minimally invasive heart surgery with no bone cutting

[heartdoc]

Heartdoc -

Did you see my response to your post in another thread with a copy of the post from a Notre Dame Statistics Instructor showing the Mathematically Correct manner of calculating the risk of having had a Bleeding Event from Coumadin over time (10,20,30,40,50 years) which contradicts the popular misconception that Coumadin risk is Cumulative?

Al,

I saw your excellent post about cumulative risk and I just responded to it in the other thread

Thanks,

Heartdoc
www.bigappleheartsurgery.com

 

[heartdoc]

What about the bypass machine, is that a seperate incision? I know many people that have that, complain more about that incision (pain or numbness or both) than they do the sternum, even a full sternum. Sometime I get the idea that people don't know they will have one with the min invasive surgery, until they wake up and are surprised.

Different surgeons will use different techniques. The vast majority of my minithoracotomy cases do not require any additional incision for the heart lung machine. All the necessary connections are carried out through the minithoracotomy incision. Check the surgical pictures in www.bigappleheartsurgery.com/page5.php . to see how all the heart lung connections are converging through the same tiny incision to avoid scars and additional incisions in the groin and under the collar bone

Heartdoc
www.bigappleheartsurgery.com

 

[Greg a]

WOW do you ever have a lot of time to promote your BUSINESS......................I'm just saying the my surgeon does not have that kind of time

I'd love to hear the input, questions, comments, personal experience of the members of this community on this hot topic in modern heart surgery. The vast majority of patients with a heart valve condition can routinely undergo minimally invasive heart surgery in advanced specialty centers accessible to everybody. The operation to repair or replace an aortic, mitral or tricuspid valve is carried out through a 2" incision in between two ribs on the right side of the chest (known as "minithoracotomy"). In female patients the scar can be hidden out of sight in the skin fold underneath the right breast. The most obvious clinical advantages with this technique are:

1) Less bleeding. Blood transfusions are seldom necessary
2) Less wound infections. Infection in minithoracotomies is almost unheard of
3) No bone cutting. That eases wound healing and avoids the problem of osteoporosis (brittle bones) in older female patients
4) Excellent pain control with most patients waking up pain-free after surgery
5) Superior cosmetic results
6) Short hospital stay. Most patients can return home in two to three days

How many of you are actually offered minimally invasive surgery? If your local physicians do not offer these options, DO NOT be shy about asking questions and consider a second opinion in a reputable minimally invasive and bloodless heart surgery center.

This minimally invasive technique is currently applied to mitral valve repairs and replacements, aortic valve replacements, tricuspid valve surgery, atrial myxoma surgery, atrial septal defect repairs. An expert minimally invasive heart surgeon can use minimally invasive techniques in most cases.

See more details and lots of surgical pictures at www.bigappleheartsurgery.com

Learn about the questions to ask your doctor before you make your choice
at www.bigappleheartsurgery.com/page15.php and www.bigappleheartsurgery.com/page2.php

Have a great day,

Heartdoc

Hi,

Thank you for your excellent questions
1) Minithoracotomies for AVR have been used since the mid 90's in thousands of patients
2)The immediate post-op results are better in the minimally invasive group because there is less bleeding, less post-op pain, less wound problems, a shorter hospital stay and most patients are satisfied with better cosmetic results. The long term results are the same as an AVR carried out through a sternotomy
3) In redo's it is important to first check a CT scan of the chest to see the position of the aorta and whether or not there are significant ascending aorta calcifications. If the surgeon is satisfied that the patient is a good candidate and therea re no specific contraindications, a redo minimally invasive operation can be carried out
4) Should the indication arise, Redo AVR through the original sternotomy or through a minithoracotomy are two options you would need to discuss with your doctors.

Warmest Regards,

Heartdoc
www.bigappleheartsurgery.com/page5.php

Hi!

To my knowledge the presence of muscle or nerve issues affecting recovery are extremely rare in minithoracotomies. In most cases a minithoracotomy can be effectively numbed up at the end of the operation with local anesthesia and that allows patients to wake up pain-free. About 12-14 hours later most patients feel a very tolerable soreness. Overall the recovery after a minithoracotomy is significantly faster than after a sternotomy with less bleeding and excellent wound healing. Ask your mother's physicians about these options and specific expertise on these techniques.

