Technologies & Innovation in Cardiothoracic Health Care

(Surgical Perspective)

Paneer Selvam Krishna Moorthy

Department of Cardiothoracic Surgery, National Heart Institute (IJN), Kuala Lumpur, Malaysia

World History of Cardiothoracic Surgery

“Any surgeon who wishes to preserve the respect of his colleagues would never attempt to suture the heart”- From a speech by Christian Albert Theodor Billroth at the Vienna Medical Society Meeting, 1880

19th Century Predictions

“Surgery of the heart has probably reached the limits set by Nature to all surgery; no new method, and no new discovery, can overcome the natural difficulties that attend a wound of the heart”

- Stephen Paget, The Surgery of the Chest, 1896

Revolution of Cardiac Surgery

The first surgery on the heart itself was performed by Norwegiansurgeon Axel Cappelen on 4 September 1895 at Rikshospitalet in Kristiania, now Oslo. He ligated a bleeding coronary artery in a 24-year-old man who had been stabbed in the left axillae and was in deep shock upon arrival. Access was through a left thoracotomy

The first successful surgery of the heart, performed without any complications, was by Dr. Ludwig Rehn of Frankfurt, Germany, who repaired a stab wound to the right ventricle on September 7, 1896.

History of Cardiac Surgery

In 1925, operations on the heart valves were unknown. Henry Souttar operated successfully on a young woman with mitral stenosis.

He made an opening in the appendage of the left atrium and inserted a finger into this chamber in order to palpate and explore the damaged mitral valve. The patient survived for several years

Souttar's physician colleagues at that time decided the procedure was not justified and he could not continue

Mayo-Gibbon Bypass Machine

March 5, 1955

1953 John Gibbon realised his 20-year vision and performed the first successful operation on a human using the heart-lung machine. The patient, Cecelia Bavolek, whose heart was connected to the machine for 45 minutes, recovered fully from the operation.

In the 1980s, researchers at St Thomas’s Hospital found that by cooling the heart to below 28°C and treating it with the right cocktail of chemicals, the heart could be stopped for many hours while intricate surgeries were performed, and then restarted with minimal damage.

A similar cocktail of chemicals is now used to keep hearts healthy while they are transported for transplantation.

Cardioplegia

DR. DWIGHT E. HARKEN“Father of Heart Surgery”

The first surgeon tohave repeated successwith heart surgery.

“We discovered that the heart wasn’t such a mysterious and untouchable thing after all.”

Cardiac Surgery – 70 years of Continuous Innovation -

Improvements

Cardiopulmonary Bypass

Surgical Techniques & Tools & Prosthesis

Post-operative cares

Diagnostic Tools

Innovative Factors

Diagnostic Tools

Modern Cardiopulmonary

Bypass

Tools in MICS

Hybrid OR

Refinement of the diagnosis

Improvement in Surgical Techniques

Decrease in mortality and morbidity

Early recovery and shorter hospital stay

Early return to functional status

Low cost

Effects of Innovations

Innovations & Developments

Innovations

Coronary Artery

Surgery

Heart Failure

Surgery

Surgery to Aorta

Heart valve Surgery

Thoracic Surgery

Surgery for Arrthymia

Any Innovations in Cardiothoracic Surgery

inMalaysia?

1977: Division of Cardiology, Medical Department,

General Hospital Kuala Lumpur (GHKL)

1980: Department of Cardiology, GHKL

1981: Department of Cardiology

Department of Cardiothoracic Surgery

Department of Anesthesiology

Royal Prince Alfred Hospital, Sydney

Royal Alexandra Hospital, Sydney

April 1982: Cardiac catheterization and angiogram

1st open heart surgery: surgical closure of ASD

Sept 1982: 1st coronary artery bypass surgery in Malaysia

Cardiac Surgery in Malaysia

1984: KLINIK KARDIOLOGI & KLINIK PEMBEDAHAN JANTUNG

THE TURNING POINT

1 am 18th Jan 1989 :

