台湾微创心脏手术现况及理念

陈劲辰亚东医院／台北慈济医院

台湾 新北市

Why MICS?

• Minimally Invasive Cardiac Surgery• Earlier surgery before worse• Low or high risk?• Equivalence to conventional open?

MICS in Taiwan

• Non-sternotomy• Videoscope or direct vision• Mini-thoracotomy• Partial upper sternotomy• Parasternotomy• Peripheral cannulation• Robotic, total or assisted• Endoscopic vein harvest

Taiwan

• Health Insurance• Cost control• Market size• New device unavailable

Pre-Op

• Endoscopic vein harvesting: Vein echo mapping

• EuroScore-II• Lung function: one -lung• Chest non-contrast CT: aorta, anatomy• Ankle-Brachial index: femoral artery• Carotid Doppler: stroke risk• Workup for medical condition

Valves

• Parasternal– Aortic valve

• Thoracotomy– Mitral valves– Others

• Heart echo: confirm, new lesion?

Schematic illustrations (1)

Schematic illustrations (2)

Less Invasive Mitral Valve Surgery

Pre-operative ImagePleural adhesion?

AP diameter Cardiac axis

Scope-Assisted MICS

Positioning

Vacuum-Assisted Venous Drainage

Figure 1

Figure 2

A B

C D

Figure 3

A B

C D

D

BA

C

Figure 4

da Vinci Robotic MVR

Delacroix-Chevalier Instruments

Emory, Dr. Puskas, 2010

Minimally Invasive Cardiac Surgery May Offer Better Survival and Safety Outcomes Than Full Sternotomy –

Materials and Methods

• Hospital-based cardiac surgery database• 01/2005 ~ 12/2012• Three approaches: N=821

– Full sternotomy (FST), N=177 (21.6%)– Mini-parasternotomy (MPS), N=283 (34.5%)– Mini-thoracotomy (MTC), N=361 (44.0%)

• Excluding high-risk outliers (non-elective, LVEF<30%, or EuroScore-II>10%), N=722 (87.9%)

Results

• Three approaches (MPS, MTC, FST) had heterogeneous preop baselines and cardiac pathology.

• MICS was preferred with lower EuroScore-II, non-MS MR, and absence of HOCM.

• Cardiac procedures were also heterogeneous among three approaches.

Preop Baselines Among Three Approaches of Low-Risk Cases (Elective, LVEF>=30%, and EuroScore-II<=10%)

　 MPS MTC FST p-valueN 261 324 137

Sex (Female) 59.8% 55.9% 44.5% 0.014 Age* 61 (22) 56 (18.5) 56 (23) <0.0001DM 10.8% 11.8% 18.4% 0.088 HTN 39.9% 44.4% 35.3% 0.199

Uremia 4.6% 2.8% 2.9% 0.493 EuroScore-II (%)* 1.8 (2.4) 1.4 (2.2) 3.7 (3.8) <0.0001

Non-MS MR 30.7% 70.4% 39.4% <0.001Non-MR MS 4.6% 14.5% 8.8% <0.001MS & MR 7.3% 9.0% 11.7% 0.333

Non-AR AS 19.5% 3.4% 12.4% <0.001Non-AS AR 53.6% 5.3% 24.8% <0.001AS & AR 18.0% 0.9% 14.6% <0.001

Non-AV MV 34.9% 93.2% 51.1% <0.001Non-MV AV 84.7% 9.0% 44.5% <0.001

AV & MV 35.6% 8.0% 27.7% <0.001TR 7.7% 19.8% 21.2% <0.001Af 14.9% 25.6% 19.0% 0.006 IE 4.6% 7.1% 18.3% <0.001

HOCM 1.9% 0.3% 5.1% 0.002

MPS: Mini-parasternotomyMTC: Mini-thoracotomyFST: Full sternotomyDenominator for all percentages: N of each approach* Median (IQR)

Preop Variables for Choosing MICS (MPS, MTC) in Low-Risk Cases (Elective, LVEF>=30%, and EuroScore-II<=10%)

N=722 OR OR 95% CI p-value

EuroScore-II0.77 (per

1%)0.69 ~ 0.85 <0.01

Non-MS MR 1.841.06 ~ 3.20 0.031

HOCM 0.080.02 ~ 0.30 <0.001

MPS: Mini-parasternotomyMTC: Mini-thoracotomy

MICS(minimally-invasive cardiac surgery): MPS or MTCInitial variable set: MR, MS, AS, AR, TR, Af, IE, HOCM; sex, age, DM, HTN, uremia, EuroScore-II,Multiple logistic regression with stepwise selection

Results

• MPS had more AV procedures;• MTC had more MV procedures;• FST had more complex procedures. • MICS (MPS or MTC) did not have longer

ischemia time or pump time.