Warmest Regards,

Heartdoc
www.bigappleheartsurgery.com/page18.php

this kind of puts Todd in a tough spot

Hook,
Would you recommend minimally invasive heart surgery instead of a sternotomy to someone you know?
Best,
Heartdoc
www.bigappleheartsurgery.com/page8.php

Most minithoracotomy cases will have one or two small drains that are often removed the morning after surgery. You can see a picture of these drains at www.bigappleheartsurgery.com.page5.php The picture refers to a mini AVR but the drains are the same in a mitral valve operation

Best,

Heartdoc
www.bigappleheartsurgery.com

Canada has an excellent cardiac surgery tradition and there are quite a number of surgeons with minimally invasive expertise. Ask your local doctor about it. He might know of a minimally invasive heart surgery center in your area.

Heartdoc
www.bigappleheartsurgery.com

Ruth,

You pinpointed a very important technical detail in your case. When I started using these techniques in the 90's I had a female patient who had similar complaints. It is not a very common situation but something can be done about it. There are two technical options: you can either place the incision 1/4" below the skin crease underneath the breast or you can place it right on the crease but making sure the incision is perpendicular to the chest rather than slanted towards the breast tissue. I like the second option better because it hides the scar but avoids a direct pressure on the soft tissue scar. I commonly recommend avoiding wire bras for at least a month after surgery to allow wound healing. A small gauze can be used to protect the wound in the first month if soft cotton bras are used. It is certainly a question to bring up when minimally invasive heart surgery is discussed with a surgeon

Best regards,

Heartdoc
www.bigappleheartsurgery.com

Al,

I saw your excellent post about cumulative risk and I just responded to it in the other thread

Thanks,

Heartdoc
www.bigappleheartsurgery.com

Different surgeons will use different techniques. The vast majority of my minithoracotomy cases do not require any additional incision for the heart lung machine. All the necessary connections are carried out through the minithoracotomy incision. Check the surgical pictures in www.bigappleheartsurgery.com/page5.php . to see how all the heart lung connections are converging through the same tiny incision to avoid scars and additional incisions in the groin and under the collar bone

Heartdoc
www.bigappleheartsurgery.com

AND FROM "THE OTHER THREAD"

Clydesdale - You had excellent advice and counseling from this forum and from your heart surgeon. I know it is scary and confusing but it is clear that surgery is in your best interest. Keep always in mind that surgery is not the problem. It's the solution to give you back your life. If you want a more detailed discussion on valve choices and their implications, I'd suggest this link: www.bigappleheartsurgery.com/page7.php

Dear Al and Brad,

Thank you so much for your detailed and valid statistical analysis of cumulative risk. I truly enjoy the mathematical order behind statistics. It can lend itself to endless academic discussions. Most patients, though, are not inclined to complex statistics and mathematical speculations when they are faced with personal health decisions. Most surgeons want to make sure they educate their patients effectively about their options. Please note that the simplistic, easy to understand 2% per year cumulative risk estimate used by most heart valve surgeons roughly mirrors the "real life" risk estimate described in your 3% risk level table. The risk described includes thromboembolic events (major and minor) and bleeding events (major and minor). I hope this explanation helps you reconcile your valid statistical objections to the common practice of heart valve surgeons. We are indeed talking about the same numbers. Having said that, I'll gladly keep a copy of your risk level tables as a reference for the rare patient inclined to discuss finer statistical assessments.

Here is a link to a good review article on coumadin therapy risk in different prosthetic heart valves and positions (mitral vs. aortic):

http://chestjournal.chestpubs.org/content/119/1_suppl/220S.long

For all mechanical valvers, a strict coumadin protocol along with improved mechanical valve designs is generating improved outcomes (less risk) and this is reflected in recent literature. This will change our risk assessment in the future. The duty of a heart surgeon is to give you the facts. The ultimate decision maker on the type of valve is always the patient.

Thank you for your thoughtful intervention..I stand corrected!

Best,

Heartdoc
www.bigappleheartsurgery.com

I just wonder why you are trying to SELL this and not talking to peers that could refer patients to you rather than placing doubts in people that are already scared and self doubting about decisions made or that need to be made. I am thinking of someone such as Clydesdale who titled a thread "Hello all - New Member scared and confused please help " and that ended up getting turned into your information session.....I just pray that there is not enough doubt that he would cancel ;;;we all know how fatal that can be ,,,,right Mary / Duffy

I am glad that you started this thread so that individuals can look to you for information here

again thank you for your participation

 

[heartdoc]

This thread has been started to exchange information and learn from your comments.

Thank you for your comments, Greg

Heartdoc

 

[Lynlw]

Different surgeons will use different techniques. The vast majority of my minithoracotomy cases do not require any additional incision for the heart lung machine. All the necessary connections are carried out through the minithoracotomy incision. Check the surgical pictures in www.bigappleheartsurgery.com/page5.php . to see how all the heart lung connections are converging through the same tiny incision to avoid scars and additional incisions in the groin and under the collar bone

Heartdoc
www.bigappleheartsurgery.com

Thanks. Are their certain mini invasive procedures you definately would use a different incision for the heart/lung for? Or is is something that each person is different?

