Robotic AVRs

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amyl

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Anyone on this board doing robotic AVRs? Or any other approaches besides sternotomy? Dr doolah here in dallas at utsw does a 2 inch incision between the ribs but it’s still a prominent incision.
How close are they to successful robotic AVRs with lateral incisions?
😓😢 just found out I’ll likely need one (mod AS from bicuspid valve.) geez getting older sucks
 
Sorry to hear that you need some heart surgery! Wish you the best of luck with it.

I have not heard of a robotic AVR, only robotic CABG, MVR, and TVR. I have seen them done with a mini sternotomy with vacuum assist cannulas for smaller cannula sizes to maximize real estate. With the mini-sternotomy, you do a J cut on the sternum instead of a full manubrium to xiphoid process cut. If you're thinking of trying to get thoracotomy approach heart surgery for an AVR over a good-old fashioned sternotomy, I would say don't. You want this thing done right with maximum visualization of structures and the way the surgeon is comfortable operating. Plus, I've heard from multiple patients that the approaches that require some rib spreading are much more painful than a sternotomy. The only advantage with a thoracotomy approach is that you have a shorter lifting restriction period (hardly worth it imo) and that you don't have the more obvious scar.
 
Damn. Yea when I did hearts as a resident at CCF they only did robo mitrals. I understand doolah does 1000s of AVRs between the rins here at utsw - I hear he’s great. I’m super vain so the sternotomy scar even mini is a no go for me.
 
amyl said:
Anyone on this board doing robotic AVRs? Or any other approaches besides sternotomy? Dr doolah here in dallas at utsw does a 2 inch incision between the ribs but it’s still a prominent incision.
How close are they to successful robotic AVRs with lateral incisions?
😓😢 just found out I’ll likely need one (mod AS from bicuspid valve.) geez getting older sucks
Click to expand...

Sorry to hear that. I've never heard of totally endoscopic AVR with the robot. Most approaches still require the small thoracotomy incision in addition to the port sites, like in the following video.



You can see the incisions at the end of the video. It's still far better than a sternotomy from a recovery and cosmesis standpoint, plus the pain isn't too bad if they do cryo ablation on the intercostal nerves or your colleagues do some kind of nerve block.
 
Angus Avagadro said:
Would you be a candidate for or consider TAVR? I understand hospitals in my area are doing those on low risk AS patients. Sorry you have to deal with this.
Click to expand...
TAVR for bicuspid is still pretty experimental and it's fraught with higher risk of complications for numerous reasons. Not to mention, amyl is presumably pretty young and wouldn't be a great candidate for any type of bioprosthetic valve, including TAVR.
 
I have worked before with a surgeon that does thoracotomy AVRs. Good results. I would consider it, particularly if you are younger.

I was under the impression that it left a relatively "virgin" sternum, thus would have a far lower risk of complications for the redo AVR later. If I knew I would be needing another valve later in life, I'd probably explore a thoracotomy first go, then sternotomy on Number 2. Or TAVR.
 
vector2 said:
TAVR for bicuspid is still pretty experimental and it's fraught with higher risk of complications for numerous reasons. Not to mention, amyl is presumably pretty young and wouldn't be a great candidate for any type of bioprosthetic valve, including TAVR.
Click to expand...
Personally, it's bioprosthetic or nothing for me. My lifestyle is not compatible with blood-thinners. I would be completely unwilling to do a mechanical valve, expecting that interventional procedures will only get more and more capable.
 
get a thoracic epidural for your case - run it until discharge, should help with perioperative and post op pain and hopefully prevent chronic pain
 
abolt18 said:
Personally, it's bioprosthetic or nothing for me. My lifestyle is not compatible with blood-thinners. I would be completely unwilling to do a mechanical valve, expecting that interventional procedures will only get more and more capable.
Click to expand...
Yeah, each of us has gotta make that personal choice, especially if you're into sports or other activities that involve contact / impact / falling.

I do think though that I hear many surgeons being flippant with the "let's just put a bio valve in and when it fails they can just TAVR / TMVR / reop it" line. Many times, the bio valve has already degenerated to the point where the valvular lesions have irreparably damaged the myocardium before the surgeon or cardiologist decides to intervene on it, and because of this the patient suffers a future mortality penalty the second the valve goes in.

That being said, even though I don't have a good reason not to take coumadin, I still wouldn't be thrilled at the prospect of taking it. I am intrigued by the trials using On-X in the aortic position and then A/C with eliquis....
 
amyl said:
On X?
Click to expand...
1692038006872.png



Actually, despite the fact that the On-X is supposedly less thrombogenic, these results were published in May and apixaban was inferior to warfarin as far as thromboembolic events. 🙁


 
buddababa said:
get a thoracic epidural for your case - run it until discharge, should help with perioperative and post op pain and hopefully prevent chronic pain
Click to expand...
You have evidence for this of course? I'm really looking forward to it
 
If i recall correctly, the data on on-x bioprosthetic sucks, no?

