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
8000
10000
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
0
500
1000
1500
2000
2500
2011 2012 2013 2014 2015
Nu
mb
er
of
pat
ien
ts (
N)
OPEN HEART SURGERY (ADULTS/PAEDS)Adult
**SOURCE FROM :- YEARLY CT REPORT 1992-2014- OT CENSUS -2015
334360
438
611641
329
479 466
375
518
0
100
200
300
400
500
600
700
2011 2012 2013 2014 2015
Nu
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of
pat
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N)
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
177
140
199
149
189207
141152
212
0
50
100
150
200
250
Nu
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N)
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
3
8
7
6
14
5
10
0
2
4
6
8
10
12
14
16
2009 2010 2011 2012 2013 2014 2015
Nu
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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: [email protected] (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
0
2
6
2
5
2
1
0
1
2
3
4
5
6
7
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Nu
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N)
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
0
2
0
2 2
4
0
1 1
7
0
1 1
2
0
1
2
3
4
5
6
7
8
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TRANSPLANT PROCEDURE
Is Innovations essential ?
Thank You