Mitral valve repair ---->OHS vs Davinci

[chai]

who has had either of these done and were they successful. Or, did you end up needing a re-op.

 

[Adrienne]

MV repair - 2005

MV repair - 2005

I had a very complicated mitral valve repair in October 2005. Because of endocarditis, the annulus of the valve was heavily calcified as well as a part of one of the leaflets. Two chordae were ruptured. The because of the partially calcified leaflet, the surgeon could not do the normal type of repair which involves cutting out a part of the leaflet and sewing the two ends together. Instead, he pulled down the leaflet with Gore-Tex neo-chordae, he put a ring around the annulus, he patched up a cleft in the posterior leaflet, and in addition he patched up a patent foramen ovale (like an atrial septal defect except that there is still a membrane separating the two chambers).

O.K., I will admit that I don't know if I will some day need another surgery since these last two years my echo has shown moderate leakage (it used to be mild which didn't worry me). However, remember that my repair was much more complicated than most because of the calcification. The important thing is to find a surgeon who has done a lot of MV repairs and has a good reputation.

 

[debster913]

MV repair- 2006

MV repair- 2006

Hi, there--

I did not have OHS nor DaVinci. My mitral repair was minimally invasive (incision directly under the right breast.) I had surgery nearly 5 years ago and my valve has been "beautiful" (my cardio's term) ever since. The likelihood of needing a re-op at this point is very small. I can expect to live to a ripe old age with this repair, barring any complications.

Are you in need of valve surgery soon? If so, have you discussed with your cardio/surgeon your options? Either way, heart surgery is still major surgery whether it's OHS or otherwise.

Best,
Debi

 

[Michelle D]

I went to the cleveland clinic because first of all they were the only ones who would agree to repair my valve and they had a high chance of being able to do it robotically. Unfortunately when the got me in the operating room my artery in my groin was too small for whatever they needed to put in there for the robotic repair so I had OHS. I didn't have prolapse, they still don't know what cause my severe leak but they fixed it and Dr. Gillinov assured me that it was highly unlikely that I'd ever need a redo. It would have been nice to have a robotic repair but my sternum is healed up just fine and at this point 6 months later it wouldn't have made a difference which route they would have taken. So even though I was sore for a couple weeks longer it really wasn't that bad to where I was disappointed, I was just happy to have it fixed and to be alive. If at all possible you can go to the Cleveland clinic I highly recommend it. Not just for the surgeons but the nurses as well. Now when I go to my local hospitals I feel like I'm in a 3rd world country compared to the Cleveland clinic. It was very clean, the nurses were very knowledgable and friendly and if you press your buzzer there was no wait, they were there. I told my husband even for minor surgeries if it is an inpatient procedure I'm flying up to Cleveland.

 

[normofthenorth]

I had a repair done to my MV during conventional OHS to repair my BAV. My repair was a circumferential Dacron ring called the "Simplici-T". Another Tirone David invention, maybe used more often at TGH than y'r average hospital, partly because it's Tirone David's "home". My MV was doing the regurg thing in response to years of back-wash abuse from my BAV. Around 6 months pre-op, my surgeon thought they'd just leave it and it would recover (like the enlarged and thickened LV that many of us BAV-ers get), but by the time they got close to it -- and by the time I stopped abusing it -- they decided to do the "Simplici-T" ring. I might never have even known, except (a) they told me and (b) it means I've got to be on ACT for 3 months. I haven't discussed durability with anybody.

 

[ejc61]

Chai, I see you are in Atlanta. I was 47. I had a basic MV tear. I was asympthomatic with no other issues. Clear arteries and all. I had sever regurg (4+). Initially, I was going to go mini-thoracotomy (right ribs) but then opted for robotic since the surgeon practice had surgeons proficient in both. OHS never came up as an option. That was 1 1/2 years ago. Today, the regurg is down to mild (1+). I may need a reop. Either technique would have been good with me. They will check you out to see what you are a candidate for. I WOULD seek out a hospital and surgeon that is proficient in minimally invasive. I truly believe that doctors and hospitals will try to sway you into a technique like OHS just because they are not as "expert" on other techniques. Feel free to PM.

 

[cp172]

Hi Chai,

I had mvr by robot in 2007. In my case I had a chordea tearing apart. So far I have had no problems.

 

[johnp]

I am new here. I will post a little background when I get a minute.

I had a MV repair done Dec 27 at the Mayo Clinic in MN. I had a long talk with the cardiologists, the EP, and the surgeon before making a decision.

