manejo del paciente operados con técnica de heart port en el postoperatorio inmediato

HEART PORT Port-Access® Operative Procedure

UCI - Policlínica Gipuzkoa UCI

UCI

PG: 200 casos

PG: 28 casos

proporciona una plataforma para la realización de procedimientos quirúrgicos cardíacos a través de pequeñas incisiones ("ports"), sin una esternotomía media - al tiempo que permite un acceso completo y con buena visión del corazón no batiente y protegido. Heart Port

UCI

Técnica Heart Port - PG

1º Universidad de Stanford (California) 1995 ‒ Heartport Manual 1997 Europa: Hugo Baron Vanermen (Bélgica)

Port Port: Robot-Assisted

Experience stages

Esternotomía C. Endoscópica

UCI


Canulación para el by-pass cardiopulmonar:

Lungs

Left Atrium

Right Ventricle

Right Atrium

Left Ventricle

Oxygenator

Left Atrium

Right Ventricle

Right Atrium

Left Ventricle

Lungs

PUMP

Técnica de Perfusión Estándar

UCI

LA RV RA LV

Oxygenator PUMP

Cardioplegia

Técnica de Perfusión Estándar

UCI

Left Atrium

Right Ventricle

Right Atrium

Left Ventricle

IVC Drainage O²

Cardioplegia

SVC Drainage

EndoClamp: Cardioplegia y Clampaje

Clamping

UCI

Técnica By-pass cardiopulmonar

UCI

Canulación para el CEC:

- Vena yugular derecha - Vena femoral derecha

- Arteria femoral derecha: EndoClamp aórtico

- Vena yugular izquierda: PVC ... -  Arterias radiales bilaterales


UCI

TOT doble luz

Sonda ETE

Cánula en V. Yugular dcha.

PVC en CVC en V. Yugular izda.


UCI

Acceso Femoral

UCI


Canulación venosa

Aurícula Izquierda

Ventrículo Derecho

Aurícula Derecha

Ventrículo Izquierdo

O²

Cardioplegia

Clampaje

Acceso Femoral Arterial Retorno arterial / EndoClamp aórtico / Cardioplegia

UCI

Acceso Femoral - Arteria: EndoClamp aórtico

UCI


Canulación arterial

Clampaje aórtico transtorácico

UCI


UCI


Exposición del campo quirúrgico:

Retractor AI

Toracotomía Puerto para

endoscopio

Puerto para Vent y CO2

Minitoracotomía 4º espacio intercostal / submamario

UCI

Técnica Campo Quirúrgico

Retractor AI

Puerto para endoscopio

Puerto para Vent y CO2

UCI


UCI

TÉCNICA HEART-PORT Port-Access® Operative Procedure

POLICLÍNICA GIPUZKOA

Resultados HEART PORT - PG

UCI

5,5%94,5%

HP

No HP

ü  Casos realizados Heart-Port (2003-2009)

192 5,53329 94,53521 100,0

SiNoTotal

FrecuenciaPorcentajeválido

Tabla de contingencia Heart-Port * Año

14 47 32 24 30 16 29 1922,6% 8,5% 6,2% 5,0% 6,2% 3,3% 6,2% 5,5%

Recuento% de Año

Si2003 2004 2005 2006 2007 2008 2009

AñoTotal

UCI


INDICACIONES:

"   Estenosis mitrales "   Insuficiencias mitrales "   CIA "   Mixomas auriculares. "   Ùtil en re-operaciones "   Puede ser útil para aortas severamente calcificadas

CADA PACIENTE debe ser analizado de manera INDIVIDUAL y aconsejado sobre sus DIFERENTES OPCIONES

48,4%

51,6%Heart-Port

192 48,4205 51,6397 100,0

SiNoTotal


Tipo de cirugía

363 91,423 5,8

9 2,32 ,5

397 100,0

ValvularCIAValv-CIAOtros_Heart PortTotal

FrecuenciaPorcentaje

válidon = 3521

UCI

DESCARTAR:

"   Problemas vasculares femorales o ilíacos "   Estudio de pulsos en EEII "   En pacientes añosos / arteriopatía:

- estudio angiográfico de vasos ilíacos y femorales "   Insuficiencia Aórtica. "   Capacidad pulmonar para tolerar la exclusión del pulmón derecho


UCI

CONTRAINDICACIONES:

CONTRAINDICACIONES RELATIVAS: "  Toracotomías previas con un pulmón derecho adherido a la caja torácica

"   Calcificación severa del anillo mitral "   Aorta ascendente dilatada de más de 4.5 cm de diámetro


Periodo: ago-03 / jul-10

ü  Casos realizados: 200

ü  Sexo: mujeres 60%

ü  Edad media: 64,9 años (16::86)

ü  2ª Intervención: 7%

ü  F.E. Media: 62,6% (min. 31%)

ü  P. A. Pulmonar Media: 43 mm Hg. (max. 106)

