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: Peter Knight, MD University of Rochester Rochester, NY Please Note:
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So the next talk is by uh Peter Knight. I've admired his work from afar. He's at University of Rochester, Chief of Cardiac Surgery. I think a true expert in minimally invasive um aortic valves. And uh he's gonna talk to us about something that I, I have not. Um I've tried to avoid, I can see how you can do it, but I myself am interested to be inspired to how to do a ram TB procedure. Thank you. Uh Like everybody else. I'd like to thank uh art and highlight the fact that they're one of the last remaining companies that actually is innovating in the surgical space and we really appreciate that very much. So, it's not just gonna be uh bent because um the leading up to bent is a lot of hard work with minimally invasive approaches to the right into our economy. And I want to stress that this is an operation. Not only not, should you not do this coming Monday, but the Monday after and the Monday after that. So my disclosures, I have uh no financial disclosures. However, um I do believe it is a small step from convert to zealot and I am a minimally invasive cardiac surgery zealot. So a little bit about innovation because that's basically what we're talking about and about our city Rochester, which has a long history of adapting, reinventing and exploiting uh new technology. It was settled in the 18 hundreds, flourished after the opening of the Erie Canal, which is basically the internet of its time. And Rochester became known as the flower four city based on the numerous flower mills along the Genesee River. And in the 1st 10 days of the canal's opening, 40,000 barrels of flour were shipped to New York City. This is what the Erie Canal looked like going across the Genesee River in downtown Rochester. By 18 50 westward expansion of the US had moved the focus of farming to the great plains. And Rochester's importance as a flour milling community had declined. And with this uh happening, Rochester was quietly becoming the largest seed producer in the world, transforming itself into the flower flow er city. This is a company that was there at the time. And in 18 50 the founding of the University of Rochester. This is our undergraduate campus. It's sort of nestled in a corner of the uh Genesee River. In the background, you can see the downtown Rochester and in the far background is Lake Ontario, the University of Rochester's uh main uh uh hospital campuses. Uh Strong Memorial Hospital was named after Henry Alva Strong. So Mr Strong and this is a picture of him. He made his fortune making buggy whips and it was the largest producer of buggy whips in the, in the world as well. But by 18 hundreds, he realized that technology was not gonna be, was doomed. And so he invented himself by partnering with this guy George Eastman to form this company, Eastman. Kodak. This is one of Kodak's initial buildings. This is the University of Rochester Medical Center in the foreground. So it now dwarfs the rest of the uh medical center. I mean of the University of Rochester and the University of itself has become the largest employer in the city. So it's not Kodak anymore as everybody knows. So the city has constantly had to reinvent and rediscover my point being that we all had to do this and we'll have to continue to do it. I won't have to because I'm kind of a senior guy, but everybody else in this room is probably gonna have to, you should learn a new operation every year. That's the key to staying relevant over, you know, 40 years. So the stone age didn't end because we ran out of stones, it ended because we came up with something better, which is a bronze. And similarly, we have not run out of sternums, but we have come up with something better. And so it's with this backdrop of adaptation, innovation and technological prowess that I present our optimistic view of the future of the tic valve root surgery. But first, we have to talk about some things, in my opinion, is the most, one of the most important technological changes to affect cardiac surgery since the development of long term mechanical support. But there are problems with Tara expanded to the general population, especially not the general population but the younger population. And we need to discuss that as surgeons and as interventional cardiologists because these things are not going to be apparent right away, but they will be apparent over time. So most of you are probably familiar with this uh paper in Jack from November of 22. It's really an eye opener. It was a series of 800 academic medical centers. 250 of them were doing ver and saver during this time frame. I'm sure all of them are doing tavern saver now. But the time uh cohort was October 2015 to December, uh 21 isolated a VRS for aortic stenosis. So there are 140,000 patients and the paper was divided into three cohorts of patients under 65 65 to 80 greater than 80 looking basically at utilization of tar over time and tar utilization doubled in the entire cohort from 45% to 88% dramatically. 80% as of 2021 patients with isolated aortic valve replacement getting tar in the under age 65 group, which is the one that's the most interesting to me. The ta ta increased 2.7 fold. So that now in 2021 probably more. So in 22 about 50% of all patients are getting ver under 65 this is the breakdown of the group of patients. 