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: Mario Castillo-Sang, MD St. Elizabeth Healthcare Edgewood, KY 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.
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We're gonna have um Mario start off with a minimally invasive mit and um Mario has been on this circuit for a long time and I think these are the best. Well, these are well made presentations that you're ever going to see. Uh So please help me welcome Mario. Thank you, Chris. Thank you very much to art. I commend you for really supporting this initiative of minimally invasive approaches. I, I think that Peter said it best. If you make a product, nobody wants, you still have a product nobody wants. And so getting into the minimally invasive space is important. I, I live in Cincinnati. I work in Kentucky uh in the northern part of Kentucky, right at the edge of Cincinnati. Um If you can take a picture of that QR Code takes it to a course. A lot of what we will talk about today will be on that online course, the steps described et cetera. So if I skip some things, you will be able to find it there. This is our setup um at Saint Elizabeth, one assistant. We do videos uh two D we don't have uh Peter has Olympus, the uh the stores company is bringing out a uh four K 3D scope on the second quarter of this year that I hope to get my hands on. I'm really, really excited about that. This is a Carl Stor camera with a 10 millimeter scope. This is the incision. Um This is the fourth in a cost space. The scope is placed about the third really low posteriorly. Um This is a pneumatic retractor which is I think clutch to do this operation, you press a button and it moves and you release the bond and it stays where you put it. So you don't need an assistant doing camera work for you, just push the button, move it around, let it go. So that's our setup. We usually place the pump to the left of the patient. We're, we're going to talk about many things today and I hope that I hope I can get through all of them. But, but I have five that I really want to get through. But let's talk about minimally invasive. Why mis we, we've seen this paper. I think everybody in this panel has quoted this paper already. Uh But if you look at uh microvalve, minimally invasive approaches all commerce, you know, robotics, right me through a endoscopic whatever they have increased over the last 15 years. And, and there will be a new iteration of this study that will show an even higher rate of adoption. Uh But that's not the only reason to do this. So proven surgeons who perform minimally invasive microvalve surgery, do more repairs, they repair, they have a higher repair rate than those who do not. And that is very important because after all, that's what we're looking for as surgeons. So if you look at this paper, this is a paper that uh compared a three way comparison robotics, minimally invasive. Uh whether it's well, right me, throaty robotics and sternotomy and minimally invasive was not inferior in mortality, stroke and all the major complications compared to sternotomy. So again, a product that is if you if you wanna call it a product, a product that is not inferior to sternotomy. But yet, when we look at other parameters, we were superior to sternotomy like length of stay blood transfusions. Uh This two facility IC U stay ventilator day. So those are important points cost. There are only two papers comparing cost of a minimally invasive. So mini to astronomy. The one papers from in uh in at Penn and that paper showed that it was superior, mostly mostly driven by the postoperative course of the patient, a shorter length of stay made up for a higher um operative cost. In the second paper, it was superior in many of the different aspects, direct cost, indirect cost and of course postoperative care. Uh but take it as as you may, these are the only two papers out there comparing me to soy and it turned out it is superior. What about the long term outcomes? Because again, this is where we have an edge as surgeons. Uh what we do is supposed to last the patient ideally their lifetimes. And so when you look at the data and what we focus today in my talk is on neo cord reconstruction using a cortex uh of any of the types, right? So when you look at these are, these are techniques that are derived or or bring a lot of their experiences from the Leipzig loop technique that Fred Moore uh brought about. If you look at the top paper, there's a more recent paper from Munich. The survival at 10 years was 83% right? Not too bad. When you compare to the paper that was published in 2013, that the survival at 10 years was 74% but both had about the same reoperative rate at 10 years, which was about 8% reoperation. Yeah. So in all these are good outcomes. I think that they can withstand comparison to any re sectional techniques and certainly to any transcatheter techniques. These are the different pathologies that you'll be able to approach through a right, meaning through economy or endoscopically, whichever route you choose to take in time, not all of them will happen immediately, but you'll be able to tackle anterior posterior leaflet pathology, bileaflet pathology, rheumatic disease, all these things of the mit valve. And as your experience progresses, you'll be able to go even further and do other things. Like, do your readers take tumors out, take stents out that migrated into the inferior and right atrium, you'll be able to do combined aortic mits, endoscopically, you'll be able to take out tumors in the apex of the left ventricle, take out towers and valves and towers and rings and all these other things. One question we were talking about last night over dinner is, does it hurt less? And, and, and, and quite honestly, I agree with the concept that a mini in the Fourth Pentecostal space does hurt if you do nothing about it, it's probably one of the most painful things you can do to a human. But if you do something about it, it can be very benign. And that's been my experience and it