UCI

Edad corregida (años) Stem-and-Leaf Plot Frequency Stem & Leaf 10,00 Extremes (=<36) 2,00 3 . 77 7,00 4 . 0112244 5,00 4 . 56679 11,00 5 . 00112223444 25,00 5 . 5556777778888889999999999 29,00 6 . 00000111111222222233333344444 29,00 6 . 55566666667777888888889999999 34,00 7 . 0000111111111222222223333344444444 31,00 7 . 5555556666667777777777888888899 16,00 8 . 0001111112223334 1,00 8 . 6 Stem width: 10 Each leaf: 1 case(s)



ü  Casos realizados: 200

ü  Sexo: mujeres 60%

ü  Edad media: 64,9 años (16::86)

ü  2ª Intervención: 7%

ü  F.E. Media: 62,6% (min. 31%)

ü  P. A. Pulmonar Media: 43 mm Hg. (max. 106)

UCI


Alto riesgo (ES >= 10.9%)

164 82,036 18,0200 100,0

NoSiTotal



ü  Estancia en UCI: 1,8 días / Md:1 día

ü Estancia Hospitalaria: 8,5 días / Md: 7 días

ü Mortalidad en UCI: 2,5%

ü Mortalidad a los 30 días: 4,5% (Media EuroSCORE log.: 6,78%)

UCI


Bajo riesgo (ES <= 2.94%)

196 98,04 2,0

200 100,0

NoSiTotal


UCI


Prueba de muestras independientes

39,253 33,868 44,63741,802 35,585 48,019

Tiempo de isquemia (min.)Tiempo de By-pass (min.)

Diferenciade medias Inferior Superior

95% Intervalo deconfianza para la

diferencia

Prueba T para la igualdad de medias

Estadísticos de grupo

192 89,11 30,141 2,175237 49,86 26,552 1,725192 128,47 35,752 2,580240 86,67 28,294 1,826

Heart-PortSiNoSiNo

Tiempo de isquemia (min.)

Tiempo de By-pass (min.)

N MediaDesviación

típ.Error típ. de

la media

CEC:

“PROBLEMAS”

ü  Entrenamiento / “curva de aprendizaje”

ü  Tiempo y Paciencia Esternotomía Heart -Port

ü Complicaciones accesos vasculares arteriales: 2%

ü  Complicaciones canulación venosa: 2%

ü  Clampaje transtorácico - Novare: 8%

ü  Adherencias pleurales: 2%

UCI


COMPLICACIONES - accesos

UCI


COMPLICACIONES - globales

Complicaciones Heart-Port 1,5% 0,5% 1,0%

6% ,0%

3,0% 1% ,0% ,0%

ACVA con secuelas IAM peri-IQ Shock Daño renal agudo (RIFLE) FRA con TDE H. Mediatínica SIN re-IQ H. Medistínica CON re-IQ Politrasfusión (> 6 C.H.) Taponamiento

0% conversiones a esternotomía *

ü  Pacientes seleccionados

ü  DIFICULTAD para realizar comparaciones

Conclusiones HEART PORT - PG

ü  HP es una técnica HABITUAL en nuestro centro


,511 -,839 -3,344 1,667,511 -,8387 -3,3442 1,6667,307 1,110 -1,022 3,242,109 -4,146 -9,225 ,933

Edad (años)Edad corregida (años)Fraccion de eyeccion (%)Hipertension pulmonar(mm Hg.)

Sig. (bilateral)Diferenciade medias Inferior Superior


diferencia


Resultados “Comparaciones” NO significativas

HP vs nHP: 2003-2009

65,12 65,9663,01 61,9041,97 46,12

Edad corregida (años)Fraccion de eyeccion (%)Hipertension pulmonar (mm Hg.)

Si NoHeart-Port

Media

Heart-Port

192 48,4205 51,6397 100,0

SiNoTotal


Resultados

Tabla de contingencia Tipo de prótesis mitral * Heart-Port

109 13356,8% 64,9%

4 212,1% 10,2%

63 2032,8% 9,8%

16 318,3% 15,1%

192 205

Recuento% de Heart-PortRecuento% de Heart-PortRecuento% de Heart-PortRecuento% de Heart-PortRecuento

Mecánica

Biológica

Anuloplastia

No

Tipo deprótesis mitral

Total

Si NoHeart-Port

Tabla de contingencia Reintervenido * Heart-Port

13 556,8% 26,8%

179 15093,2% 73,2%

192 205

Recuento% de Heart-PortRecuento% de Heart-PortRecuento

Si

No

Reintervenido

Total

Si NoHeart-Port

“Comparaciones” NO significativas HP vs nHP: 2003-2009

Resultados

Tabla de contingencia IAM peri-IQ * Heart-Port

190 20399,5% 99,0%

1 2,5% 1,0%191 205

No

Si

IAM peri-IQ

Total

Si NoHeart-Port

Tabla de contingencia Shock * Heart-Port

189 19999,0% 97,1%

2 61,0% 2,9%

191 205


No

Si

Shock

Total

Si NoHeart-Port

Tabla de contingencia FRA con TDER * Heart-Port

191 205100,0% 100,0%

191 205

NoFRA con TDER

Total

Si NoHeart-Port

Tabla de contingencia H. Mediatínica sin re-IQ * Heart-Port

185 19796,9% 96,1%

6 83,1% 3,9%

191 205

No

Si

H. Mediatínica sin re-IQ

Total

Si NoHeart-Port


Port-Access®: tiempos de isquemia y CEC más prolongados

Resultados

Tabla de contingencia H. Medistínica con re-IQ * Heart-Port

189 19599,0% 95,1%

2 101,0% 4,9%

191 205

No

Si

H. Medistínica con re-IQ

Total

Si NoHeart-Port

Tabla de contingencia Politrasfusión (> 6 C.H.)