12% were in the under 65 group and then the others were split evenly between 65 to 80 greater than 80. So this slide is colorful and a little bit complicated, but I'll just walk you through it pretty quickly. Um It's a simple way to look at it is to the left of each one of these groupings. The light blue is uh 2015. And um well, actually, maybe it's darker blue, but the other blue to the other side is the 2021. So the first set of bars is Tara volumes or percentages in the under 65 groups. So it went from about 15% to about almost almost 50% in 2021. Similarly, the saver group in that uh uh age group went from about 85% down to about 50% in the 65 to 80 group. Um It went from about uh what is that? Maybe 40% to now, about 90%. Um And similarly, you're down to about 12% in the 65 to 80 groups. And then of course, in the over 80 essentially, everybody's getting the tavern. And I think most of us in this room would agree that Tara is appropriate in, in that age group and then we can quibble about the others. So in our institution, uh as of 2022 actually, the last numbers in the under 65 group, 85% of our patients are getting uh surgical A VR. So that, that compares with about uh 40 about 50%. So about um 30% root crude number increase in, in, in Sara and in the 65 to 80 38%. So three times the number of uh that's uh in this series of patients at 12% ours is 38%. And now I'm not trying to bash ta because I do a lot of tas and I think we would all agree. It's helped us out a lot. There are lots of patients who we don't want to do. A VR. There are a lot of patients who never got referred for surgical A VR and it is an amazing technology. However, I think it's being overused. Uh So why are numbers that way? Well, that's a good question. And this, I think is the answer. Um It's the right answer thot or uh ram procedure. Um People. So I think, you know, we can discuss what's the value of thoracotomy, mini anatomy, full sternotomy. Is there, is there an improvement in survival? Is there an improvement in in mortality? Admittedly, blood loss is probably less. So you can probably argue that. But I submit, it doesn't matter matter you if you build something that nobody wants, it's still something nobody wants and nobody wants aster anatomy. So I, I think we have to get over this concept that we're gonna, that we're gonna um dig our heels in because the data shows that 88% of all isolated A VRS done in this country right now are done by a transcatheter val. So this brings me to a topic that I say frequently you'll hear me say it many times the requirements for saver relevancy. One, a non anatomy incision to low gradients, preferably single digits with EO A is greater than 0.85 per meter square to body surface area. Tar has brought that to be the new normal. Now, we may argue, hey, does it really matter if it's eight or 16 for a mean gradient? Probably not hard to know, but Tar has brought us single digit gradients and we need to have uh an operation that is reasonably close to that, which means you've got to be able to do uh root enlargements, uh annual annual enlargements uh when, when necessary. And you gotta go by the charts. So you actually get these numbers, you need zero, I mean zero perry value leaks and I'll talk to that in a second and very low pacemaker rates, ideally 1% or less, it could definitely be in the 2% range. So why do I feel so strong about three and four? Because, because those are the weaknesses of probably will never be able to get lower pacemaker rates than we've got right now because of the intrinsic nature of the product. Now that I mean to be proven wrong on that, but we've gone through 10 years of development and still it's 10 to 15% and there's a per, per value legally, which has of course gotten better but is not down to zero. And, and what are the impacts of that? I go back to the younger age group people. What is the impact of a, a mild per on an 80 year old? Not very much, what is it? And, and on a mild per or a pacemaker and a 55 year old, probably significant. But do we know that? Well, we don't know that in the group because we haven't followed them long enough. Keep in mind that when we started putting these things in, they were 80 90 year old. Our initial, we were in um in, in one of the clinical trials and our initial cohort of patients, average age was 82.5. I mean, they were old people. So we don't know the the the the effects of tar in, in younger folks, but we do know in surgical cases and I would submit that in, for instance, permanent pacemaker does it really matter whether you've had a ta or saver in terms of the implications of permanent pacing. Uh probably not. So this paper from U VA, I'm not going to bore you with the details. It's just going to go through 2600 patients median follow up of 7.5 years. If you had a permanent pacemaker within 30 days at the time of the implantation of the or valve, you had an odds ratio for death of 1.481 1.5 fold increase in mortality and a median follow up of 7.5 years. Is that isolated? No, it's not. Here is another paper from, from mayo larger series of patients. Basically the same identical number 1.5 uh has a ratio of 