I'm not who you asked, but There are a couple kinds of minimally invasive surgeries and incisions. CCF has some good info with little diagrams if that helps http://my.clevelandclinic.org/heart/disorders/mini_invasivehs.aspx
minimally invasive heart surgery with no bone cutting
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I'm not who you asked, but There are a couple kinds of minimally invasive surgeries and incisions. CCF has some good info with little diagrams if that helps http://my.clevelandclinic.org/heart/disorders/mini_invasivehs.aspx
Hi,
Ascending aortic surgery can be performed through an upper ministernotomy. If the surgery also has to address the entire aortic arch, a full sternotomy will be necessary to have proper exposure and perform a complete arch repair
Heartdoc
www.bigappleheartsurgery.com
Hi Kathy,
A ministernotomy approach can also be described as minimally invasive heart surgery
In cardiac surgery there is a broad definition of what we mean by "minimally invasive". There are basically two types of "invasions":
1) Surgical incision: if they are smaller than a full sternotomy (i.e. minithoracotomy, upper ministernotomy, lower ministernotomy, parasternal incision, robotic port incisions) they are all called minimally invasive. A distinction has to be made, though. A mini thoracotomy is more gentle on the patient and truly less invasive and less prone to bleeding because no bone cutting is involved.
2) The use of the heart lung machine "invades" our natural blood circulation but it is necessary for valve surgery that by definition requires work inside the heart. If a patient instead requires only coronary bypass grafting, it is possible to do the grafting on the beating heart without using the heart lung machine because the coronary arteries are on the surface of the heart. See www.bigappleheartsurgery.com/page9.php about "beating heart" or "off pump" surgery
HeartDoc
www.bigappleheartsurgery.com
deogloria11
Member
Man, I wish I could have had that surgery instead of ending up with the big, long, ugly scar I have now! ("Four inches", yeah right.) But I had to have an aneurysm repair, so not an option. However, I'm hoping that when my bovine valve gives out (hopefully many, many years in the future) and I have to get an artificial valve, that it will be a minimally invasive procedure. I'm STILL waiting for this stupid scar to fade. It's healing from the center outward, with the top part being the most red and puffy still. (Of course, the most noticeable place. No v-necks for me, unless I want people to stare...and not at the cleavage! A little scar underneath the breast sounds so much better!
Hopefully when you need your bovine valve replaced, they will be able to replace it in the cath lab.
Thanks, it is so nice to have you here to pick your brain.
Radiation therapy can compromise the quality of blood supply to the sternum by literally "burning" small and medium sized arteries that normally feed the bone. The mammary arteries are often used for coronary artery bypass grafting and once they are harvested they no longer contribute to the blood supply to the breast bone. That's why it is important to know about them and about the timing of the radiation therapy. CAT scans can also give you information about the quality and density of the bone.
HeartDoc
www.bigappleheartsurgery.com
so obviously there could be benefits to not cutting the sternum that doesn't have a good blood supply, but if you HAVE to would a muscle flap help the healing, since If I'm remembering right, part of the reason they used a muscle flap after they cut away alot of Justin's sternal tissue was because muscles beside holding it together instead of wires, also were a good source of blood and oxygen?
Just wanted to add, I'm not thinking about just sternums damaged from Radiation, but any sternum that might not be the best as far as sternums go.
ok totally different question. Do you know of a link to "normals" of Heart MRIs? that have the valves for EDV Indexed EDV SV ect in mls? I know the right side pretty well, but having trouble finding the left side "normals"
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Hi Lyn,
That is correct. Muscle tissue has an excellent blood supply that can deliver more oxygen and help in healing and clearing infections from a debrided sternum.
I'll search my files and see if I can find a copy of a normal MRI. I'll keep you posted.
Best,
Heartdoc
www.bigappleheartsurgery.com
Thank you so much for looking. and I'm glad to know I rememberred that correctly..Some times you can almost get information overload, when alot is going on and it can be alittle hard to keep everything straight.
BTW since you are a Heart Surgeon, I don't know if you already recommend something like this to your patients, but I've found it really helps to have an online site like www.caringbridge.org or carepages.com set up for surgery/hospital stays, it is a much easier way to update everyone, (instead of a million phone calls) AND since alot of things DO become a big blur, especially if you have a few surgeries, its also a good way to keep track of what happened when so you have your own recrd to go back and reread. Justin's 1st few surgeries we didn't even have cell phones yet, so computers made a big difference
Jkm7
Well-known member
Welcome to the VR.org community, Heartdoc.
It's wonderful for you to join us. This community has helped educate many of us regarding our various surgeries and conditions and provided much support during those anxious days awaiting our surgeries and helping us through recovery and getting back to our normal routines.
My Mass General surgeon offered me mini my second surgery but I chose sternum cut and have not been sorry. I've been fortunate to heal well and easily. Perish the thought I need a third surgery, but if so, if percutaneous valve placement isn't an option, I would request mini the next time around.