happened serendipitously. My P A said, well, I used to do private blocks in everybody and it was again, like everybody has testified here. It's like an hour of delayed anesthesia care that doesn't work. So I decided to do away with it. And I was using just, and it kind of made a little bit of a difference, but not much. So we came about uh longer acting and we combined it with regular to this tune of two vials of to one of the exper which is expensive. It's $800 a vial and not everybody has it in formulary. But if your orthopedic surgeons have it then you may be able to get it. And so we do that and we infiltrate and I'll show you how, what the technique is. So that has helped us extubate EOR and have a shorter length of stay dramatically for all elective patients. So, remember we talked about, you know, transitioning from a media renay to this kind of incisions is not easy. And it's going to take a transition from using, you know, old fashioned ear instruments to using long shafted instruments. The balance is different, the way the torque is different, the way your needle angles go is different. So that's important to, to understand this is how we do it in general. As you can see on the left, the pump is to the left knee of the patient. We have monitors everywhere. That's the pectoralis muscle. We don't cut it, we reflect it, we push it to the side. Of course, I chose the skinniest man to show you how to do it right. Not everybody's that way and you'll suffer through some of the bigger patients growing, cut down. Uh Somebody said earlier in a panel, I do cut, I think it was uh bill. I do cut down because it's in my hands is the safest way to avoid a complication. I told my, my P A our job is to avoid tragedy and that's how I avoid tragedy. So I grow growing, cut down on everybody typically is the left growing, not the right. I don't know why I did it on the right this time, but uh echo guided cannulation, incredibly important, incredibly important. So, arterial first, Venus second, uh we use biomed exclusively by uh generation two Biomedic. Uh Can we go on bypass early on and open the card on bypass? Something that I learned from Jola, I used to put a double tube do this whole production. It took time. Um It, it wasn't worth it. Just single tube go on bypass, open a card and place your per card stitches. And this is an older video. If you look at that, you can see me looking through the incision, right? You can see the headlamp going through the light. Uh So these are older videos, but that's how I started. I started with direct visualization at camera aiding into some steps of the operation. And, and in time you progress to realizing that you can see a lot better if you have a good scope again, a good scope. But that good scope cost comes at a cost and it's a 10 millimeter scope. So we dissect the P A from the aorta bluntly, we'll put our root vent and we'll always do integrate. I do not do retrograde. I don't remember the last time I put a retrograde cannula in a heart and we'll use uh we talked about clamps earlier. We'll use AC clamp, which is very, very versatile. There are newer clamps out there. The glover clam that we talked about earlier. There's a new clamp called detached clamp. It's a Jola Invention two that detaches the head of the clamp. I've used that one too. Very versatile. We'll always open the oblique sence. You can see the pump sucker and the oblique sinus and we'll always uh develop a little bit so groove, always through thunder groove for just about everything. Unless there's a large A SD and then we'll go through the right. Um Notice that again, this is just a single uh cannula. No, no. Uh no IJ catheters, there are some caveats to that, but in general, that's the way we do it. So how do we do the infiltration? This is for, for Peter, I told him I would put this in. So that's the same case. I bent a spinal needle, I hit the rib and I sky over the and then I inject the exper each way anteriorly, posteriorly. I encircle the space and then I get the soft tissue with this bar, that combination of X and regular. And then we'll do the same for the groin and all the little holes that we make except for the little Carter uh Thomson uh holes or the uh su pass hole. So that's uh worked out really well for us. Uh My experience with this has been much like Peter's that patients don't go home often with, with narcotics. If they take a script, they almost never fill it and come back to office, taking Tylenol and Ibuprofen, um sometimes the trauma. So with that quickly, what are the contra indications when you open the book and you open the articles and you read, what are the contra indications to do minimally invasive microvalve surgery? And they'll tell you, you know, acute settings, right? Uh red, uh especially if it's uh several time redo uh after a or obesity and advanced station, there are ample number of papers showing that those are not real contra indications. You can do it, you're not gonna start doing that. But once you get to a level that you're very comfortable with a set up and your team is very, very pro you will be able to do all these cases. A that in the middle is a popular muscle rupture with an impella and somebody with a, with a delayed presentation of a stem. Uh and it was a replacement again, morbidly, obesity. I think that those are the patients that probably benefit the most from not having astronomy. And so that's the way we approach them. So today, I wanted to talk about of all the things we could have talked about of minimally this of micro valve, whether the set up or the cannulation, I wanted to focus on the repair because I think that's the part that uh I would like you to take home if anything. So there are two different types of cortex. One is an adjustable and one is a premeasure cortex that premeasured is the same concept that uh Fred Moore and Leipzig taught us, right, same concept. And the off label one you see on the right is me cutting the the he the tails of the premeasured to debulk declutter the field. There