1.5 of uh of uh death at I think the media follow up was uh uh 15 12 years or something like that, but very similar numbers. So permanent pacemakers and old people probably doesn't matter, permanent pace maker and a 55 60 year old probably makes a very big difference. So how about a insufficiency post procedure? This has also been studied in the surgical literature. Um the impact of residual regurgitation after or valve replacement. And I just pulled out a couple of papers. There's millions of them really well, not millions but lots. Um This is 3200 patients operated on between 92 and 2011 and then followed um and basically two cohorts of patients. Group one had a trace or zero erotic insufficiency. And then group two had uh mild or greater, but I, but almost all of the mild degrade were mild. And that makes sense because who in this room would leave with moderate or severe A I on your, on your uh uh a brand new uh erotic valve replacement. So they were mainly mild A I patients. There were 4% of 100 and 35 and at all time points in the follow up, residual a regurgitation resulted in the hazard ratio of death of 1.7. So these are, these are real things that, that impact, that will impact the problem is we won't see it for a while because we're just now doing the 55 year olds, the 60 year olds, the 63 year olds, and we're not going to know for another 8 to 10 years what the impact of this is. So I go back to this small non anatomy incision, low, preferably single digit meaning gradients. So we need to be comfortable with annular annular enlargements, zero per a leak, which means we've got to quality assure what we do every single case and minimal pacemaker rate. So that's my pitch on many A VRS. And the reason I say it is because you got to be good at this before you go to this, which is the mini bil because it's not easy. Mini Bal is a hard operation. You really need to be an expert at the mini, right? An approach. So what I've learned is, first of all, become an expert with writing anterior Thot exposure and robust mini A VR experience. And I started, I did my first mini writing to throaty which by the way, in, in um Catherine, I did all my many A VR for 15 or 20 years, meaning upper hemi. And I vowed I would never do an anti throaty because like, why would you, it's, it's, you can, can you centrally both spots? It's the exact exposure. Why would you, then I had a patient come to me who want, who did not? She was getting married and she did not want an incision in the middle of her chest and she wanted the anti which I've been doing in the cadaver a few times because I really wanted to try it. So that was my first case, which was in two, early 2015 and we never looked back. So we have well over 500 many A VRS at this point through an ant, get comfortable using an endoscopic camera. Now, you don't need a camera from mini A VR but we, but when you do need it, if you have a difficulty exposing, for instance, the right corner annuus, it's very, very helpful. And again, it's a great tool for quality assurance because when you're done seating and corn in that valve, you can drive the camera straight through the leaflets of the valve and look up against the annuus and the sewing cuff to make sure there's no pair val or leak. You can actually see it start with younger healthier patients as they tolerate longer. Cross climb times. I won't lie to you. The cross climb, I'm gonna show them to you. The cross climb times are long. Um The circle rest times are longer. There's no question about that. And if that's bothersome, then you shouldn't do many bent because I don't think you can get it any short order than this. It's just, it's, you can't rush through it, avoid calcified aortas and as has been talked about. And this is very true. If that aorta is against the sternum, that's a bad case. So the best, best, first case is starting out an aorta to the right and at least two centimeters between the sternum and the order. And the other thing I like to see is the annointed vein, cephalad to the takeoff of the annointed artery, ideally like a centimeter above because the innominate vein, unlike in the sternotomy bent, you can't loop the vein and pull phal it's gonna be in your way. And that's a problem. Um, a bad case is this case. Uh Let's see, let's play. Well, there we go. Um There's a plural effusion. So you already know the patients got heart failure ef was like 25%. The order is way to the right side, it's up pretty high. Um So I didn't do, I did a uh a full anatomy uh on, on this case. This is definitely not a good case. So I will make it a uh disclosure about this video which I'll show you it's a composite of multiple different cases because I wanted a good video imaging of a variety of different parts because I wanted to show all the options so it cuts into. So there'll be a calcified aorta which isis there's an A but the patient is described as an A I I took clips from a, a variety of cases just so you're well informed before. Here's what the room setup looks like. The patient is 47 years old, no coronary disease. He has a bicuspid aortic valve with severe aortic insufficiency, shortens the breath on exertion and a five centimeter A and an aortic aneurysm. Our plan is a minimally invasive bal with a mechanical aortic valve. Again, here's the