Op Characteristics Among Three Approaches of Low-Risk Cases (Elective, LVEF>=30%, and EuroScore-II<=10%)

　 MPS MTC FST p-valueN 261 324 137

AV Involved 92.3% 4.0% 54.7% <0.001Combined 46.7% 40.4% 73.7% <0.001

MV Involved 44.8% 94.8% 72.3% <0.001MV repair 19.5% 54.6% 19.0% <0.001AV & MV 37.9% 1.5% 34.3% <0.001

TV 10.7% 20.4% 40.2% <0.001Maze 13.0% 25.0% 18.3% 0.001

Myxoma 0.4% 0.6% 1.5% 0.431 Ao/Root 2.30% 0.00% 5.10% <0.001

Redo 5.4% 12.7% 30.0% <0.001Pure Fresh AV 48.7% 1.5% 11.7% <0.001Pure Fresh MV 5.4% 67.3% 18.3% <0.001

Non-MV AV 52.9% 1.9% 17.5% <0.001Non-AV MV 6.1% 75.3% 20.4% <0.001

Septal myectomy 1.9% 0.3% 5.1% 0.002 Ischemia TIme

(min)*59 (32) 53 (29) 61 (39) 0.008

Pump Time (min)* 94 (46) 98 (47) 109 (52) 0.066

MPS: Mini-parasternotomyMTC: Mini-thoracotomyFST: Full sternotomyDenominator for all percentages: N of each approach* Median (IQR)

Results

• Non-AV MV and MV repair procedures preferred MICS.

• Combined, septal myectomy, TV, Ao/root, and redo procedures preferred FST.

• MICS had Kaplan-Meier survival benefits over FST.

Procedures That Affect the Choice of MICS

N=722 OR OR 95%CI p-valueNon-AV MV 1.81 1.03 ~ 3.18 0.039Combined 0.35 0.21 ~ 0.58 <0.001MV repair 2.24 1.34 ~ 3.76 0.002

Septal Myectomy 0.13 0.04 ~ 0.43 0.001TV 0.57 0.34 ~ 0.97 0.038

Ao/Root 0.27 0.08 ~ 0.90 0.034Redo 0.25 0.15 ~ 0.42 <0.001

MPS: Mini-parasternotomy

MTC: Mini-thoracotomy

MICS (minimally-invasive cardiac surgery): MPS or MTCMultiple logistic regression with stepwise selection

Survival Curves Zoomed to 1 Year

Results

• Compared with MICS (MPS and MTC), unadjusted for EuroScore-II or propensity score, FST had worse non-complication rate, non-complicated length of stay, non-complicated ventilator hour, 30-day mortality, pneumonia, sepsis, stroke, and prolonged ventilator over 48 hours; non-complicated ICU hours showed no significant difference.

Postop Outcomes Among Three Approaches of Low-Risk Cases (Elective, LVEF>=30%, and EuroScore-II<=10%)

　 MPS MTC FST p-value

N 261 324 137Non-complicated

(NCx)95.0% 90.4% 83.9% 0.001

NCx LOS# (Day)* 12 (6) (N=248) 12 (7) (N=293)16 (14)

(N=114)<0.000

1

NCx ICU Hour*49.5 (25.3) (N=248)

48.5 (25) (N=293)

61 (30.3) (N=114)

0.316

NCx Ventilator Hour*

12.6 (15) (N=243)

9.6 (15.3) (N=243)

19 (13.6) (N=114)

0.001

30-day Mortality 2.3% 4.0% 8.0% 0.031 Pneumonia 2.7% 4.0% 11.0% 0.002

Sepsis 2.3% 3.4% 11.0% 0.001 Stroke 0.4% 2.2% 2.9% 0.070

Ventilator Over 48 Hrs

7.7% 9.9% 21.2% <0.001

MPS: Mini-parasternotomyMTC: Mini-thoracotomyFST: Full sternotomyNon-complicated (NCx): survivors with ventilator use under one week or intensive care unit stay under two weeks

* Median (IQR)# LOS: Length of stay

Results

• Adjusted for EuroScore-II and propensity score, compared with FST, MICS had shorter non-complicated length of stay, lower 30-day mortality, and less pneumonia.

Effect of MICS Choice on Outcomes and Complications*Adjusted for EuroScore-II and Propensity Score

Endpoints MICS Effect Statistics 95% CI p-value

K-M Survival HR 0.40 0.16 ~ 1.01 0.053

NCx LOS (Day) Beta -4.66 -7.43 ~ -1.88 0.001

NCx ICU Hour Beta -3.23 -12.40 ~ 5.91 0.486

NCx Ventilator Hour Beta -0.65 -6.77 ~

5.47 0.835

30-day Mortality OR 0.36 0.14 ~ 0.96 0.041

Pneumonia OR 0.25 0.08 ~ 0.72 0.010

Sepsis OR 0.36 0.13 ~ 1.01 0.053

Stroke OR 0.40 0.09 ~ 1.85 0.241

Ventilator Over 48 Hrs OR 0.62 0.28 ~

1.35 0.229

* FST as the reference groupK-M: Kaplan-MeierHR: hazard ratioAll regression models adjusted for propensity score and EuroScore-IINCx: non-complicated; survivors with ventilator use under one week or intensive care unit stay under two weeksLOS: length of stay

Conclusion

• In optimally-selected cases, MICS can offer better survival and safety outcomes than full sternotomy– Shorter length of stay– Lower 30-day mortality– Less pneumonia

• Efficacy outcomes of MICS need to be addressed in the future.