is an important concept when you do coral reconstruction through the right chest, the sutra control is paramount and I placed my annular stitches first. So I have a ton of stitches coming out through that little incision to do that. Um We will go through that in a second. Uh Let me see if I can show you that. So outside the assistant has control of the cords. Gay freighter will do the trick. You'll lower them down into the incision and it'll work just fine exposure internally is very important and also keeping control of rotation because you don't want to end up with your cords twisted as in the right lower picture. So external uh control of suture is paramount to having a good operation if you're using neo coral reconstruction with a cortex system. And then one of the things that I looked back and I thought to myself, well, what were my difficulties coming into this field and doing mentally invasive mit surgery? And so this this power point is meant to help my younger self uh do a better job in those days. And so one of the things when we talk about prolapses. You know, we, we, we just say, OK, you had a P two prolapse, just put a cord in it, right? I heard somebody very prominent say that recently and of course, just put a cord and that's it. But if we talk about standardizing uh standardizing the, the concept of where do you put your sutures and where do you measure? I think we'll be able to teach this better. So I came up with this little thing you, you let's call it great small, medium and large P two prolapses. Just talk about P two prolapse for the sake of argument. And where do you measure? And where do you put the cords? And that's really important and I'll show you cases of my own failures and how to bail yourself out of that. So let's start with the first one. So this is a grade two. So there you see, you see it, uh you see several rupture cords, central P two, large, moderately large. And as you can see, I put my ring stitches and I put them under tension to conform the valve. I, I cannot see the valve in another way, I'm not used to it. Valve analysis is really important. Always check your valve with your nerve folks and make sure that you don't have any hidden pathology. Sometimes a very large jet, especially commercial jets will hide other jets and you won't find that pathology until you think you're done. With the valve and you have another problem. But in this case, this is an older case, I'm using an older type of more cier and I'm measuring from the pipeline muscle to the edge of the leaflet. In this case, I caught the sutures. So to make it simple, I think I had somebody observing this case and I wanted to show them that you can do this without having a clutter of sutures on the outside. So the at this point, this is a Leipzig loop technique, you have to hook each one of those with AC B four go and now you're off to the races to put them on the leaflet. We go a little bit further into the measurement. But now you have, in this case, I did four, I added 1/4 1. Now you have four suits. And if you look here, let's, let's just for the argument sakes there, analyst and where that suture was placed, who here thinks that suture is being applied by a show of hands in a correct location? Is it too shallow? Too close to the edge? Is it in the sweet spot or is it too close to the uh for those who think it's too shallow, please raise your hands. Not many. For those who think that it's in a sweet spot, please raise your hands. Well, Mario, it depends how long your loop is. So that's uh so this is a premeasured and I believe this was a, a 16, 16 core that was from the pathway, muscle head to the anus to, to from the muscle head to the, to the basically close to the edge of the pathological leaflet in diastolic arrest pushed down. Right? And so here we're getting into the weeds of how to measure, right? Because Fred Moore taught us, you can measure from the tip of the muscle to the adjacent normal leaflet and that's your size and that's not incorrect. I would argue that another easier way to do it. And I think Michael Borger will argue the same is you push down your pathological flap, your, your pathological prolapse and you measure from the area of the muscle. You want to measure to where you want to anchor it close to the edge and that will be your length. The difference here. Now, we're talking about this is a great two prolapse. There's a lot of tissue and let's, let's see how it played out. I thought I was putting it in a sweet spot. Of course, I'm the surgeon doing the operation. I thought it was great. And uh here goes, this one's a little deeper into the body and that's another concept. The further away you go from the, from the anchoring point. Of course, you go closer to the edge, right? It makes sense as a fan. Uh and courts are premeasured, they're all the same length. But in this particular case, I'll show you the testing. These are surgeons knots. So I'm not committing to this repair, but I just said there's no leakage, but there's still a prolapse. I don't like it. Um But it's salvageable. So you take your fine nerve hook and you undo your surgeon's knot and you can then re move back closer to the annuus. There's me taking the, the stitch out. I choke back on the body of the leaflet. Even if it's a couple of millimeters as you can see there and then throw another surgeon's knot, do the same on the other side. So, remember, cortex has two arms. The one arm is already gone through the leaflet. If you don't do the knot, you take the sister arm that's free and you can go again and choke up on your bite. Do a surgeon's knot, tie it and test it. And that's one way of getting yourself out of a, oh gosh, I didn't take enough of a height. That, that's the, the repeat, right? It's so much better. Now, we do have a little bit of a prolapse on the, on the P one segment and we'll do, we'll fix that. Uh There's a little indentation to there. So we'll close that we'll use the fourth, uh the fourth chord to put those two together P one P two. And