room set up standard I use a camera and everybody echo image of the aortic valve and ace in order aortic insufficiency and an A an A aneurysm. We routinely use hemodynamic monitoring, continuous trans echo monitoring as well as cerebral oxy met. The incision is five centimeters in the second intercostal space and we will normally dis articulate the third rib from the sternum is an Alexis wound protector as well as an intercostal retractor. This gives very good exposure through a separate staff incision. A five millimeter camera port is placed for the 30 degree five millimeter scope. The pericardium is open, the safest spot is to open it with the right atrium and the order to come together as that is normally a potential space and it avoids cardiac injury. Perc stays are placed laterally and brought after separate stab incisions, liberal use of peral stays will improve the exposure. On the medial side. The state features are usually sewn to the wound or clamped to the Alexis wound predictor. I just keep, keep, keep on putting stays in until we get cannulation is by a femoral artery and femoral being cut down. It's very valuable to have echo confirmation of intraluminal placement of the wire for the arterial cannula. Here you can see the uh wire in the descent thoracic order we do this routinely. So on the mini I can the order directly, I wire placement, the arteries dilated the arterial can cut it placed. Venus canel is similarly placed with ultrasound guidance. The wire is seen in the superior cava in the cable view on I think it's really important as it's been pointed out following. They gotta have, they gotta be excellent venous drainage is critical to this operation. And if there's any question, you can actually through the wound, you can buy manually palpate with a forceps and a sucker and make sure that it's in the superior cave. If you don't get good imaging, it is possible to get retrograde card diplegic cannula through this incision. Although I rarely do it anymore, but you can see that the purse string is readily playable. And with ultrasound guide echo guidance, you can uh identify the corner, the corner and get it in. Please. You can you for retrograde card diplegia. Nowadays, what I do is integrate cardio plegia down the route for an A S patient and directly into the Corona for an A I case. You can confirm that the retrograde card plegic can is in when it's pulsatile. I routinely use a superior Pulmy vein vent which is relatively easy to place. As you can see here, the suture is being placed in the superior pulmonary vein and then we fill the heart up and place the, the vent into the left ventricle. So like everybody else, if I can't get it in, I'll use one of those small pediatric. I use a waiting one. Something in the left ventricle is an navy sump like this but uh small pulsatility through the sump. As seen here operating over the screen. This part will be through the hole to facilitate places in order to ensure that you are fully across the order, it is advantageous to encircle the ascending order with an umbilical tape as shown here, an a great cardia needle is placed and we use Histidine crypto ketoglutarate cardle two liters, which is adequate for at least two hours of continuous cross claim time. So I've gone almost three hours opened at the site of the cardio cannula and then transected. Once transected, the distal aortic remnant is tacked back to the pericardium aiding. In exposure. In this case, we have a biotic valve with aortic stenosis and in aortic stenosis cases that will place a sponge in the left ventricle to catch any debris. Following that we start the valve removal. I've noticed since using the camera that are bicu bowels routinely, there's an area free of calcification just counterclockwise to the right main coronary. And that plane is easily entered with a 15 blade that allows for rapid definition of the plane between the annuus and the valve in a calcified calcium free area, which really aids in removing the valve. As you can see here. Once you're in the right plane, the valve can usually just be dissected free from the annuus. So that plane usually just cleaves the fibrous tissue is cut and with gentle traction on the valve, it usually just comes out on the on the appropriate plane once the valve is removed, then of course, the packing is taken out, left ventricle is irrigated with saline solution to remove any other particular matter that might have dropped down past the sponge. And then the valve is sized, we're cooling. Obviously, while we're doing all of this till we get to whatever temperature we want to get to. And I'm usually down to 18 for, for, for the mini bals. When satisfactory temperature is reached, the patient is placed in trend Ellenburg, the flow is turned down to 50 CCS a minute and the order cross knife is removed. The remaining portion of the A in the order up to the level of the nominate order is resected. A sump is placed into the aorta and dynamos has commenced. This is with the forro suture. So here the camera is really very helpful. The posterior wall is actually pretty simple to do. The interior wall can be challenging depending upon how much room there is between the aorta and the sternum like in every but especially in the mental evasive case, all of these Anestis have to