24th Jan 1989 : CABGs performed

July 1992 : IJN started operations

Sept 1992 : corporatized

12th June 1993 : Official Opening

IJN 1992

IJN2005

Workload

0

2000

4000

6000

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12000

14000

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Cardiology Procedures 6,314 7,016 6,862 7,298 7,818 8,298 8,482 8,441 8,276 10,308 10,023

Thoracic 60 102 63 81 105 243 329 362 147 154 159

Closed Heart 717 548 659 773 807 767 735 759 861 941 933

Open Heart 1,925 1,770 1,697 1,950 2,048 2,100 2,012 2,145 2,154 2,560 2,864

Transplant 4 0 2 0 1 1 1 0 1 2 11

Expansion

1313

19982077 2113 2122

633

843 783 837910

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2011 2012 2013 2014 2015

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OPEN HEART SURGERY (ADULTS/PAEDS)Adult

**SOURCE FROM :- YEARLY CT REPORT 1992-2014- OT CENSUS -2015

334360

438

611641

329

479 466

375

518

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2011 2012 2013 2014 2015

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CLOSE HEART SURGERY (ADULTS/PAEDS)Adult

**SOURCE FROM :- YEARLY CT REPORT 1992-2014- OT CENSUS -2015

Coronary Artery Bypass Grafting

Evolution of Coronary Surgery

May 2, 1960 Goetz RITA to RCA Tantalum ringPt died in 8 months of AMI

April 4, 1962 Sabiston SVG to RCA Suture Pt died 3 days later

Feb. 24, 1964 Kolesov LITA to LCx Suture No angina at 3 years’ follow-up

Nov 23, 1964 Garrett, DeBakey SVG to RCA Suture No angina at 7 years’ follow-up (The case first reported in 1973)

March 22, 1967 Kolesov LITA to LAD Stapling No angina at 3 years’ follow-up

May 9, 1967 Favaloro SVG to RCA SutureSuccessful

Feb 29, 1968 Green LITA to LAD Suture Successful

Robert H. GoetzVan Etten Hospital, New York

New Approaches to Coronary Bypass Surgery

Arterial Graft

Off Pump

Imaging

Graph flow monitoring

Coronary Bypass Surgery

Arterial grafts

Coronary Bypass Surgery MID-CABG and MICS

Cardiac Valve Replacement

Surgical Treatment of Valvular Heart Disease

ReconstructionOr

Replacement

All 4 valves can be replaced

Ideal Prosthetic Valve

Excellent hemodynamic characters – unimpeded forward flow with minimal transvalvular gradient upon opening and produce a competent valve with minimal regurgitation upon closing

Non thrombogenic Resistance to infection Non destructive to blood elements Durable Easy to implant Readily available at reasonable cost

Pulmonary Autograft(Ross Procedure)

Valve Reconstruction

All 4 valves can be reconstructed

Mitral Valve Repair – Various Techniques

MVRepair

Annulus

Leaflet

Chordae

Papillary Muscle

Mitral valve Repair – Various Techniques

Mitral Valve Repair - Techniques

621

43 3852

76

46 44 4759 66

52

72

115134

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199

149

189207

141152

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MV REPAIR PROCEDURE

**SOURCE FROM :-MV REPAIR DATABASE 1992-2012-TRAKCARE 2013-2014-CT REGISTRY 2015

Aortic Valve Reconstruction

Aortic Valve Reconstruction

Ozaki's Method :Aortic Valve Reconstruction with Autologous Pericardium

How to do?? - cutting

Pericardium is excised

The excised pericardiumis treated with0.6% glutaraldehyde solution

The each cusps and commissure distanceis measured withOriginal sizing apparatus

http://www.lab.toho-u.ac.jp/med/ohashi/cvs/treatment/aortic_valvular/self-pericardial_sac.html

How to do?? -stitch

http://www.lab.toho-u.ac.jp/med/ohashi/cvs/treatment/aortic_valvular/self-pericardial_sac.html

Draw cusps and put dots according to the corresponding window on the templateAnd, Cut them.