it's starting to look better, right? I'm not gonna bore you with what it looked like. The point was to show you the mistake and how to get out of it. Um sight seeing. Uh it's important. Let me see where my uh sizing is important and we'll show you the sizing in a second. Another case, this is now a grade one. This is a very small um P two central P two good pa muscle view. Now, this is a more recent case. You can see the size is a cord exci is uh on exci. It's really important. What I'm trying to show there is the physical contact of the tip of the size with a muscle to tell you that you're in the right spot because there's something called parallax. And on the scope, you may think it's, it looks great. But in reality, this second arm is way too high and the parallax is, is lying to you. So physical contact, I'm make, I'm turning the, the, the size here to make contact with the leaflet and to make contact with the, with the tip of the peanut. Now again, pushing down that prolapse segment will allow you to do this. Now, let me, let me stop there. So I anchor, I measured from here to the pro prolapse segment, but I anchored it on the opposite side. That was a, that was a mistake. So I'm redoing it, I'm taking it out and I'll re anchor it in the right position where I measured it. So I'm going to go with the courts facing the pathology and coming in at the point where I measured the distance not to bore you with that part, I'll take you again to now the haptics, what, what are the other cues than the, the visual cues that you're in a better position is the knots. If you're doing premeasure courts and you relax the cords, the ventricle will fall down and the knots will fall in the area of cooptation. If you see them being at that level of the anus, you might as well just cut it, don't do anything else, take them out, you sized wrong. And so that is a very important concept of visual cues. I'm pointing that out there. Uh You see the knot is falling in the area of cooptation. Now again, this is a great one. This is not a very large prolapse. There's not a lot of volume in this leaflet. And where are you going to put it? The answer is about 3 to 5 millimeters from the edge and no less than one centimeter from the annuus. So somewhere there's a sweet spot and it's a little bit of a visual assessment of things. But again, remember the areas that are central and closest to the papillary muscle will have a deeper bite and the ones farther away will have a shallower bite. It's it, it makes sense. It's physics. So as we go here, I think this was a better positioning of the courts. On hindsight, when looking at the case today. Surgeons. Not again, I'm not committed. I test and I like it. So the height is better is it, it doesn't look like the first case where it was still prolapsing. Now, I have an indentation on a cleft flanking P two and we'll close that. Um, but I'm not gonna bore you with that part. Then comes the s right, the, the sing of the ring. Uh The way I size this case is because you're not respecting leaflets and you're not diminishing the area of quotation. What you're going to do is you're gonna pressurize your valve with the repair and you're gonna put your size in there and it has to fit within the anu, right? And you check your qut zone and then you have a great quotation zone. That's the size you use. If you have a, a qut zone that is mediocre, downsize it by one. OK. That's my algorithm to these repairs. It serves me well, serves the patients. Well, let's go to another case where uh this one's a good one. What happens when P two is central? I remember the, the concept of do not cross the midline, right? But this P two could go either way once you look at it, uh it could have gone either way you could anchor to that lateral muscle or the or the media muscle. You can see the, the heads are very broad. So these muscles are not like one defined 10 head. It's, it's a very broad one. This is the pathology there and it could go to this head or it could go to this head, right. We're going to measure the medial because this is what convention says, go to the media muscle if it's A P two and we're going to size there. And what you're going to see is that I'm trying to show here the parallax, right? This is in contact and this looks like it's in contact, but it wasn't, it's completely proximal to the leaflet. So I'm oversizing that either way we get a good measurement out of that one. But I decided to go out of the media of the later in Mosul because it looked shorter and I still believe that post year course should be shorter than longer. So 12 to 16 for the post leaflet, anywhere between 16, 20 or 24 for the anti leaflet and sometimes even longer. And if that's the case, then use adjustable cords. So in this case, let's go to the uh media measure the lateral measurement and you can see the contact of the papillary muscle with the device. And then here approximately with a blue tip with the leaflet. And I know that I have the right measurement. So these turn out to be long cords, longer, longish cords, I think they were 16. Um and they were anchored, this is a grade one prolapse. Again, you don't have to go too deep into the body of the prolapse. 