I opted for the Robot Assisted MV (da Vinci) repair since all Drs felt I was a good candidate for this procedure and the statistics on success for minimally invasive vs open heart were about the same. I am 48 and very active - heavily involved in running and triathlons etc. The one area where there was a slight difference was in an additional procedure that I opted for - a modified Maze. Due to my severe MV regurg, I had an enlarged atrium and the EP felt I might have problems with Afib later in life. He suggested a Maze, and mentioned that a regular Maze appeared to have a slightly higher success rate that a modfied maze (which is basically a cryo ablation type of approach).

I still opted for the modified Maze.

Overall, the biggest difference (from a patient perspective) is the recovery. The Doctors told me my immediate recovery time was exceptional. Perhaps, but I seriously doubt I would have been able to bounce back a quickly if I had regular surgery. In my case, both leaflets had to be repaired. Here is a time line

Surgery Dec 27. I woke up that afternoon and had a hard time believing I had heart surgery. I felt pretty good in ICU and then in the step down.
Up and walking Dec 28
Discharged from the Hosp Dec 30
Went out for a light Dinner NY Eve
Back to work Jan 6

So far the follow-up echoes indicate a very good seal, but it will take months or even years to see how it holds up.

Happy to answer any other questions.

 

[Nupur]

OHS -> sternotomy?

OHS -> sternotomy?

Confused about terminology, when you all say OHS you mean cutting the sternum, right? I thought OHS means cutting the heart, which is needed anyway..whether by opening the sternum or by robotic arms. just wanted to clarify.

 

[Adrienne]

Confused about terminology, when you all say OHS you mean cutting the sternum, right? I thought OHS means cutting the heart, which is needed anyway..whether by opening the sternum or by robotic arms. just wanted to clarify.

I have seen both definitions used. It's true that it is very confusing.

 

[ejc61]

Confused about terminology, when you all say OHS you mean cutting the sternum, right? I thought OHS means cutting the heart, which is needed anyway..whether by opening the sternum or by robotic arms. just wanted to clarify.

I consider OHS as cutting the sternum. I'm told that the techinique whether robotic, mini-thoracotomy, or OHS is the same. I'm not a doctor though but I stand by this.

 

[catwoman]

My husband had MV repair in May 2007 due to a ruptured chordae caused by a car accident (December 2005). His sternum was fractured when the airbag deployed during the accident, and it was quite painful. Thus, I wanted to spare him the discomfort and pain I had with my sternotomy.

Dr. William Ryan in Dallas was able to repair the chordae with a thoracotomy incision under the right breast. Other than an arrthythmia that required warfarin for 7 months (no big deal, since I'm on it), John's recovery was amazing, compared to mine. We traveled out of town 2 weeks later for the weekend; I would not have been able to do that. His scar is almost invisible today.
Dr. Ryan had said that if the valve was not repairable, he could do a replacement via the same incision.

One note: John did have an incision in the groin in conjunction with the thoracotomy. It caused lymphedema in that leg and took about 3 months to resolve. No treatment was needed, other than elevating his leg when he could. In his case, the lymphedema was caused by injury to a lymph node from the catheterization.

 

[normofthenorth]

I think "OHS" is a smidge of a misnomer, the way we typically use it. Maybe we should all switch to "OCS" = Open Chest Surgery, which is what I think we mean most of the time. Any time a chest is cracked open and the heart is exposed to air and bright lights is "OHS" in my books. The minimally invasive and robotic options are still variations on OHS in my mind, even though they are relatively common in some centers.

The competition/choice between the various general options, and the regional (and chronological) variations in their use, is a fascinating topic for us, and maybe for some other students of medicine and history. Of course, the choices change depending on exactly what has to be done to the heart, but speaking generally:

When minimally invasive heart surgery was first developed, I think it looked like the obvious way of the future. It increased fairly fast from zero, but I think its progress has been very slow or "sideways" or possibly even "backwards" in recent years. I see it partly as a conflict between the convenience of the patient (smaller scars are always better, and a cracked sternum is a negative, so avoiding it is a Good Thing) versus the convenience of the surgeon (getting better access to your "workplace" is a Good Thing, and learning new and tricky techniques is mostly a negative, as are having occasionally to switch approaches mid-surgery, or God Forbid losing a patient or compromising a patient's clinical outcome).