Cusps are sutured on annulus from downward

Completion

Completely Reconstructed Aortic Valve

February 2016 to October 2106 : 10 cases done in IJN

Surgical Approaches to the Heart Valves

Conventional MedianSternotomy

Minimally Invasive Surgery

MIS : Mitral Valve Repair/Replacement or

Aortic Valve Repair/Replacement

Robotic Valve Surgery

Additional Combined Approaches

TAVI/TAVR

TAVR is recommended in patients

Who meet an indication for AVR (Section 3.4)

Who have a Prohibitive risk for surgical AVR

A predicted post TAVR survival greater than 12 months (71,72). (Level of Evidence: B)

Consensus of Heart Valve Team

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2009 2010 2011 2012 2013 2014 2015

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TAVI PROCEDURE

**SOURCE FROM TAVI DATABSE

Aortic Surgery

Approaches to the Aortic Root Replacement

Surgical mortality < 10%

Approaches to the Ascending Aorta/Arch

17th Annual Scientific Meeting of MATCVS

Surgical mortality < 10%

Replacement of thoracoabdominalaorta

Hybrid Approach

17th Annual Scientific Meeting of MATCVS

Technically Challenging

Thoraflex Hybrid Plexus Stented Distal Graft

CT Images

5.0 cm

6.6 cm

5.0 cm

4.0 cm

3.0 cm

2.5cm

6.7 cm5.0 cm

5.6 cm

3.0 cm

PRE POST

PRE POST

Total Arch Replacement (Frozen Elephant Trunk)

No of cases

Jan 2016 to Nov 2016 5

Congenital Heart Surgery

Arterial Switch

Tetralogy of Fallot

Mitral Valve Reconstruction in Children

Contemporary long-term outcomes of an aggressive approach to mitral valve repair in children: is it effective and durable for both congenital and acquired mitral valve lesions?†

Mohd Azhari Yakub, Paneer Selvam Krishna Moorthy*, Sivakumar Sivalingam, Jeswant Dillon and Pau Kiew Kong+ Author Affiliations Department of Cardiothoracic Surgery, National Heart Institute, Kuala Lumpur, Malaysia *Corresponding author. Department of Cardiothoracic Surgery, National Heart Institute, 145 Jalan Tun Razak, 50400 Kuala Lumpur, Malaysia. Tel: +60-3-26178505; fax: +60-3-26928418; e-mail: paneer@ijn.com.my (P.S. Krishna Moorthy). Presented at the 28th Annual Meeting of the European Association for Cardio-Thoracic Surgery, Milan, Italy, 11–15 October 2014. •Received September 20, 2014. •Revision received January 28, 2015. •Accepted February 17, 2015.

Thoracic Surgery

Thoracotomy

VATS

VATS

Hyperhidrosis

What level should we perform surgery?

Hyperhidrosis Denervation

Craniofacial T2

Palmar T2-T3

Axillary T2-T4 or T3-T4

Heart(Long QTS)

T1-T4

Surgery for Heart and Lung Failure

Ventricular Assist Devices

Medium and Long Term VAD

1. Type of VAD device used Thoratec - 6 (2 IVAD & 4 PVAD)

HeartMate II - 8

HeartWare - 9

HeartMate 3 - 1

VAD Statistic of 24 VAD patients from 2005-2016

1 1

0

3

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6

2

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7

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

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LVAD PROCEDURE

Heart – Lung Transplant

Procedure Year Total Cases

Heart Transplant

1997 25 pts 26 surgeries

(1 redo)Lung Transplant

2005 6 pts(1 single lung tx5 double lungs

tx)Heart & Lung Transplant

2007 4 pts

1

3

2

3

4

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2 2

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1 1

7

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1 1

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TRANSPLANT PROCEDURE

Is Innovations essential ?

Thank You