3 to 5 millimeters from the edge, the farther away you are from the anchoring point, the shallower you get, you can see it there and you'll see the result on the testing. This process should take about, you should spend about 2 to 3 minutes sizing and it'll take you about five minutes anchoring and that's it. And that's the result. So it is, this can be done. Now, here's an interesting case. This is when you really, really screwed it up and, and you don't even realize you're screwing it up as you're doing it. You, you get tunnel vision. This is an older case. You can see the caliper is an older caliper and I sized it number one, I put it on the opposite side of the, of the muscle right now. Look at the cues here. Look at where the knots of the uh premeasure cords are sitting. They're sitting really, you'll see it in a second. They're sitting really close to the right there. Look at that. They're at the height of the, I mean, if I were doing that today, I would tell myself what are you doing? Take them out, take them out. Don't waste your time. I tied it. I was the time and now I see that they're super long. But wait, there's more. So you can see this is a great three prolapse. It's, it's massive and in a great case. So here by a show of hands, is that a good bite? Yes. Raise your hand. You think it's a good bit, here's what happened. The 23 people think it's a good bite. I think it's too shallow. But now this is the retrospective scope, right? I think it's too shallow and I, I keep doing it right now, I'm in that tunnel vision. So when you're doing this processes, you always give yourself a little stop moment. Is at the right height. Is it the right height? And you can tell it isn't because you can see the anus and you can see in a second how much tissue there is. Look at that, we're gonna test it and look at that. That is not a repair. OK? So there it goes out. Now, I've wasted 30 minutes or 25 minutes of cross glamp doing this. I remeasure right now. Look, contact to the muscle to the edge of the leaflet, the right height. Now, the visual cues are that the chords, the knots, look where they go, they sink into the ation zone, they're being pulled right now, but look how they sink when you release the sutures. All right. So that's another visual cue that you're in the right track. All these little steps are meant to help you not make the mistakes I made. Look at the difference right as they correct and now you're going to place them and you're going to place them. But then look at me, I place them in the same exact spot. I did the other ones. So, so that was not the greatest idea. Yes, I shortened the cords. But this is a massive poster leaflet. And by a show of hands who here would say, why are you doing this? Just cut the damn thing out, just do a triangular resection. Who would do that? We want to just about everybody. Yeah, but I'm stubborn and I wanted to do Neoral reconstruction. And you'll say, well, you have a ton of leaflet there. It'll look awful when you look at the echo at the end if you get a good result, right? So I do that. I put the cords in a slightly better location and uh this one was by definition going to have a second set of courts on the lateral muscle, of course, but I'm gonna test this one and no, no. So second time, second failure. No. Now it's put, but you can salvage it just like we did. In the first case, you take the one sister out, you choke back up and you tie it. All right. So you tie it, you do your surgeon's knot, you test it and if you like it, you keep it right. You don't, you don't commit to the repres yet. Now we're going to do the lateral, the la I I skip the testing, but this is the testing that looks better. Starting to look a little better. We'll do the testing on, we'll do the uh lateral muscle anchoring. We measured it. I'm not gonna board you with that part. We anchor it. These are 16 millimeter cords and we'll place them on the lateral aspect of that P two, grade three, prolapse again, deeper bites into the body. And this is, let me go back. This is a test. We're still not committed. Right. That looks pretty darn good. I think you put the ring. That's a result. And this is the echo and the zone is massive. It's massive. It's a kilometer long. All right. And, and you know, I don't see anything wrong with that unless I have Sam, but I don't have Sam because that poster Lea is gonna be stuck in that position forever. The key here is a couple of things. You can always salvage a situation where you do need a quarter reconstructions you haven't committed. Um Try to avoid the mistakes that I made here twice. And last that when you're doing a ventricle repairing a ventricle that's very enlarged or it's not conical and it looks like a football, uh restrict that posture leaflet more than you think because that's the mode of failure of neo coral reconstructions. If you have a slight, slight prolapse, what mark uh mark called the uh and you have that when the ventricle remodels that papillary muscle head will move upwards and you'll have that prolapse become a real problem. All right. So how are we doing on time? How are we doing on time? Chris? OK. Good. Yeah, keep going. Looks good. We'd like to see all 10 but we won't be able to. Yeah. So this is another uh case is a grade one prolapse. The purpose of this case was to show that not all post, your cords are 12 to 16. That's all this is a good measurement. There's conduct in the papillary muscle, there's parallax. Here. You see the parallax, there's a little bit of parallax. So I got a better measurement later. This is the anchoring uh to the media papillary muscle head. Uh The course look long, don't they, let's go back, let's go back. So again, this is let's go to the measurement and let's see if you can spot there's contact here, I touched the muscle, but right here, it looks hard, doesn't, it looks like it may be at the right level. But in reality, the parallax is that it's really high and I put the cords and now I'm a little wiser and I see the knots being close to the. So I don't like it. I take them out and throw them away and get a new and they get a new measurement and a new set of cords. So measure again. And now I show myself that there is contact, look at the difference that's contact. OK? And that's the right coral size. I'm not gonna bore you with the anchoring of the courts. Um And then this is a great one. So you don't need to go. Look at the difference in the height of the knots left is super high. You don't need to go very deep on the body of the prolapse. You just go 35 millimeters from the edge. Again, the same concept, the farther away you get from the anchoring point, the shorter the, the shallower you get on the bike, we'll get the surgeons not going on. We're gonna bore you with that. That was the farthest away. It's a little bit shallower. Notice the