Benchmark

59

2004-2012

MICS= parasternotomy + thoracotomy

Total case number=677

60

Method

Reference listAbbreviation Cited Article title

MICS Case

number

Impact factor(2012 JCR)

ATS 2013Ann Thorac Surg 2013 (Epub ahead of print)

Minimally Invasive Mitral Valve Surgery: Influence of Aortic Clamping Technique on

Early Outcomesn=103 3.454

ATS 2006Ann Thorac Surg 2006;

81:1599-604

Minimally Invasive Versus Standard Approach Aortic Valve Replacement: A

Study in 506 Patientsn=232 3.454

J Heart Val Dis 2004

The Journal of Heart Valve Disease

2004;13:887-893

Propensity Score Analysis of a Six-Year Experience with Minimally Invasive Isolated

Aortic Valve Replacementn=233 1.51

J Card Surg 2003

J Card Surg 2003;18:133-139

Prospective Comparison of Minimally Invasive and Standard Techniques for Aortic Valve Replacement: Initial Experience in the

First Hundred Patients

n=30 1.071

JTCS 2002J Thorac Cardiov Surg 2002; 50: 337 – 341

Midterm Results and Quality of Life after Minimally Invasive vs. Conventional Aortic

Valve Replacementn=70 3.526

EJCTS 1999

Eur J Cardio-Thorac Surg 1999; 16:647-652

Minimally invasive aortic valve replacement (AVR) compared to standard AVR n=29 2.674

死亡率低于国际文献 !

62

ATS 2006 JTCS 2002 亞東0.0

0.5

1.0

1.5

2.0

2.5

3.0 2.62.9

1.83

Mortality (%)

Ann Thorac Surg 2006; 81:1599-604J Thorac Cardiov Surg 2002; 50: 337-341

重症监护住院天数与文献值相近

63

ATS 2006 J Card Surg 2003

JTCS 2002 EJCTS 1999 亞東0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

2.1

3.0

1.8

2.5 2.3

ICU stay (days)

术后恢复快，可较快转入普通病房

Ann Thorac Surg 2006; 81:1599-604J Card Surg 2003;18:133-139J Thorac Cardiov Surg 2002; 50: 337-341Eur J Cardio-Thorac Surg 1999; 16:647-652

ATS 2013 ATS 2006 J Heart Val Dis 2004

J Card Surg 2003

JTCS 2002 EJCTS 1999

亞東0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0 86.0

61.8

79.0 73.6 71.0

77.9

60.2

Cross-clamp time (minutes)

64

主动脉横夹时间低于国际文献 !

Ann Thorac Surg 2006; 81:1599-604The Journal of Heart Valve Disease 2004;13:887-893 J Card Surg 2003;18:133-139J Thorac Cardiov Surg 2002; 50: 337-341Eur J Cardio-Thorac Surg 1999; 16:647-652

时间越长，心脏缺氧越久，越不利于术后恢复

ATS 2013 J Heart Val Dis 2004

J Card Surg 2003

JTCS 2002 亞東98.0

100.0

102.0

104.0

106.0

108.0

110.0

112.0 111.3

110.0 110.1

105.0

102.5

CPB time (minutes)

65

体外灌注时间低于文献时间 !

Ann Thorac Surg 2013 (Epub ahead of print) The Journal of Heart Valve Disease 2004;13:887-893 J Card Surg 2003;18:133-139J Thorac Cardiov Surg 2002; 50: 337-341

时间越短，预期术后全身发炎，反应越轻微

ATS 2013 ATS 2006 J Heart Val Dis 2004

亞東0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

1.9 2.1

3.4

1.3

Permanernt stroke (%)

66

术后永久性中风远低于国际文献 !

Ann Thorac Surg 2013 (Epub ahead of print) Ann Thorac Surg 2006; 81:1599-604 The Journal of Heart Valve Disease 2004;13:887-893

ATS 2006 亞東0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5

4.3

3.5

Pneumonia (%)

67

术后肺炎比率低于国际文献 !

Ann Thorac Surg 2006; 81:1599-604

ATS 2006 J Card Surg 2003 亞東0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

10.0

3.4

10.0

1.9

New renal failure (%)

68

术后肾脏衰竭比率远低于国际文献 !

Ann Thorac Surg 2006; 81:1599-604J Card Surg 2003;18:133-139

ATS 2006 J Card Surg 2003 亞東0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0 31.0

21.0

6.8

Atrial fibrillation (%)

69

术后心房颤动比率远低于国际文献 !

Ann Thorac Surg 2006; 81:1599-604J Card Surg 2003;18:133-139

心房颤动会使心脏收缩力减弱，并增加中风之风险