 

[heartdoc]

Lyn,

Good point! True: each person can have slight differences in the heart anatomy. In minimally invasive procedures carried out through an incision underneath the right breast (4th intercostal space) I might opt to make a small incision in the skin crease of the right groin to insert one small arterial cannula. This is a very infrequent technical situation that arises in patients with a short aorta. The incision is about 1" in length and tends to heal fast and with very little discomfort.

 

[AndyCap]

My 69 yo father was having difficulties due to a PVL from a recent AVR. This summer he underwent a percutaneous transcatheter obliteration of the defect using an Amplatzer vascular plug in NYC. According to the surgeon, the PVL was said to have been decreased immensely, however the hemolysis is now greater... causing him to be much weaker and lethargic.

That is our experience.

 

[heartdoc]

My 69 yo father was having difficulties due to a PVL from a recent AVR. This summer he underwent a percutaneous transcatheter obliteration of the defect using an Amplatzer vascular plug in NYC. According to the surgeon, the PVL was said to have been decreased immensely, however the hemolysis is now greater... causing him to be much weaker and lethargic.

That is our experience.

Hello Andycap,

I'm sorry to hear your father had all these problems. If the hemolysis is severe after the percutaneous transcatheter obliteration and he is more symptomatic he would be better off with an early reoperation to eliminate the PVL once for all. He is still young and should be considered for a definitive repair. Were you told he also needs an ascending aortic aneurysm repair and a mitral valve operation? In that case, the indication for a reintervention is even stronger

Heartdoc,
www.bigappleheartsurgery.com

 

[nate_c]

I was given the option of a mini-thoracotomy, though I eventually went with a standard sternotomy. I spoke to three PAs at my surgeon's office (a large practice with many doctors) about the two options. I figured that since the PAs were the first-responders to patient calls after surgeries, they'd have a good, ground-level sense of how patients do after both procedures. They all said basically the same thing: they see more patients struggling with pain control from the MT than the sternotomy. They also noted that recovery was slightly faster with MT for most people, but not by too much. All three said they would likely go with a sternotomy if they faced a valve replacement. This may, of course, just be a regional bias.

For his part, my surgeon had no strong preference, other than to note that he gets better visualization through a sternotomy and the MT often takes longer. He also claimed that a lot of people originally thought that the MT would become the standard procedure for most valve replacements, but it obviously hasn't turned out that way. Interestingly, I met a cardiac rehab employee during recovery who had both procedures done (two different valves, about 1 year apart), and he personally preferred the sternotomy, noting that he had lingering nerve damage/pain from the MT. It sounds like many others have had great success with MT. Don't mean to be down on that procedure. Just thought I'd share my experience.

 

[Hank]

HeartDoc,

Thanks for all of your great advice here. Your experiences are definitely valuable to those with questions here.

 

[Sandi C]

I had minimal invasive surgery for bicuspid AVR. Small incision above right breast. Slowly decreasing in size. No pain and no pain killers. Tenderness in nipple and had to sleep somewhat upright for a week at home. Driving at 3 weeks and now I can work out for an hour or so. My blessing came from Dr. Lamelas at Mt. Sinai hospital, Miami.

 

[hensylee]

nice to see you again. We don't often have a real heart dr to talk with in VR so this is a very good thread - so informative. Look at the response from members in such a short time. Thank you so very much for your participation. Blessins...........

 

[heartdoc]

I was given the option of a mini-thoracotomy, though I eventually went with a standard sternotomy. I spoke to three PAs at my surgeon's office (a large practice with many doctors) about the two options. I figured that since the PAs were the first-responders to patient calls after surgeries, they'd have a good, ground-level sense of how patients do after both procedures. They all said basically the same thing: they see more patients struggling with pain control from the MT than the sternotomy. They also noted that recovery was slightly faster with MT for most people, but not by too much. All three said they would likely go with a sternotomy if they faced a valve replacement. This may, of course, just be a regional bias.

For his part, my surgeon had no strong preference, other than to note that he gets better visualization through a sternotomy and the MT often takes longer. He also claimed that a lot of people originally thought that the MT would become the standard procedure for most valve replacements, but it obviously hasn't turned out that way. Interestingly, I met a cardiac rehab employee during recovery who had both procedures done (two different valves, about 1 year apart), and he personally preferred the sternotomy, noting that he had lingering nerve damage/pain from the MT. It sounds like many others have had great success with MT. Don't mean to be down on that procedure. Just thought I'd share my experience.