difference. This one's a lot deeper than that one. We tie them up. We test it. It's not, it's under pressurized by the way, such an Irrigator laparoscopic Suction, Irrigator key key. And another thing that we haven't mentioned here is when you test, test with Del, if you use Del test with Del, if you test with, you're gonna wash out all your and you're gonna have some my dysfunction post up. So this is the final test. You can see that it's over, it's pressurized enough when you see the ventricle go down and that's the end result. Uh So we'll get to an, an interior leaflet because I think it's, uh, we'll skip the, the P three, we'll go to the anterior leaflet because I think it's, I do not do premeasured for an interior leaflets, it so happens that an interior leaflets are probably, in my opinion, one of the easiest things to fix when they're like very isolated lateral L A two. Um Well, I think the data from, from the old days that it was very difficult. It's wrong. Uh In this particular case, you saw it's a medial A two. And what you see is that all of it is depending on that one chord, all of that lateral medial A two was depending on that cord. So a little testing and you can see the pathology. Here's the pathology from here to here. Here's the echo of how it looked before and one chord is responsible for it all. So we're going to anchor to the, in this case, a media muscle, the uh premeasured uh cord system and the way I conduct those is by doing a figure of eight uh with each of the arms and then locking each of the arms, each of the sister arms. So you'll see it here, next one arm again, about three millimeters from the edge. It's very thick and heavy uh scar down tissue. It'll hold this. The scope is great for this. You will never be able to see this in, in the indirect visualization with great, great, great detail. This is a crappy two D scope, but it does a trick and it's a 10 millimeter, it does a trick with 3D surgery with 3D scopes. I've seen that in life surgery. It's amazing. It, it's a game changer like, uh the, he said, it's a game changer. So that's a figure of eight and then I'll lock it and that when I failed to lock it on the first batch, but we'll lock it. And what it'll do is that it won't slide on you. So you'll be able to adjust that. Now you don't, you keep the leaflet prolapsed so that the adjustment happens by pushing the, the leaflet down while holding the cord intention. So you need two pickups for that. In this case, I thought only two out of the three were needed. I kept the third one just in case of the Neo courts. There's the locking and now comes the adjustment part. I pressurize the ventricle and see where this lands. Right. I push it down. I push the other one down. It's a little millimeter, you know, adjustments, but it takes no time. It really does not take any time. Uh Little ink test looks pretty decent. Now, I look at the car zone, it looks pretty decent. A little more adjustment, not gonna bore you with the rest. But we get to the point where we size the Aulus. All right, we're committing to it. I like the computation and we're gonna finally tie them. I usually will tie them by applying a surgeon's knot first and building upon that with regular knots. And that's the final result on that anterior leaflet that took less time to do than any of the other case that you saw for the post ti leaflet. Um So with that, um there's a barlows case. Let's look at the P three because I think the barlows case is just, it's, it's just post to your leaflet. What I wanted to show about this case and the bar, let's just show the echo is that it looks like there's an an interior leaflet prolapse too. But it's quite frankly, what's happening there is that the there's mad and the ventricle is basically averting the an so you can see that. So all this case took was post your leaflet uh reconstruction with courts and they were adjustable with the figure of eight that you just saw on the anterior leaflet. So our goal then if you remember is to not just make a small incision for the sake of the incision. I've seen a lot of people uh not a lot. Well, I can say that it's a lot, but I've seen some patients go get a uh robotic operation and they have small incisions and yet they come back with moderate Mr uh if it's robotic, if it's, if it's endoscopic, it's, that's not the goal. The goal is not the incision is the outcome. And so the goal is to get a low gradient. And I think with neo Coral reconstruction, the one thing that's been proven is that you can actually apply larger rings. And if you do reseal techniques, uh you get a great quotation zone and you have a patient that heals uh faster. So with that, what are the key take home messages? I would say being in the moment if you looked at the, at that case with a grade three prolapse, you could tell I wasn't there. I didn't show up to work that day. My mind was somewhere else and I wasn't really focusing on what I was doing right or wrong. I was just going through motions of what's the next step? What's the next step? And now it wasn't calibrating my actions. So make sure you have physical contact with that caliber, right? I do recommend I did not use your caliber that cortex caliper before and I've come to find that you can actually move swivel that tool. So that one's facing one way and the other one's facing the other way makes it very easy to measure. So use that make physical contact. So you don't have the parallax effect which can really hurt. You measure twice or three times or four times and implant once. Uh use the optical cues that I mentioned. If you're lowering the cords down and the knots are really high, that's not your length change it. Um An implant on the papillary muscle at the location that you measure too, very important, maintain very, very crucial, the external control of the sutures or you, you'll be miserable. Uh because you'll be looking at a scope or through an incision, try to, on things that are twisted from the top down and just remember cues like the poster leaflet, it's