I think it's also partly a conflict between "the best" and "what works well", or "the good enough" -- and between the novel and the tried and true. There are SO MANY things that have to go right for a heart-valve op to be a complete success (and so many possible "bumps" on the recovery road), that even many World-Class surgeons don't consider it worthwhile to risk their great track record (and the benefits it gives their patients) by "changing their game", in return for benefits that are mostly either cosmetic or "convenience" (like being able to lift 30-pound objects a month sooner post-op. That group of World-Class surgeons includes mine and his colleagues -- surgeons who invented and pioneered many important and revolutionary surgical breakthroughs, including "The David Procedure" and the "Simplici-T" ring for MV repairs, etc. These people aren't shy about trying new things that are necessary to save a life, or to restore good quality of life, or to maximize the odds that a patient will be healthy and fit. But my guy was very clear about how uncomfortable he is whenever he performs minimally-invasive heart surgery -- uncomfortable mostly because he's unusually nervous that the surgery won't go well. Maybe that discomfort is mostly because they only DO minimally-invasive heart surgery rarely and under duress, like for young "babes" who REALLY don't want a sternotomy scar added to their décolletage. I.e., maybe they'd become comfortable if they just DID the M-I approach more, maybe first "interning" in a place where they are the standard approach. But what they're doing NOW is working so well, they get to use phrases like "Gold Standard" in the titles of their peer-reviewed articles, so should they really be downplaying the surgical approach that works that well, in favor of one that MAY (or may not) ever be quite that successful? There are some good reasons and some less-good reasons not to change.

I don't have the answer, partly because I don't know whether the results will ever be as good as Dr. David's and Dr. Feindel's in terms of cardiac outcomes. I've also found my sternotomy to be a relatively short-lived and painless nuisance, and my scar isn't going to change my life, either. (I'm planning to spend next week skiing downhill at Whistler, 8-9 weeks post-OHS, and my still-healing sternum is probably THIRD on my list of new post-OHS worries, AFTER my still-weird heart function, my ACT/Warfarin/Coumadin [My cardiologist thinks that NOBODY who's on ACT should EVER ski downhill!], and only THEN my sternum. I'm adding a heart-rate monitor AND a helmet AND some chest padding to my ski gear, to try to minimize those worries.)

So I wasn't crushed when I found out that Dr. Feindel really did NOT want to do my surgery minimally-invasively, and I stuck with him and his team, and I still don't regret that choice. Somewhere there's a parallel universe, where I went to Ottawa or Manhattan to get the job done through a much smaller opening, or two or three -- but not in this universe, and that's OK with me. Interesting issue, though.

 

[johnp]

I think animportant questions to ask is:

"What is the history and volume of procedures for a given hospital and surgeon offering the Da Vinci / Robotics?"

 

[ejc61]

I find it interesting that on a board that does a great service that there seems to be some anomosity between the open sternotomy and the minimally invasive. Not everyone is a candidate for each procedure. Not everyone's condition is the same. My problem was mitral valve prolapse. I never had sympthoms. I still don't have sympthoms. Twenty years ago, they told me that they would not have done a sternotomy in my condition. They would probably treat it with drugs until my heart was ready to explode and then do the sternotomy because the sternotomy was a major surgery. By that time, I'd probably have other **** to be fixed. Now they are able to attempt to fix the problem the same way except less invasively. Also, they can repair it or replace it if necessary while I'm still young, 47, instead of waiting until I'm 60 or so. Willl the repair last? I don't know. The longer the better. Would the repair been better with open sternotomy. No one can prove that. The procedure is the same. Does the surgeon have a better view through the chest? The two surgeons I consulted with didn't think that is always the case. One did robotics, one did mini thoracotomy. They were both in different hospitals btw. It depends what needs to be done. Why is minimally invasive such a bad thing? I'm not going to call anyone out, but I sense some kind of jealousy. We are supposed to be on the same side of the mountain people.

 

[johnp]

Thats an interesting point. I guess robotics Da Vinci is considered the next wave in terms of surgery and we would all want to be associated with or treated with what is perceived to be the newest and the best.

My surgeon gave me a little color on this. He felt that it was natural for a hospital or practice to want to announce that they offer certain types of leading edge procedures.

Generally speakling, the trouble is that not everyone has the background, sees the volume of patients etc. to really make the most of certain medical procedures.

One of my cardiologists (from a very well respected hospital) gave me a little background on why his hospital was not offering a certain procedure that we agreed was something I probably could benefit from. He told me nearly all of his patients are controlled by medication and I am one of the rare cases. He told me he honestly didn't have the critical mass of patients for his hospital to develop the necessary excellence in those techniques. And he was more than happy to refer me someone he knew at another hosiptal that did see more high risk cases like mine.

The other thing about Robotics is that your anatomy must be suited for the heart-lung machine etc. Before we agreed to move forward, I had to have tests and a CT scan of my entire upper body. They had to feel confortable I had good passage ways. Luckily I did.

