minimally invasive heart surgery with no bone cutting

[heartdoc]

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

 

[ottagal]

Welcome to VR.org Heartdoc,

I am female, live in Canada and undwent aortic valve replacement surgery last year. I personally was not offered minimally invasive heart surgery for severe aortic stenosis. When I asked about this option, my cardiologist discouraged me. I did receive a full sternotomy; however, the surgeon gave me a smaller incision (3.5 inches).

I do have a few questions/comments. One question I have is:
How long has minimally invasive surgery been around for AVR?
Are the post-op results (and long terms results) the same as those through regular sternotomy?
What about re-dos? What would be the reasons that one would not qualify for this type of surgery?
As I received a tissue valve, would minimally invasive surgery be an option for an AVR re-do?

With kind regards,

 

[watson524]

This is something I've been wondering. My mom's local cardio did mention that sometimes a mini thoracotomy (sp?) is possible for MV replacement. I've been reading about those along with mini sternotomy (sp?) where for the MV, apparently they can just do the bottom 3-4" of the sternum. My mom would love to get to CCF and find out that's an option especially if it gets her back to driving faster (she's always on the go and flipped when she heard about the no driving thing LOL!) but...

From what I've read from some folks, a mini thoracotomy can have more difficult/different recovery issues because of muscle/nerve damage that can happen but isn't necessarily an issue with a sternectomy. Anyone have any experience with that? Scarring isn't really a concern in my mother's case and heck, if you have the strength and midset to get through this type of event, I'd be showing my scar off proudly (but that's just me and getting a shot freaks me out!)

 

[hook]

I had minimally invasive surgery. I had no complications, and went home in four days; I think two or three days is far to aggresive. The pain was not that bad, I was off pain killers in a week. My only complaint is the right side of my chest is sore under the nipple.

 

[watson524]

Good to know, and your's was a replacement too so a similar situation. I can't even imagine having this kind of surgery, even with minimally invasive methods, and being sent home in 2 to 3 days. Wow! So I'm assuming your's was a mini thoracotomy vs the mini sternotomy? You still get all the other little openings for the tubes and stuff with that, right?

 

[daveguy14]

I believe aortic repair/replacement can be done through the minithoracotomy, but is usually accomplished either through a full sternotomy or mini sternotomy. The latter is known as hemisternotomy but uses a smaller incision. This is also considered minimally invasive, although it's different than the minithoracotomy. See here for a good explanation: http://www.cumc.columbia.edu/dept/cs/pat/mirobotic/procedures.html.

 

[Marcia58]

I had a mini-thor MV repair. The incision was about 4 inches long, between the 4th and 5th ribs, so most of it doesn't show, except for a little "tail" of it where the side of my breast meets my underarm. I had quite a bit of pain for the first 24-36 hours, but I'm assuming that was because I woke up just as they were transferring me from the gurney to the ICU bed. (Which several people told me they had never seen happen before!) I'm assuming that means that I may have been moved w/o benefit of anesthesia or pain meds, since staff didn't realize the anesthesia was wearing off! I also had a surgical fellow say that the mini-thor is more painful short-term, because they go through 3 layers of muscle, but it quickly improved and I was only Aleve w/i a couple days of being home. Six weeks post-op, I carried my 2yo granddaughter an half mile on my shoulders!

I had femoral and axillary incisions for the pump hookup, which both apparently resulted in a little nerve damage/numbness. That issue is still resolving. I had a central line, 2 chest tubes, an IV, a Foley, and the vent. I was off the vent in <4 hours. I went home 5 days post-op, but I also had other health issues that factored in.

With my cardio's blessing, I went looking for minimally invasive--actually for the DaVinci robot. Because of my other health issues, however, my surgeon thought the mini-thor was the better way to go. Through that opening, he repaired my MV, (including installing an annuloplasty band), installed some Gortex chordae, and closed an ASD that I didn't even know I had!

I definitely agree with Heartdoc...ASK about minimally invasive OHS!

 

[bdryer]

Do you know of any hospital in Canada that performs the minimally invasive Aortic valve replacement technique?

 

[Duff Man]

Can you do minimally invasive resection of the ascending aorta AND the arch?

 

[Greg a]

Do you know of any hospital in Canada that performs the minimally invasive Aortic valve replacement technique? My preference is Calgary Alberta. Yea we are the province with the oil sands. LOL!

there are plenty in Canada as in McLeans
Toronto heart surgeon Dr. Tirone David. From India, where David is teaching just now, he responded by email to questions I asked through his office. Here’s what he said:

“I don’t know the reasons Mr. Williams opted to have his operation in Florida. It is certainly not because minimally invasive mitral valve repair is not available in Canada. Canadian heart surgeons routinely do minimally invasive mitral valve repair including techniques involvng endoscopic and robotic approaches.

“There is absolutely no evidence that robotic mitral valve repair is superior to other minimally invasive approaches, such as a limited sternotomy or lateral thoracomy, with or without the aid of endoscopes. Moreover, when it comes to heart valve surgery, there are very few places in the world that can match the outomes we have provided at Toronto General Hospital.