be very meticulous to avoid any bleeding because bleeding complications following this can be difficult to handle for oh when you put that back in, you gotta be careful are compared to an open case, usually about 20 to 24 minutes as opposed to uh 15 minutes or so in an open case. So we do cool substantially. Usually about 18 °C, the cerebral vessels, arch ceres and graft deed and then the cross clamp is reapplied and warming is commenced. We now fashion the uh left and right, main coronary buttons and mobilize them as appropriate to your point about the uh stay stitches in the stays in the comma are helpful to gain exposure. Again. As in every bent, the critical part of the operation is the left main dissection and the left main Anestis as this is the source of most of the complications. Once the coronary buttons are mobilized, they attacked back both cephalad and to keep them out of the way. While we do the inflow suture line, the non coronary sinus tissue is removed in the angle. The sutures are then placed. I use non pledgeted sutras from left ventricle to aorta. This is an outtake showing use of the ram device which is an automated su device. The suture come either pledgeted or non P. It can really be on the speed and accuracy of uh annu of sutures if you have a really hard time exposing it and it comes with pleasure, either pledgeted or non pledge. Back to the original video when we're seeing the valve conduit, which will then be secured with knots. The camera can be very helpful in ensuring that the valve is well seated to the annuus. We start with the left main corner and Amos first. These are, this is the performed with running 50 pro sutures. Exposure is actually quite good for this part of the operation since you're coming from the right side, the right to, to sew it. It's just a question again, as important as hemostasis is critical to the success of this operation. No, this is a connector. Yeah. Although most of the time I make them, they're, it's just too expensive. You know, it's not worth the money in my mind. And I think basically you can use, I use a uh either a uh use of 28 with a 25 valve or uh 27 or 30. Can everybody, right. So you can make it ahead of time. I don't really like to connect to coffee. You are complete. It's like their micrograph a graft and as the is performed with running for after securing this suture, the graft is de aired. I think the one big difference and these many thot with regard to air, the order the clamp is removed. CO2 actually works here because the opening is so small CO2 being more dense than air, don't really get air in case. So you don't have to worry as much about the airing. This is before reversal of the and this is the final product HKHDK for all uh A VRS and B or been closed. And this is the patient 3.5 weeks later in the post op clinic, the patient had a length to stay of about four days in the hospital. So in terms of uh characteristics, we've done 51 I think now we are actually at 52. Um that actually includes a couple of week procedures and a couple of ascending orders. But most of them are BS as I said, the uh uh clamp times and pump times are long. Unfortunately, I can't read that from here, but it looks like 100 and 96 maybe 10 minutes. But what, you know, it's fairly long. The clamp times are 100 and 50 minutes. Um, the circle rest times are definitely more elevated than it. Anatomy length of stay in the IC. 26 hours. Read admissions to the IC. We had four of them post-op length of stay was five days. We had one per M I, no strokes, two people can went back to the R for bleeding. We had two readmissions uh within 30 days and we had no 30 day mortality. Two conversions. One was a media Steny. The other was actually not a mini J. It was a, it was a transverse sternotomy across to the other side which is very helpful. It was a bleeding issue that we just had difficulty exposing. 49 patients were discharged to home, two who went to school nursing facilities. And uh in terms of intermediate outcome mean follow up of 2.9 years range 34 days to uh 6.7 years. And uh everybody's uh alive at this at this stage. Um I would also tell you that my first case was in a cadaver, not in a live human, which I think is really valuable uh because you want to work out the kinks and not have to worry about bleeding. Uh Thanks. Ok. So let's start out with questions for, uh, Peter Knight who's got, who wants to lead off on this one? Ok. Well, well, as we're taking our seats, um, and since you mentioned it, Peter, um, the, uh, cross clamp times on yours were about 100 and 20 minutes, 100 20 130 minutes. So that brings up the, um, the, um, the issue of cardio plegia and myocardial protection. So you said you use the custodial, the HTK, just so everyone knows custodial is approved for, for, um, cardio plegia in Europe. But for some reason when it comes over across the Atlantic, it's not approved in the United States. Uh So the way you're using it is exactly how the Europeans would use it. Um, what do people think about Cardios? My card of protection for cross clamps going over 100 and 20 minutes, a good user of as well? I think that it, you know, you can probably stretch it to three hours with, I would rather read those than reach all the way to three hours. So the way I split things is that if I