The good news is that you won't need a replacement for a while, no? is your cards really gonna start your clock at 49 with mod AS? do you have aortic dilation?

Personally i'd go with a mini sternotomy with the bioprosthetic valve with the best data if i was gonna get it soon. But mechanical replacement is also a viable option.
 
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Related/unrelated (thread highjack but I hope one @amyl is ok with). If one worked at a small institution (in a city that they didn't trust surgeons in) how would you advise a friend to go looking at large institutions and finding a surgeon.

Sts database and look at mayo/ccf/cedars Sinai/etc? I'm reminded about the former ct chair at UPMC - making that data questionable in utility.

I have less confidence in the opinions of friend physicians, even when they are anesthesiologist or surgeons (due to the variety of biases that humans have).
 
Lol, just put an On-X in a thirty-something Aortic.

Surgeon asked me what to do, I said “there’s this thread online”
/kidding
 
So I’m told my velocities are close to being symptomatic. Valve area 1. Aorta okay I’m echo… getting ct as I know surgeons will want to see anatomy. I’ll post my echo stats when I get a copy… maybe a good learning experience for residents here.

I trained at ccf and have talked to my old staff there. They said Doug Johnson was the best for thorocotomy AVRs but he just left - I believe for northwestern (anyone on here from there?). My only concern is that if something happens (bleeding etc.) with thorocotomy you buy yourself the whole sternotomy and femoral cannulation can have issues. Ct has to show compatible anatomy for thorocotomy anyway
Mini AVRs are routine these days so less risky.
I’m conflicted too with in town Vs out. Dchz and his group have all recommended a great surgeon in town I’ll definitely go see her (bonus woman surgeon 💕). But will likely also trot up to Cleveland to see a surgeon my old staff recommended up there. This is important enough to me to get several opinions
 
amyl said:
So I’m told my velocities are close to being symptomatic. Valve area 1. Aorta okay I’m echo… getting ct as I know surgeons will want to see anatomy. I’ll post my echo stats when I get a copy… maybe a good learning experience for residents here.

I trained at ccf and have talked to my old staff there. They said Doug Johnson was the best for thorocotomy AVRs but he just left - I believe for northwestern (anyone on here from there?). My only concern is that if something happens (bleeding etc.) with thorocotomy you buy yourself the whole sternotomy and femoral cannulation can have issues. Ct has to show compatible anatomy for thorocotomy anyway
Mini AVRs are routine these days so less risky.
I’m conflicted too with in town Vs out. Dchz and his group have all recommended a great surgeon in town I’ll definitely go see her (bonus woman surgeon ). But will likely also trot up to Cleveland to see a surgeon my old staff recommended up there. This is important enough to me to get several opinions
Click to expand...
It just hit me that we never heard another word about this by way of updates. You end up having surgery? Everything go well?
 
Thanks for thinking of me. I got a second opinion on my echo and they said it’s not that bad actually. First guy mis read my velocities and That relative to my size my valve area isn’t that bad…. He recommended yearly echos to make sure it doesn’t progress quickly and of course come in if I develop symptoms. I’m hoping to hold off on surgery as long as possible 🙏
 
I did almost exclusively Cardiac Anesthesia for a decade. 100's if not 1000s of TAVRS. If I needed an Aortic Valve replacement I would chose to go to a center that does a very high volume of TAVRs through the femoral vein. Best of luck to you
 
gator2886 said:
I did almost exclusively Cardiac Anesthesia for a decade. 100's if not 1000s of TAVRS. If I needed an Aortic Valve replacement I would chose to go to a center that does a very high volume of TAVRs through the femoral vein. Best of luck to you
Click to expand...

Trans-caval TAVR would not be my suggestion for a young, otherwise healthy patient….
 
teacher2md said:
Trans-caval TAVR would not be my suggestion for a young, otherwise healthy patient….
Click to expand...
Agree. Get the largest, fracturable bioprosthetic you can fit in the first time, minimally invasive if feasible. Then you can get 1, maybe two replacements in the future via TAVR as necessary.
 