anywhere between 12 to 6 millimeters and you're 20 to 24. But I assure you that it doesn't have to be that way every time it can vary. Um With that, I will leave it out questions. All right. So I'll, I'll, I'll, I'll start the discussion here. Well, there's got to be some questions on this one. Fantastic video. This is just, it gets better every single year Mario. And you said it's available on that QR code, correct? Ok. All right. And uh you get paid for every hit that, that every click you get. It's actually free. Of course, art is a full disclosure. Art is a sponsor of that. Um And uh and the idea is to democratize this thing. Spread it, right. And so, um I think we have like 480 people signed up for it around the world that go through the basis. And so you can see all the steps. Yeah, I think it's, I think it's really important. Um So I'm, I'm gonna, I'm gonna lob this question to the whole panel here. So there are still some Cartier people here who like to do a re sectional technique. Why is it that people have moved to um Coral Respecting the um leaflet and gone away from reception techniques for minimally invasive surgery. I'll, I'll start, I, I did not train in doing Neoral reconstruction. I may have seen one Neoral reconstruction in fellowship. One you know, Mark Moon used to respect everything, Ralph used to respect everything. And uh I took a trip to Leipzig which brings another point that somebody earlier mentioned, always do a pilgrimage, always go to a place that does things better and learn from them, take it back home and the next year go to another place, right? Um And I saw that they could do uh you know, has 10 rooms, you walk into one room, they're doing a P two prolapse with these cords and you go to another room and it's another surgeon and it looks exactly the same like it's uncanny. So what you can reproduce this thing for me, my, when I was in training, it was this mystic thing, right? You know, jump on 1 ft, close one eye and then you get a good result, do a chant and you know, it's not that way. So I think that the answer is it's reproducible uh is teachable. It doesn't take much to learn it. I think where we failed is not being able to really do a step voice approach of all the little nuances, right? But if you get those in a little laundry list, people can follow it. And so it's reproduce reproducibility. What about the rest of the panel? Cat, your, your, your site does robotic and a bunch of mits as well. What do you think? Yeah, I don't do any of that anymore. Um The only time I really do a mit now is when I'm doing like a double valve, triple valve or an emergency, um I was trained by the same person who trained Mark Moon, so I'm still team Caron resection. Um So I do mostly, you know, resections if I have to. Um I do think that both of them have a system like you, you get used to walking around the valve. You know, I had Miller taught us this great system of how to respect things, find the two chords that are normal and, you know, you can have a system for both. But when you're figuring out the chords, there's more of a, you know, like a buffer. If you make it, if you get it wrong, you can just redo it. Whereas if you get a resection wrong, you know, you're done, you have to convert to a um a replacement. So I think that's, I think they both have good systems. But I think when you're first starting out, the cords are obviously a little more forgiving. Yes. So the re sectional technique, you've, you've crossed you, you've committed to something, right? What about the rest of the panel? Um Who is anyone doing re sectional for their mini Mars? Any reception techniques? Um Yeah. So I, I was training quite a classic car technique. It does work, makes sense to get rid of a lot of that extra tissue like like the grade three that you showed that I would have respected it because um I was actually worried for Sam because if you keep a lot of the Pussier leaflets, you're creating a ball that might push the inter leaflets towards the track. The other thing that we have learned is that cores are super powerful. They're easy to do. You can then put them everywhere and they are very powerful tools of fixing micro valves. So I probably nowaday use half and half, you know, so I, I don't think that we need to be um zealots. Yeah, you don't need to be a zealot or to be uh whatever the religion involves a course or, or leaflets or sections. But, but often, often time I find myself using both in the same case, right? I take the bulk out of the leaflets and then on the edges, it looks a bit still collapsing. And I would have one or two cords and um it might not be as reproducible from one operator to the other and it might be a bit more arts into it by using both techniques. But that's what I do today. Mark you have some comments on this. Uh Yeah, well, a couple uh because I always have something to say. But um so, you know, for the, during the 1st 10 years of my career and I, I echo, uh I visited Cartier, I visited Tyrone David. I visited NYU Colvin Galloway and I learned something from all them. So it's really important. I think that people steal ideas from different surgeons and the kinds of different things that you see, that you think facilitate your operation. I've certainly learned from, from Mario and Tom, w we've spent some time together on some of these things. Uh Mario, I noticed that you went in, I'm a huge user of chords. I think the RV folks will tell you I was one of the earliest adopters of their device. Uh and initially used all premeasured chords and then eventually moved to the adjustables because you were doing the adjustables. Now, I think I'll just do the adjustables and now you're using the premeasured a lot because I think it's fun. Uh And I just wanted to hear how you got there. So, yeah, good observation. I've come full circle. I, I did the premeasured and I had, I guess I had my moments like that case where I wasn't in the moment and I had a couple of cases where they were the wrong length and mistakenly I took the