have an, an hour and a half of work and less I would go to and for an hour and a half and more, I would go and, um, you can give it now if that was for a, with, you know, a lot of a, I, I would give it to, you know, you would spend it. It's almost two liters to full dose. And um I, I didn't know that it was not available uh in the US for that, but in Canada it's, it's not very, very frequently used, but it is definitively uh available in the market. So that would be my strategy. So, 90 minutes for Del Nito and Ari it seems a little long for a Del Nido shot 90 minutes for El Nido, but that would probably redose halfway at 45 minutes. Ok. Yeah, half of those. Ok. That, that one sounds, sounds better. Um, wants to talk. Go ahead. Yeah. No, I mean, we've used Doma up to 90 minutes. No problem at all. Um, and we give 1250 CC as a first dose. Um, when I get to 90 though, I'm very cognizant about redosing if I think I'm going to be another even 15 or 20 minutes. And we give like three or 500. Again, we've used custodial and I learned how to use custodial when I was operating in India. And we use that actually before we use Del Nado and again, two hours, no sweat, patients, heart, you know, you have to do some different things. You have to zebu, you have to hemo concentrate. Um, and, and all that. But, um, it, it's, it's a great, uh cardio plegia. The other issue is you have to pay for it and it's, it's not horribly expensive. But, uh, Delma was basically cheap. Pennies in Canada. It's probably, uh, $600 per case for, for the, yeah, the only is we do that, uh, in the hospital. Bill Kent. What do you think? My cardio protection? Yeah, I, I agree with, uh, Del Nito. No, seeing every 45 to maybe 60 minutes. Uh, got a lot of comfort with that. I have used custodial but I like, um, I like having some blood in there. I, uh, I don't have any experience with uh HDK only and II I think I do more like Mike has described. Uh our dose is, are usually about 1500 perfusion is usually might spend 15 minutes and then 20 minute intervals after that or at 70 I would give if I still have a lot of work to do and I'll usually give 300 or so cab 100 30. So, while you're aware, we started, um Peter's slide was about 100 30 minute cross clamp time. Uh HTK one shot. What do you, what is your preference for? Uh my Carter protection? Long cross clamp time. Uh I use for everything um, every 45 minutes. Um I've never had a problem. Well, I mean, that's, I mean, that's great to hear. Um Mark what I'm the same. We use Del Nito for everything and Ari is at 55 0 minutes if I think I'm gonna be there for a little while, if not. Uh, if I think I'm gonna be finished in the next 2030 minutes then actually, I might not give any or just a little tiny bit. Right. But, uh, yeah, we've enjoyed that too and we use micropsia. So, you know, no, in there and, and as you mentioned, Del doesn't cost anything so. Well, I think this is a rare time when we have a consensus among surgeons on how to use. That's, that is awesome. Peter. Yeah. Go ahead. It's, it's, it's interesting the timing differences and it's so experiential. Right. There's nobody said, you know, at this time you give this much, uh, it's just a little bit of it. Yeah. I mean, I, if you give it like five minutes or 10 minutes before you take the cross cap off the heart notices. So, like if you're close, wait. But, right, Peter. Any, uh, any you want to say anything in your defense for the custodial? I don't have Del Nito. I just have custodial. Yeah. I mean, if I was short in the, in the, I would still be using, uh, custodial because as you point out it's 2.5 hours of lamp time. But, uh, I'd be perfectly happy to use. But the rules and regulations in our institution about compounding stuff is such that they don't want us to do it. Don't ask me why I told them they could save $400 a case. A lot of money. Maybe. Now that things are really tough. They'll go back to it. That's interesting. Yeah, that's really interesting. Yeah. So, the other thing I, the other thing I noticed and I didn't realize it's, uh, you, you use the scope a lot on that and that didn't seem, um, the view was fantastic. What do you think about a 3d scope? And I'd like to rope in. I saw on the guest list here that Danny Ramsey is here. I'm guessing that Danny Ramsey is the person who answered robotic A VR are you the only one, Danny, who's, who answered that? So, what, what is, does someone else answer that? But I don't know if somebody else answered that. So what, what do people think about that's robotic and then 3D views for these things? I'm just always impressed with the um the videos, the video is beautiful Peter. Well, I, I uh the, you know, I'm just transitioning to the robotic approach from the, you know, piece meal that, you know, I do. I, I also like saying rath instead of whatever else, it's just sounds, sounds wrong. So it's, it's perfect. We're, we're the outliers still, you know, we still, it's only 7% of the cases. Um So I, you know, I, I'm very comfortable with the right an interior approach uh for anything that needs to be done through the through that is required. So I don't have any exclusions unless I can't get into the right chest because even if you can't clap as long as I could do a uh ach under the circle arrest, I could take care of the