It's wonderful for you to join us. This community has helped educate many of us regarding our various surgeries and conditions and provided much support during those anxious days awaiting our surgeries and helping us through recovery and getting back to our normal routines.
My Mass General surgeon offered me mini my second surgery but I chose sternum cut and have not been sorry. I've been fortunate to heal well and easily. Perish the thought I need a third surgery, but if so, if percutaneous valve placement isn't an option, I would request mini the next time around.
Is the "go time" for surgery on an ascending aortic aneurysm in an asymptomatic and not so complicated bicuspid patient still 5.0 or 5.5 cm for most or all surgeons? I have a pretty good understanding of the reasoning behind the wait, but I was hoping you could tell us why we should wait from your point of view.
Duff Man,
The timing of surgery has to do with both the size of the aneurysm and the degree of malfunction of the BAV. Patients with BAV are more at risk for aneurysm complications than patients with normal aortic valves and that's why the size threshold for intervention is in the range you described. A size of 5.0 to 5.5 cm in a BAV patient would be considered an indication for surgery by most CT surgeons even if the valve is still functioning well. In that case some surgeons might consider a valve sparing operation. On the other end of the spectrum, if the valve has severe stenosis or insufficiency and the patient is symptomatic and/or the echo shows the heart is weaker and dilated most surgeons would recommend surgery regardless of the aneurysm size. If the valve has severe stenosis or insufficiency and the patient has relatively few symptoms, an aneurysm size 4.5 cm or higher would be a threshold indication to recommend taking care of both the valve and the aneurysm at that time. The reasoning behind the proper timing of surgery is always based on statistics and individual patient conditions. When the risk of surgery is less than the risk of leaving a heart condition untreated, it is time to recommend surgery. I hope this answers your question.
Best,
HeartDoc
www.bigappleheartsurgery.com
The timing of surgery has to do with both the size of the aneurysm and the degree of malfunction of the BAV. Patients with BAV are more at risk for aneurysm complications than patients with normal aortic valves and that's why the size threshold for intervention is in the range you described. A size of 5.0 to 5.5 cm in a BAV patient would be considered an indication for surgery by most CT surgeons even if the valve is still functioning well. In that case some surgeons might consider a valve sparing operation. On the other end of the spectrum, if the valve has severe stenosis or insufficiency and the patient is symptomatic and/or the echo shows the heart is weaker and dilated most surgeons would recommend surgery regardless of the aneurysm size. If the valve has severe stenosis or insufficiency and the patient has relatively few symptoms, an aneurysm size 4.5 cm or higher would be a threshold indication to recommend taking care of both the valve and the aneurysm at that time. The reasoning behind the proper timing of surgery is always based on statistics and individual patient conditions. When the risk of surgery is less than the risk of leaving a heart condition untreated, it is time to recommend surgery. I hope this answers your question.
Best,
HeartDoc
www.bigappleheartsurgery.com
This leads me to a related question: Why do most, if not all, surgeons / medical centers advocate the 5.0cm minimum for resection of an ascending aneurysm, yet some centers/surgeons definitely have better mortality rates than others?
Say for example I go to a local yocal surgeon in my town that's performed a total of 100 aneurysm repairs... he's not as good as the guy at Mayo Clinic and neither are the nurses and equipment, but their criteria for the size of the aneurysm for repair is the same. Should it not be lower for Mayo than it is for the local yocal? Is it just that no one's surpassed the risk-benefit ratio of 5cm or like 5% mortality for the surgery?
In other words, why isn't mayo at 4.x cm instead of 5.0? The medical community kind of quietly acknowledges the connective tissue / aorta problem of bicuspid valves, but we don't operate on them at 4.5cm like we do with marfans for a person without comorbidities... it seems like age should play a big factor, to me.
ALCapshaw2
Well-known member
Thank You for that insight.
The Radiation Damaged Heart Specialist at the Cleveland Clinic is Dr. Lytle.
He has reported that Valve Damage from Radiation typically shows up around 20 years After the Radiation Treatments.
This correlates well with what I have read from Radiation Survivors who come to these forums.
The threshold measurements for surgery on an ascending aortic aneurysm are generally applicable across the board (yes..including the "yocal local surgeon"). Most cardiac surgeons had excellent training and can carry out an ascending aortic aneurysm repair with good results and an overall risk that is lower than leaving the aneurysm alone. Do not be shy about discussing the surgeon's experience and results for specific operations. A cardiac surgeon might also consider a referral to a "superspecialist" in aneurysm surgery if he or she feels that a particular aneurysm is anatomically complex and requires special expertise beyond his own.
Heartdoc
www.bigappleheartsurgery.com
Welcome, Heartdoc!