I agree with you on the fact that you might have dealt with a regional bias. Only expert minimally invasive heart surgeons with extensive experience in both sternotomies and minithoracotomies can really make a fair comparison between the different surgical approaches. In expert hands that have made MT surgery their standard procedure, over 90% of isolated or double valve operations, ASD repairs, Atrial myxoma excisions are performed with minimally invasive techniques. There are a lot of excellent cardiac surgeons out there that do an outstanding job with standard sternotomy surgery. Most of them did not have the time, willingness or opportunity to become proficient in thminimally invasive techniques. You can't build a solid experience and evolve towards MT surgery based on occasional patients' requests. The best results and early postop recovery are achieved in centers that offer a MT approach to most of their patients. Suffice it to say that MT's routinely performed by an expert minimally invasive surgeon have a faster recovery and unquestionably less pain and discomfort than a sternotomy. Thank you so much for sharing your experience.

Best Wishes,

Heartdoc
www.bigappleheartsurgery.com

 

[heartdoc]

HeartDoc,

Thanks for all of your great advice here. Your experiences are definitely valuable to those with questions here.

Thank you Hank,

I am glad to be part of this community.

Best,

HeartDoc
www.bigappleheartsurgery.com

 

[ShezaGirlie]

Welcome Sandi...!!

Welcome Sandi...!!

I had minimal invasive surgery for bicuspid AVR. Small incision above right breast. Slowly decreasing in size. No pain and no pain killers. Tenderness in nipple and had to sleep somewhat upright for a week at home. Driving at 3 weeks and now I can work out for an hour or so. My blessing came from Dr. Lamelas at Mt. Sinai hospital, Miami.

Hi there Sandi ~ just wanted to pop in here and welcome you. Hope you hang around and share your personal experience with anyone interested in a minimal invasive surgery for themselves.

PS....love those Miami beaches and art deco hotels..:thumbup:

 

[ShezaGirlie]

Thank you Hank,

I am glad to be part of this community.

Best,

HeartDoc
www.bigappleheartsurgery.com

And a big Texas welcome to you HeartDoc..!!

 

[ALCapshaw2]

Interesting information comparing the various entry procedures.

Questions for Heartdoc -

We have several members who have had considerable Radiation Damage to their hearts.
Have you performed AVR and/or MVR on patients with Radiation Damage?
(mostly from Hodgkins treatments but some for other chest issues)

If so, were these first time surgeries or had they undergone multiple surgeries?

What method would you recommend for repeat surgeries to radiation damaged patients who had prior sternotomies?

 

[heartdoc]

Radiation damage to the heart

Radiation damage to the heart

Hi Al,

Yes, I have seen a number of patients with radiation damage to their hearts. The vast majority had a history of mediastinal Hodgkins treated with high dose radiotherapy. The radiotherapy chest field affects more often the aorta, the aortic valve and the proximal portion of the coronary arteries because they are more anterior than the mitral valve. These patients are often younger than the typical aortic valve stenosis patient and they might have had already stents put in their blocked coronary arteries. In a redo situation, you have to make an assessment of how viable and well vascularized the sternum is before you make a decision on the surgical approach (redo sternotomy vs. thoracotomy). Most surgeons will need to know:
1) If the radiation therapy was applied before or after the first OHS
2) If one or both mammary arteries were used in the first operation
3) A CAT scan of the chest to assess the anatomy and the scar tissue around the heart
4) The type of surgery required
5) Whether or not the patient is a suitable surgical candidate

Heartdoc

 

[Lynlw]

Hi Al,

Yes, I have seen a number of patients with radiation damage to their hearts. The vast majority had a history of mediastinal Hodgkins treated with high dose radiotherapy. The radiotherapy chest field affects more often the aorta, the aortic valve and the proximal portion of the coronary arteries because they are more anterior than the mitral valve. These patients are often younger than the typical aortic valve stenosis patient and they might have had already stents put in their blocked coronary arteries. In a redo situation, you have to make an assessment of how viable and well vascularized the sternum is before you make a decision on the surgical approach (redo sternotomy vs. thoracotomy). Most surgeons will need to know:
1) If the radiation therapy was applied before or after the first OHS
2) If one or both mammary arteries were used in the first operation
3) A CAT scan of the chest to assess the anatomy and the scar tissue around the heart
4) The type of surgery required
5) Whether or not the patient is a suitable surgical candidate

Heartdoc

Thanks, it is so nice to have you here to pick your brain. Can you explain a little what you mean by "how viable and well vascularized the sternum is" and how do you determine that?

 

[Kathy McCain]

Heart Doc,

I had a mini AVR surgery. It is my understanding this is not the same thing as minimally invasive surgery? I did have blood transfusion for the surgery, and again for my pericardial window that was done appox 1 wk after the AVR.