case. Um And I think with the robotic approach, I first just cut the valve out another case, I would just open the order and close the order. And then once you get all these procedures done, because I am cognizant of increasing clamp time. And now I could do the whole case in a reasonable, the same virtually the 15 minutes longer craft clam time than a anti earth approach. The my experience with the right anti approach sort of I I it's in LA, I trained some of the fellows to do it. So it's do, it's trainable. The robotic APR is not possible. That's, that's just uh I need to learn it. So, but the right Anthony approach is the approach so that we actually have a legitimate discussion with the patients because we're the sternotomy is a product that they don't wanna hear about as truly. Well said, they don't want to hear about it. So they will take a ver, they'll, they'll take a ver with inferior result. They'll take a ta that's high risk ta is a very little risk surgery. And I think the right anti approach is the way to do it. Whether you're shingle or don't shingle your big incision, small incision is irrelevant. Do it the way you're comfortable to do it. The, the, the and just have your bailouts. If you don't shingle shingle, you'll get great exposure. Crank that chest retractor open pain that you could deal with a dead heart or, or, or bleeding from that corner of death is going to get you not the pain and, and uh for pacing wires, I forgot I wanted to mention but I, I forgot to do to, to do that. I have a bailout strategy. I have the six French sheet temporary wires in the room. It gets, I've had a wire cut. I have a wire pulled. I have a sudden block and the transcutaneous doesn't work. If it's in the room, everybody is comfortable and, and, and I think that's the key. You don't want to have AAA disaster. These approaches are, you could do and uh you could do this practically Monday right into your throat if you are, if you, if you have it prepared, well, you could use a regular cross clamp for first end case. I used a regular cross hospital. Didn't want to buy anything. I just had to use. What was there? It's doable. Now you don't do a, I, you don't do crazy cases but you could piece meal your way until you have no excuse. I'm gonna disagree with you on that 1 g. T just don't, don't wing it, don't wing it. Yeah, you have to be prepared but you could do it. Don't wing it. You gotta, you gotta come in with a plan. That's, this is like you're, that's an NFL game there. You gotta come in with a game plan on that one or what? Um, what do you think about 3d vision, 3d vision for valves, especially for special aortic? You think it's beneficial? So I haven't used it on the aortic, but I've used it. I do it on all my micros and it's amazing once you've got it, you can't go back. I'm gonna try it on the, the the problem is it's a bigger incision, right? So these are the, the scope I was using this 30 millimeter uh five you know, uh 30 degree scope five millimeter. The um 3D N I is a 10 millimeter scope 11 millimeter port. So it's a much bigger incision. But on the mit it's, it's amazing. Yeah, it is Denny. What do you think? Um Well, a large part of our Microvalve practice is robotics. So we use 3D camera and um it, and it's obviously much nicer if you do everything videos and in, in the regular M I where, you know, you have a bit of a larger trio like a four centimeter incision. I end up being doing most of it on direct visions with extra camera view for difficult corners. And um and, and if you use it, it in that fashion 3D is probably not necessary. But if you want to do fully videos, I think it's a, it's a central oh Great. Any um any questions on this one? Um Just some of my thoughts on robotic A VR so we had uh vine bad come and speak last year on Robotic A VR. His series has since expanded. But what strikes me is that he just, and I went out to see him at West Virginia as well. He is not getting it much lower, Danny, much lower than a 90 minute cross clamp time for isolated A VR. That's, that's a lot for this room. I think it's, and he's really cut out a lot of steps to really make it as fast as possible. So that's a challenge which means that's an area of innovation. So I'm hoping to see maybe Danny next year. Tell us how to get that robotic A VR down to a cross clamp below 60. So we can do a one shot Del Nido and get out of there with a robot. I mean, that, that would be just sort of the goal on that one. Ok. Yeah. Want to give you, they've all seen it virtually all cases and we don't talk about it. It tears. So if you're gonna just do the, your first case, it's gonna tear because you're gonna pull and you're gonna pull harder than you, you think you're pulling, you make, you should and, and there's a lot of nuance and tricks to, to, to, to keep yourself out of trouble. But it's, it's, if you're gonna go that route. See, see, see a few surgeons do a robotic A VR and piecemeal the operation. Don't do an entire operation your first time. That's a good point. Yeah, I hate the coffin corner, right. So up to this point, these talks have been coming from the perspective of full sternotomy to a minimally invasive approach for A br these next two talks are here because some people are doing mini mits and now they wanna do aortic valves. So.