I don't remember being offered mini for my AVR. I also don't recall if I asked about it. I was pretty familiar with what to expect during/after surgery because I lost my younger brother during his 4th OHS. I probably said something like "just crack me open and do what you have to do."
I would certainly like the option of the mini the next time around. Unfortunately, I know the homograft won't last forever; but, I'm hoping the surgeon will just be able to waive a magic wand over my chest
I don't remember being offered mini for my AVR. I also don't recall if I asked about it. I was pretty familiar with what to expect during/after surgery because I lost my younger brother during his 4th OHS. I probably said something like "just crack me open and do what you have to do."
I would certainly like the option of the mini the next time around. Unfortunately, I know the homograft won't last forever; but, I'm hoping the surgeon will just be able to waive a magic wand over my chest
My best wishes to you, Lisa. Who knows...maybe a magic wand will be available
Heartdoc
Heartdoc
normofthenorth
Well-known member
HeartDoc, it's great for many of us to have you here, including this pre-op BAV newbie. I've perused your web-site, and quizzed my surgeon about it. He's at Toronto General Hospital, in the department headed by the well-known Dr. Tyrone David. He said they do some minimally invasive surgeries, but only under pressure and then they usually feel stressed while doing it. You've mentioned the "practice" and "comfort" issues, and they're obviously important in any surgery, and especially so in major surgery like OHS.
Personally, I've spent the last 10-odd months thinking and blogging about an unrelated medical condition -- Achilles Tendon Ruptures! As "normofthenorth" at achillesblog.com , I worked hard (and with some success) to introduce fellow ATR patients to the recent studies that produced excellent results WITH or WITHOUT surgery, provided a modern (fast) rehab protocol was used. Many patients who read my stuff became "difficult" patients for Ortho Surgeons who were doing the same ol' same ol' ATR repair surgery on everybody -- and then often keeping them on crutches and immobilized much longer than the new evidence suggests works best! Some of my readers were quick enough to skip the surgery completely, while others got the op but speeded up their rehab protocols, and/or recovered in a boot instead of a cast, and otherwise improved their rehab while challenging their health professionals. (Thank Heavens, everybody who changed their treatment while thanking me for the advice has recovered very well! I'm not a Doctor, and my wife was afraid I was going to get sued if somebody turned out badly -- which is ALWAYS a risk!)
I didn't mind making all those doctors uncomfortable in the LEAST, in return for getting those patients onto a recovery path that had better odds AND was quicker and more convenient.
I haven't totally wrapped my head around the applicability of your M.I. surgeries to my specific situation -- facing an AVR, Aortic root replacement with Dacron, and maybe a MV repair or even replacement -- but I'm finding that my attitude has subtly changed with my migration from achillesblog.com to VR.org! My general choice of surgery now reminds me a lot of the choices I influenced at AB.com, but I'm now VERY concerned with keeping my surgeon and his team in their Comfort Zone!
I'm not the kind of person to just "go with the flow" or to place my fate in the hands of an Expert, or even God, without first checking out the details. But when facing the prospect of having somebody holding my heart in their hands (with a scalpel in their OTHER hand!), I find myself more tempted to go along with a local, well respected, highly practiced, "Good Enough" process that seems to produce low-risk quality repairs -- even if it means that I'll be worried about my sternum knitting back together for months instead of days or weeks, and vulnerable to injuries etc. for maybe longer than necessary.
I'm finding it very interesting to "get in touch with" my preferences on this decision. Of course, decisions about the type of surgery, and the kind of replacement valve, etc., ultimately HAVE to be made by the patient, via informed consent. Many people (and websites and books, etc.) can play the role of adviser to make that informed consent more informed -- and the medical team ultimately has to be willing to DO what the patient WANTS. But when it came to the decision to have ATR repair surgery or skip it -- after FOUR recent randomized trials, all since 2007 have pretty consistently shown identical results except for the surgical complications -- I would have pushed my friends and relatives pretty hard to get them to skip the surgery. "It's your decision, but so is jumping off a bridge" type thing. Some choices are smarter than others!
Your approach to minimally invasive heart surgery -- on your own website and here -- seems very familiar to me, because it reminds me of my approach to the choice of "op vs. non-op" for ATR treatment, and the choice of modern fast rehab protocols vs. old-fashioned slow protocols. So I consider you a "breath of fresh air" and a "kindred spirit" in your attitude, your preferences, and your willingness to speak frankly and bluntly in favor of the choices you see as best for the patient. Who knows, if I lived in NYC, I might even ask you to take on my surgery. (Or not! My hesitation is personally fascinating to me. Hope it's not boring to everybody else!)
Sorry to ramble on, but facing this surgery has made me think of things in ways I don't often do. If nothing else, the experience has made me more understanding of the people who read the Achilles evidence I presented on that other website, and STILL just went along with their Doc's surgical plans, or his old-fashioned slow rehab protocol -- or both!