 

[Greg a]

Do you know of any hospital in Canada that performs the minimally invasive Aortic valve replacement technique? My preference is Calgary Alberta. Yea we are the province with the oil sands. LOL!

there are plenty in Canada as in McLeans
Toronto heart surgeon Dr. Tirone David. From India, where David is teaching just now, he responded by email to questions I asked through his office. Here’s what he said:

“I don’t know the reasons Mr. Williams opted to have his operation in Florida. It is certainly not because minimally invasive mitral valve repair is not available in Canada. Canadian heart surgeons routinely do minimally invasive mitral valve repair including techniques involvng endoscopic and robotic approaches.

“There is absolutely no evidence that robotic mitral valve repair is superior to other minimally invasive approaches, such as a limited sternotomy or lateral thoracomy, with or without the aid of endoscopes. Moreover, when it comes to heart valve surgery, there are very few places in the world that can match the outomes we have provided at Toronto General Hospital.

 

[Ruth]

When I expressed concern over the cosmetic issue of a chest scar I was told by my cardiologist that a "between the ribs" option was available. My surgeon did a right thoracotomy (not mini, my scar is maybe 4 inches) and the cosmetic result is fantastic.

I had a fair amount of pain in my ribs, did not have a shorter hospital stay, had the usual tubes, etc. and was fortunate that the groin incision healed extremely fast with no scar at all. If I had it to do over again I would make the same choice.

I will advise the ladies that while the scar can be hidden right in the fold of the breast (as mine is) it has one tactical disadvantage that I didn't realize until later. It has been 3+ years since my surgery and I *still* cannot wear an underwire bra. Even regular bras irritate my scar even though it has healed up nicely and is almost invisible. Camisoles with a shelf bra are my best option. I wish the scar was just about 1 inch below the fold of the breast. Sure it would show in a bikini but it wouldn't show in regular clothes so I think that a lower incision point should be offered to ladies if possible, especially those who are ample so to speak.

 

[heartdoc]

Welcome to VR.org Heartdoc,

I am female, live in Canada and undwent aortic valve replacement surgery last year. I personally was not offered minimally invasive heart surgery for severe aortic stenosis. When I asked about this option, my cardiologist discouraged me. I did receive a full sternotomy; however, the surgeon gave me a smaller incision (3.5 inches).

I do have a few questions/comments. One question I have is:
How long has minimally invasive surgery been around for AVR?
Are the post-op results (and long terms results) the same as those through regular sternotomy?
What about re-dos? What would be the reasons that one would not qualify for this type of surgery?
As I received a tissue valve, would minimally invasive surgery be an option for an AVR re-do?

With kind regards,

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

 

[heartdoc]

This is something I've been wondering. My mom's local cardio did mention that sometimes a mini thoracotomy (sp?) is possible for MV replacement. I've been reading about those along with mini sternotomy (sp?) where for the MV, apparently they can just do the bottom 3-4" of the sternum. My mom would love to get to CCF and find out that's an option especially if it gets her back to driving faster (she's always on the go and flipped when she heard about the no driving thing LOL!) but...

From what I've read from some folks, a mini thoracotomy can have more difficult/different recovery issues because of muscle/nerve damage that can happen but isn't necessarily an issue with a sternectomy. Anyone have any experience with that? Scarring isn't really a concern in my mother's case and heck, if you have the strength and midset to get through this type of event, I'd be showing my scar off proudly (but that's just me and getting a shot freaks me out!)

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

 

[heartdoc]

I had minimally invasive surgery. I had no complications, and went home in four days; I think two or three days is far to aggresive. The pain was not that bad, I was off pain killers in a week. My only complaint is the right side of my chest is sore under the nipple.

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

 

[heartdoc]

Good to know, and your's was a replacement too so a similar situation. I can't even imagine having this kind of surgery, even with minimally invasive methods, and being sent home in 2 to 3 days. Wow! So I'm assuming your's was a mini thoracotomy vs the mini sternotomy? You still get all the other little openings for the tubes and stuff with that, right?

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

 

[heartdoc]

Do you know of any hospital in Canada that performs the minimally invasive Aortic valve replacement technique? My preference is Calgary Alberta. Yea we are the province with the oil sands. LOL!

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

 

[Lynlw]

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

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.

 

[ALCapshaw2]

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?

 

[heartdoc]

When I expressed concern over the cosmetic issue of a chest scar I was told by my cardiologist that a "between the ribs" option was available. My surgeon did a right thoracotomy (not mini, my scar is maybe 4 inches) and the cosmetic result is fantastic.

I had a fair amount of pain in my ribs, did not have a shorter hospital stay, had the usual tubes, etc. and was fortunate that the groin incision healed extremely fast with no scar at all. If I had it to do over again I would make the same choice.

I will advise the ladies that while the scar can be hidden right in the fold of the breast (as mine is) it has one tactical disadvantage that I didn't realize until later. It has been 3+ years since my surgery and I *still* cannot wear an underwire bra. Even regular bras irritate my scar even though it has healed up nicely and is almost invisible. Camisoles with a shelf bra are my best option. I wish the scar was just about 1 inch below the fold of the breast. Sure it would show in a bikini but it wouldn't show in regular clothes so I think that a lower incision point should be offered to ladies if possible, especially those who are ample so to speak.

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