clamp off because there was no leakage, but there was still a to that leaflet. So I take the clamp off and uh the prolapse is more than I would definitely allow somebody to go home with even if there's no regurge because it's going to recur. So I had to put the clamp on, take it out, do it again and it, I lost my taste for that. Right. And so with premeasured, it doesn't fail, you just adjust until you restrict to the height that you like and done, but it takes longer, it takes longer. And so, um, I've come full circle because I don't want it to take longer because I, I got some stuff to do. So. Um so I use a premeasure because it's quick and through that process, I've come through these uh trials and, and tribulations of what did I do wrong. So I record every case and if something didn't go right, I go back and go look at that case. And what did I do? Why did it go that way? And I learn a lot from my own mistakes. I also, I'm an avid consumer of sur surgical videos from other people. Um And uh and I think we all should in this day and age you can learn a lot from other people. Um So, yeah, that's why I came full circle time. Yeah. So uh one thing I think I would add is for the premeasured the loop uh chords that are established length. Uh I have cheated by actually shortening them at the paley muscle when they were too long. So, you know, taking kind of a broader pledget with the go suture and then kind of just folding down that, that bottom part at the paley muscle is just a suggestion if somebody's trapped in that situation, if you're gonna shorten all of them. Yeah. So I heard for chords, it's faster. It's reproducible. You gotta be versatile with these techniques anyway. And um you can undo them if uh they weren't right. You haven't committed like you have for a sectional technique. OK? I think those are all good points. Any, anything from the uh from the Yeah. Thank you. Thank you so much for sharing your video. Question about utilization of uh posterior annual Plasty Band. If you're only addressing posterior leaflet pathology, I see all the videos have a complete ring. I, I don't know how to suit your, I don't know how to put in a band. I said it. I really don't, I've never put in a band in my life and I was trained using complete rings. The data that I had read was that complete Rings were the thing to do. I know that the data I guess has pseudo change. And now we have an incomplete band that is almost complete but it isn't uh that's pseudoscience. OK. And the reality is what works in your hands. Stick to it because changing your approach for the sake of a fashion or is not worth your patient to your patient is not worth to your patient, but there's nothing wrong with putting maths. I just don't know how to do them, Ramsey. I, I really enjoyed your uh presentation. Uh I was trained at the car. I, I think I did the first cord in Canada in April of 2019. I think Devin can correct me if I, if I'm wrong. Uh I have not done a single resection since then. I've always used premeasure chord over 100 cases. We had excellent results. Uh And almost all these I think, except one case, I've used 18 millimeters for the posterior uh leaflet always 16. I've always tempted not to do, use the measuring device, but it doesn't cost us anything. So I still use it. But it's been always 16 and uh full cords and, and it's been, it's been great for me. It's been a game changer. I've not done a single resection. I do the same technique as you do. If I think that I may have am with too much tissue, I just go closer to the and fold the fold the tip. I I agree, you know, not to, not nobody here is trying to disparage the carpenter techniques. I think that that's how we started doing repairs and they have a role. And if you don't know how to do a triangular resection, you should go and learn it because you will need it or a quadrangular section, you will need it, especially that triangular resection. But uh they're complimentary. They can be complimentary, should be complimentary if you can master both. I'll tell you where it comes and shines the best is an endocarditis. You have a young person with a poster lea infection, you resect that up, you do a carpenter technique and you reinforce it with cords and all. It's good with the world Benny. Fantastic talk. I, I gotta commend you for presenting success and things that you, that I wouldn't say failures but struggles. Um And that's sort of something that I, that I also had to learn is, is if it doesn't look right, it's not right. Stop because it's gonna cost you more time. And I think the master surgeon does all the approaches. So if you, you know, resect chords, I've had a very small P two P three al almost at the, I'll just put a, a card, not closed it down. The case was over. You don't have to put chords, resect and get down the rabbit hole and not every case is the same. And uh and I think this, this was, this is just fantastic. And I'm, I, I took a picture of the QR Code so I could show all the fellows myself, my staff like you could go there and look what, what works. And, but I do, I, I do like the, your systematic approach to it. I think that it, it's not voodoo and it's not II I thought the same way. It's like how I, I love my and how I'm gonna do this it seems like it was some voodoo. It, it isn't, you just, it's all valve analysis before, during and once you're done, if you don't like it, fix it. Right. That's great. That's awesome. Yeah, that's awesome. Mario, thank you. Let me open this presentation because is on here as well. Ok. Well, I think I've heard, I've heard a couple of comments I think are really important. The first thing we've moved beyond from just leaving the or with no Mr now we're looking at the valve to make sure that there's going to be no Mr 10 years down the road because that's what we're up against. And I think we could beat the papers that were presented earlier with 8%. I think the number was 7% re up at 10 years should be 0% in 10 years. This really should be a permanent fix for these patients.