Personally, I've spent the last 10-odd months thinking and blogging about an unrelated medical condition -- Achilles Tendon Ruptures! As "normofthenorth" at achillesblog.com , I worked hard (and with some success) to introduce fellow ATR patients to the recent studies that produced excellent results WITH or WITHOUT surgery, provided a modern (fast) rehab protocol was used. Many patients who read my stuff became "difficult" patients for Ortho Surgeons who were doing the same ol' same ol' ATR repair surgery on everybody -- and then often keeping them on crutches and immobilized much longer than the new evidence suggests works best! Some of my readers were quick enough to skip the surgery completely, while others got the op but speeded up their rehab protocols, and/or recovered in a boot instead of a cast, and otherwise improved their rehab while challenging their health professionals. (Thank Heavens, everybody who changed their treatment while thanking me for the advice has recovered very well! I'm not a Doctor, and my wife was afraid I was going to get sued if somebody turned out badly -- which is ALWAYS a risk!)
I didn't mind making all those doctors uncomfortable in the LEAST, in return for getting those patients onto a recovery path that had better odds AND was quicker and more convenient.
I haven't totally wrapped my head around the applicability of your M.I. surgeries to my specific situation -- facing an AVR, Aortic root replacement with Dacron, and maybe a MV repair or even replacement -- but I'm finding that my attitude has subtly changed with my migration from achillesblog.com to VR.org! My general choice of surgery now reminds me a lot of the choices I influenced at AB.com, but I'm now VERY concerned with keeping my surgeon and his team in their Comfort Zone!
I'm not the kind of person to just "go with the flow" or to place my fate in the hands of an Expert, or even God, without first checking out the details. But when facing the prospect of having somebody holding my heart in their hands (with a scalpel in their OTHER hand!), I find myself more tempted to go along with a local, well respected, highly practiced, "Good Enough" process that seems to produce low-risk quality repairs -- even if it means that I'll be worried about my sternum knitting back together for months instead of days or weeks, and vulnerable to injuries etc. for maybe longer than necessary.
I'm finding it very interesting to "get in touch with" my preferences on this decision. Of course, decisions about the type of surgery, and the kind of replacement valve, etc., ultimately HAVE to be made by the patient, via informed consent. Many people (and websites and books, etc.) can play the role of adviser to make that informed consent more informed -- and the medical team ultimately has to be willing to DO what the patient WANTS. But when it came to the decision to have ATR repair surgery or skip it -- after FOUR recent randomized trials, all since 2007 have pretty consistently shown identical results except for the surgical complications -- I would have pushed my friends and relatives pretty hard to get them to skip the surgery. "It's your decision, but so is jumping off a bridge" type thing. Some choices are smarter than others!
Your approach to minimally invasive heart surgery -- on your own website and here -- seems very familiar to me, because it reminds me of my approach to the choice of "op vs. non-op" for ATR treatment, and the choice of modern fast rehab protocols vs. old-fashioned slow protocols. So I consider you a "breath of fresh air" and a "kindred spirit" in your attitude, your preferences, and your willingness to speak frankly and bluntly in favor of the choices you see as best for the patient. Who knows, if I lived in NYC, I might even ask you to take on my surgery. (Or not! My hesitation is personally fascinating to me. Hope it's not boring to everybody else!)
Sorry to ramble on, but facing this surgery has made me think of things in ways I don't often do. If nothing else, the experience has made me more understanding of the people who read the Achilles evidence I presented on that other website, and STILL just went along with their Doc's surgical plans, or his old-fashioned slow rehab protocol -- or both!
I'm having AVR in January. I personally am hoping the On-X valve will fit me. Can you do minimally invasive AVR with a mechanical valve? What if the patient is somewhat overweight? At what point is that a factor?
My surgeon intends do a mini-sternotomy. I did discuss the between the ribs approach, and he said it is possible, but if he gets in there and finds another problem, he would end up doing the mini-sternotomy anyway.
My surgeon intends do a mini-sternotomy. I did discuss the between the ribs approach, and he said it is possible, but if he gets in there and finds another problem, he would end up doing the mini-sternotomy anyway.
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A miniAVR can be performed with either a mechanical or biological valve using identical techniques. A good percentage of AVR patients are somewhat overweight but that it is not an issue that affects their candidacy for a minimally invasive approach. They can almost always get a minithoracotomy approach. Actually, a minithoracotomy approach in an overweight patient might be a better choice because the wound would tend to heal faster and better than a sternotomy because there is no bone cutting and the wound healing would not be affected by the mechanical stress originated by excessive weight on the two sternal halves. Not many surgeons have minithoracotomy expertise. It sounds your doc would feel a lot more comfortable with a sternotomy.
Best Wishes,
Heartdoc
Best Wishes,
Heartdoc