But my surgeon made it very clear that even though this was planned as a Robotics/minimally invasive, there was always that chance they might have to convert to an OHS, and that he was going to have certain people on standby and ready go if that were the case. It was simialr with the repair vs replace decision. I think I had to sign some type of consent form on my artificial valve preferences in case they could not do the repair. Sure, I wanted them to do a repair, but I was assured that they would not do a repair if they did not think it was going to work.

 

[ejc61]

Hello johnp. You are absolutely correct and couldn't have worded better myself. My testing and discussions with cardios and surgeons were exactly like yours. Certainly, I wouldn't go through a technique without a surgeon being proficient and me being qualified. I was going with an mechanical valve if the repair wasn't possible as plan b. I wish there were more level headed articulate comments made. Thanks. I may stay.

 

[Marcia58]

I had mitral valve repair almost 2 years ago, via mini-thoracotomy incision. My surgeon also placed an annuloplasty band, as well as discovering/repairing ruptured chordae and an ASV while he was there.

At my 6-week post-op visit, he said that my valve should never need any more surgery.

At my annual echo last month, my cardio said the valve looks "perfect".

 

[Johnz]

I had a successful MV repair using the da Vinci robot at the Cleveland Clinic last July. I had severe regurgitation for many years, though no enlargement. The prolapse was classic "Barlow's syndrome." I'm 44 and not terribly concerned about the scar, though recovery time was an issue for me as I'm self-employed. Like all of us, the first concern is a successful repair, and cosmetics are not really important. The surgery became necessary after a nasty bout of endocarditis earlier in the year caused further degeneration. I consulted first with a very well-respected Manhattan expert (to whom all my NJ cardios referred me) who explained that it was a difficult surgery but he was completely confident he could repair it. Although he bragged he could do a minimally invasive repair better than many surgeons could do a full open chest, he still felt strongly that the open chest approach was best. I didn't doubt him. However, I had been intrigued by the da Vinci and researched the hospitals that had done the most work with the machine. Cleveland has an outstanding track record in pioneering the use of the da Vinci for MVR and my surgeon had recently presented a paper on the results being virtually identical to traditional repair approaches. I know that papers and statistics are often skewed to show what the presenter wants, but Cleveland's reputation canceled out that concern for me. The problem was I had no objective doctor to help me decide. Those in NJ and those who are not really familiar with the (admittedly short - barely 5 years with MVR) history of the da Vinci naturally come out a bit conservative in favor of the traditional approach. What sold it for me was the surgeon - he explained to me that he was so comfortable on the equipment that he would perform all of his surgeries using it, no matter the difficulty. The limitation is often from the patient, whose arteries might not be large enough to accomodate the bypass catheter. So I went to Cleveland hoping for the da Vinci but knowing that if they measured my arteries before surgery and they weren't wide enough, I would settle for the traditional surgery. Either way, I was at the #1 heart surgery hospital in the country and could reasonably expect a good result. My result was fantastic and my recovery amazingly fast. I was in the OR on Wed morning and discharged Saturday morning. My post-op echo detected no murmur whatsoever. That Saturday I toured the Cleveland Art Museum for 2 hours on my own steam. Took a nap and then went to a bar-b-que party. I was out of the hosptial and away from the various infections that threaten recovering patients. I had little or no pain with no need for the narcotic painkillers I expected to be on. I could have gone to work in a few days but took the week off because everyone expected it. No post op depression. No physical limitations to speak of. All those things contribute to a successful recovery and they matter. I know there are others who did not have as easy a time after the da Vinci, however, from what i've seen, their problems are typical of the risks with any heart surgery (a-fib, etc) and not specific to the robot. I gotta say, if the actual surgery is performed the exact same way on the valve, despite the different entry, and by an experienced surgeon and is going to produce the same result, then the robotic approach is the wave of the future. The future will show whether or not this optimism is warranted, but it doesn't seem to me that there is any logical reason to expect different results. Let's be clear, my surgeon had done hundreds of traditional repairs before moving to da Vinci and he's really comfortable with it. I don't know if I would have trusted anyone else. My six month check up was perfect and I go forward with faith, hope and confidence that I won't need more surgery.

 

[Bear72]

I have to agree with many of the points made here and disagree with a few others. The DaVinci approach is much more easier to recover from vs a traditional sternotomy. You are usually out of the hospital a little sooner and able to resume normal activity earlier as well. However, it's not the wave of the future with isolated mitral repairs/replacements. Every surgeon that I've spoke to in both Cleveland, Philadelphia and NY agree it will all be intracatheter down the road.

In terms of quality repair, even though I had DaVinci, I sincerely believe that a sternotomy, mini-sternotomy or thoracotomy is superior to the robotic approach. My surgeon is well versed in robotics and known for isolated mitral repairs, but I think the old fashioned way is a little better.
That's just my opinion, not fact.