DolphinVA said:
Agree. Get the largest, fracturable bioprosthetic you can fit in the first time, minimally invasive if feasible. Then you can get 1, maybe two replacements in the future via TAVR as necessary.
Click to expand...
Or find a surgeon that does a lot of Ross procedures.
 
gator2886 said:
I did almost exclusively Cardiac Anesthesia for a decade. 100's if not 1000s of TAVRS. If I needed an Aortic Valve replacement I would chose to go to a center that does a very high volume of TAVRs through the femoral vein. Best of luck to you
Click to expand...
Do you mean femoral artery?

Also, last I heard we're still not doing TAVRs for bicuspid AV.
 
Haha new vein approach!
We do selective BAV TAVRs.
Def. adds risk.
 
gator2886 said:
If I needed an Aortic Valve replacement I would chose to go to a center that does a very high volume of TAVRs through the femoral vein. Best of luck to you
Click to expand...
Where is this place?
I've never even heard of one fem vein tavi.

How would you even do that? A 90 degree turn down thru the mitral, then a 100 degree turn up the lvot... Sounds cool
 
PpfSuxTube said:
Where is this place?
I've never even heard of one fem vein tavi.

How would you even do that? A 90 degree turn down thru the mitral, then a 100 degree turn up the lvot... Sounds cool
Click to expand...


pubmed.ncbi.nlm.nih.gov

Transcaval Access and Closure for Transcatheter Aortic Valve Replacement: A Prospective Investigation - PubMed

Transcaval access enabled TAVR in patients who were not good candidates for transthoracic access. Bleeding and vascular complications, using permeable nitinol cardiac occluders to close the access ports, were common but acceptable in this high-risk cohort. Transcaval access should be...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov



IMG_2516.jpeg


IMG_2517.jpeg



 
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On here everyone is an expert whether it's cardiac or pain.
 
Last edited:
Iso4ane said:
Just okay? We all know what that means.
Click to expand...

Patients usually end up okay. It’s the usual 2-3 hours of hemming and hawing about “are they bleeding? are they not bleeding? are they stable? are they not stable? should we do a closure device? should we leave it alone?” that occurs after valve deployment.
 
anaesthetic said:
Patients usually end up okay. It’s the usual 2-3 hours of hemming and hawing about “are they bleeding? are they not bleeding? are they stable? are they not stable? should we do a closure device? should we leave it alone?” that occurs after valve deployment.
Click to expand...


We don’t do them where I work but it seems like some centers use a closure device for all their cases.
 
Another approach for folks with bad access. Only saw it at a talk, not in real life.


Intravascular Lithotripsy-Assisted Transfemoral Transcatheter Aortic Valve Implantation in Patients with Severe Iliofemoral Calcifications: Expanding Transfemoral Indications - PMC

(1) Background: Transfemoral transcatheter aortic valve implantation (TAVI) has become the standard treatment for most patients with severe symptomatic aortic stenosis. Intravascular lithotripsy may facilitate transfemoral TAVI (IVL-TAVI) even in ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov

 
nimbus said:
Another approach for folks with bad access. Only saw it at a talk, not in real life.


Intravascular Lithotripsy-Assisted Transfemoral Transcatheter Aortic Valve Implantation in Patients with Severe Iliofemoral Calcifications: Expanding Transfemoral Indications - PMC

(1) Background: Transfemoral transcatheter aortic valve implantation (TAVI) has become the standard treatment for most patients with severe symptomatic aortic stenosis. Intravascular lithotripsy may facilitate transfemoral TAVI (IVL-TAVI) even in ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov

Click to expand...

Although we aren’t doing trans-caval, we are doing a fair amount of intra-arterial lithotripsy for the extra crunchy folks.
 
teacher2md said:
Or find a surgeon that does a lot of Ross procedures.
Click to expand...
OP wouldn't even consider a mini-sternotomy/thoracotomy for SAVR, I doubt they want a bigger incision and twice the surgery and pump run. Not to mention root mismatch. A surgeon once said something along the line: a good surgery shouldn't need a great surgeon to be successful. Maybe if I'm at Mount Sinai I would think differently, but no thanks.
 
dchz said:
Learned about that 5 years ago. Still haven't seen one.
Click to expand...
We've done a few. When you do do one, keep in mind that if you're doing a really mild sedation on a sick patient, when they bovie through the cava to get into the aorta it really fking burns for a second. Caught one of my colleagues off guard when the patient arched their back a foot off the table.
 
vector2 said:
We've done a few. When you do do one, keep in mind that if you're doing a really mild sedation on a sick patient, when they bovie through the cava to get into the aorta it really fking burns for a second. Caught one of my colleagues off guard when the patient arched their back a foot off the table.
Click to expand...
This feels like something good to know. My sedation for TAVRs is usually a little fentanyl and a little precedex. Maybe 1-2mg midazolam added if they're squirmy.
 
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