no like seal. Uh Yeah. Yeah. Katherine for, for your redo cases. Um Did you consider putting retrograde sometimes, you know, close to the right for so had pretty decent exposure to put in a retrograde and counterbalance the open lema for retrograde. Um I I have not been putting in a retrograde, you know, normally through a mini incision. No, that would be another way to to that. Yeah, honestly II, I used to do a ton of redo minis after cabbage, um, back in the, you know, partner, two partner three randomized days. But now most of those patients just go to. So I it's been a while since I've done a redo mini um after cabbage because that's just becoming, I think the standard now for that is, is ta pretty much um, unless they have really bad anatomy. Um But yeah, you, you certainly could, it's possible to place a uh retrograde uh through the mini uh you know, with anesthesia guidance on te um which is have it needed to so kind of streamlined. Yes, sorry. Who's, who's next one caveat that, that I found doing these Semino is that um specifically you can easily place the mentally invasive um retrograde. And the one that I like the best is a Metronic one that's got the glass balloon, the glass uh in the uh balloon. So it's, it's like a, it's like a light bulb as you see it, you can the coronary sinus. And I do that actually before I do Venus Canula, once the Venus canu is in, it's, it's, I find it's impossible to do that. But um the other thing is um are you using uh just standard blood card plegia? I do del, so just one dose of Del Needto is generally I can get the whole case done in one dose. Um The other thing is um, your $20,000 tractor. The one that I think we found works the best is a pediatric coolie. Yeah, the coolie is nice with the, the way it is. Yeah, the cool shape is nice. It's just harder to get in. Um, that's what I use for a while. But the genesis is great. Presentation. Lovely. Look into it. It is. That's when I got hired I was like, I want my retractor but now I, I had one and everyone else started borrowing it. So now we have, we have six because everyone else wants to use it. It's really good for my too. The tractor is delightful way better than the. I like to add on what Mike Moran is a, is a specialist in minimally basics vowels. But what he said is really important. You don't need to buy anything new to do this procedure. Like you could go home this weekend and Monday you can do this case without buying anything new at all. And uh just ffy that Genesis retractor is designed by Frank Wells. He's a British surgeon who does. He probably the biggest microvalve surgeon in the UK. Yeah, it, it is expensive. I also like that delightful for everything. So and um that picture that you showed with the exposure that I think that's like your 5/100 mini stern incision. That's, that's not what it's gonna look like when um they do a four, I was a little bit there. Yeah. No. Um So a lot of my partners do the fourth all the time. You know, it's kind of get bored after a while. You can start big and push it smaller and smaller, but definitely start through the fourth. Get comfortable with it and then you can, yeah, when you can go to the third, then you can make your incision smaller and smaller. Right. So I think that progression is really important. I think everyone in this room should be at least doing a mini sternotomy isolated. Replace my challenge, everyone to be able to do this case. Um The one thing that's always concerning we keep in the back of our mind is uh the conversion. So you said that um if you're through at uh J and you have to convert that um your, your backup is just goes straight to the sternotomy. Are, are there other ways you can bail out to get a better to get a better exposure? I mean, I, I got an answer in my head but it's interesting what, what you guys would do if you're in a through a mini stern and you're just not happy with it. You just want to get the case done. What, what is your bailout extension? Yeah, I mean, that's, I just wanna make, I try to make that point. Um Don't let them pass this off at all like normally you know that you do the tsay they pass this off to get, uh, recycled or whoever the next case the saw, the regular saw needs to stay on the table until the patient is out of the room because you don't know, like some whole, if you need to be able to, um, you know, zip it down. Um, it, it depends on what, what's the problem? Like, I've never, I've never bailed out just because I'm like, annoyed at the exposure. I just struggle and complain about it. Like most of the time, the reason you have to convert is because, well, it used to be because anesthesia had like poked a hole in the coronary sinus or, or the pa I had to do that. So it's, it's a more emergent situation and is gonna give the answer. So um I started off with the J and, and just like you, like you, you've had tremendous success with, but as you pointed out, you have to be very careful, the right memory and I, I had a number of bleeding from that. And actually, Alan Wolf is the one that taught me how to do a transverse strey through the third or fourth. And um I, I respectfully, I think the, the exposure is dramatically different and, and, and improved, you never fight with that right side of the left side of hemi sternum. Um And um I mean, I do elephant trunks through that, that incision. Um So, uh I think, and then obviously converting is just taking the saw right down the middle again. Um, I think the, um, the achilles heel of that is getting the bone to heal nicely and there's, I've been through many machinations about how to get it to do it right. And, um, yeah, if I have to convert, I'll still do my wires regularly. And then at the kind of, you know, X you developed, I'll do like a figure of eight kind of to try to get all 3.5 back together. I've also done uh redo pulmonic through a hemi te it off it off to the left side. You gonna hate this. But Vince got that incision. So did you, so, so everyone heard that right. So if you, if you have to convert to a full sternotomy, like someone's like the coronary sinus or your resident has stuffed the chest tube in the bottom of the heart. It's got to be a sternotomy. Um But if you're just upset with the exposure, just turn it into A T and it's gonna look just beautiful and it's still a minimally invasive case for you. So I think that's, that's a big key. All right. So you didn't have to spend any money. But if you want to spend money on something, what is the first thing that you would get if you're not? If you don't have, you need to get to first thing. What do you, what would you spend money? First, if you had to spend money on this case. Well, I didn't know that was extra money but not that, but now that I think of it 7 50 a pack. Yeah, that would be, that would be a great, um, and I are pretty cheap. I would, I would stick with that. But if you had, if you had to buy something for the case to make it easier, what would you get? Well, II, I think that any time that you're starting M ISA VR, I think one of the rapid deployment or less product is also something that makes it a bit of a smoother operation at the beginning. That sounds real. That sounds more expensive. Very expensive. Yeah, I, I think, uh, you know, m invasive long shaft and instruments. Those, those help tremendously. You use, those, those are fantastic and open cases too. I think that's what, yeah, that's a good investment because shocked that he isn't, you don't think core or not, you have to spend much on. Certainly, we, certainly, we, we get scrutinized for that. Yeah, certainly. I put in all my stitches with the hart, uh, needle drivers. Um, I, I didn't really think of that as a different thing that most people don't. You spend a little bit of money on but you can buy a pickup and a, and a driver or a pair of each and, and you'll spend close to about $10,000 in that you have 22 pair. So minimum, minimum, invasive the long, not the super long. So there are 16 inches, uh, 14 inches and 10 inches for the A VR you don't need, the short to medium is fine. You just want to have the small shafts with the, the way you have a clear view, but you don't need much length. Right? And not, and not pusher probably. But then you don't need enough and Peter you say, oh, I, I think uh it's essential. I mean because uh it's a lot easier to be sure. You don't have to worry about that. Yeah, I work at a private practice physician and hospital so I can tell you how much everything costs. And my disposables for many a VR is $7053. It shows up in epic nowadays. Yeah. Well, for me, I would say I would spend money on a, on, ahem, Venus canal. I know they're all back order nowadays. We can talk about, we can talk about that but getting canals out of this field uh makes it easier and that's, that's a little bit cheaper. Those who are running about 100 and $600 for ephemeral Venus candles. I agree with you though. I sleep the deep sleep of someone who doesn't have a retro Paal Hematoma. Ok. Well, great, great, great.