51 50100,0% 92,6%

0 4,0% 7,4%51 54

No

Si

Politrasfusión(> 8 C.H.)

Total

Si NoHeart-Port

Tabla de contingencia Taponamiento * Heart-Port

191 201100,0% 98,0%

0 4,0% 2,0%191 205

No

Si

Taponamiento

Total

Si NoHeart-Port

Tabla de contingencia ACVA con secuelas * Heart-Port

188 19498,4% 94,6%

3 111,6% 5,4%

191 205

No

Si

ACVA con secuelas

Total

Si NoHeart-Port


Resultados

Heart-Port

192 48,4205 51,6397 100,0

SiNoTotal


Tabla de contingencia Mortalidad a los 30 días * Heart-Port

184 194 37895,8% 94,6% 95,2%

8 11 194,2% 5,4% 4,8%

192 205 39748,4% 51,6% 100,0%


No

Si

Mortalidad alos 30 días

Total

Si NoHeart-Port

Total


-3,92828 -5,65610 -2,20045Se han asumidovarianzas iguales

EuroSCORE Log. (%)


95% Intervalo de confianza para ladiferencia


Estadísticos de grupo

6,5582 8,37325 ,6042910,4865 9,05432 ,63549

Heart-PortSiNo

EuroSCORE Log. (%)Media

Desviacióntíp.

Error típ. dela media


Tabla de contingencia Alto riesgo (ES >= 10.9) * Heart-Port

159 12182,8% 59,6%

33 8217,2% 40,4%

192 203

No

Si

Alto riesgo (ES >= 10.9)

Total

Si NoHeart-Port

Resultados “Comparaciones” NO significativas

HP vs nHP: 2003-2009


,001 2,048 ,828 3,267Estancia media (días)Sig. (bilateral)



diferencia

Prueba T para la igualdad de medias205 3,91 8,582 ,599192 1,86 2,147 ,155

Heart-PortNoSi

Estancia Media (días)en UCI

N MediaDesviación

típ.Error típ. de

la media

Pacientes seleccionados

DIFICULTAD para realizar comparaciones



ü  HP es una técnica FACTIBLE y SEGURA

Bibliografía

HEART PORT ¿Factible y Seguro?

Ann Thorac Surg 2002;74:660-4

Minimally-Invasive Mitral Valve Surgery: A 6-Year Experience With 714 Patients Eugene A. Grossi, MD, New York University School of Medicine. New York, USA.

Results: Hospital mortality for primary isolated mitral valve repair was 1.1% and 5.8% for isolated mitral valve replacement. Overall hospital mortality was 4.2% (30 of 714). Mean cross-clamp time was 92 minutes and mean cardiopulmonary bypass time was 127 minutes. Postoperatively, median ventilation time was 11 hours, intensive care unit time was 19 hours and total hospital stay was 6 days. Complications for all patients included permanent neurologic deficit (2.9%), aortic dissection (0.3%), no mediastinal infection (0.0%). Follow-up echocardiography demonstrated 89.1% of the repair patients had only trace or no residual mitral insufficiency.

Conclusion: This study demonstrates that the minimally invasive port access approach to mitral valve operations is reproducible with low perioperative morbidity and mortality and with late outcomes that are equivalent to conventional operations.

Objective: To analyze a single-institutional experience with minimally-invasive mitral valve operations of 6 years, reviewing short-term mortality and morbidity and long-term echocardiographic data. Method: Between Nov 1995 and Nov 2001, 714 consecutive patients had minimally invasive mitral valve procedures. 561 patients had isolated mitral valve operations (375 repairs, 186 replacements) . Mean age was 58.3 (30.1% > 70 years) and 15.4% had previous cardiac operations. Arterial cannulation was femoral in 79.0% and central in 21% with the port access balloon endo-occlusion used in 82.3%. Cardioplegia was transjugular retrograde (54.1%) or antegrade (29.4%). Right anterior minithoracotomy was used in 96.6% and left posterior minithoracotomy in 2.2%


The Journal of Heart Valve Disease 2008;17:48-53

Video-Assisted Mitral Surgery through a Micro-Access: A Safe and Reliable Reality in the Current Era Ernesto Greco MD, Juan M. Zaballos MD, Luis Alvarez MD, Stefano Urso MD, Ivana Pulitani MD,Rafael Sàdaba MD, Arantxa Juaristi MD, Juan J. Goiti MD Policlinica Gipuzkoa, San Sebastian.

Objective: To describe the author´s experience with video-assisted mitral surgery through a micro-access. Method: Between September 2003 and September 2006, 100 patients (mean age 65.7 years; range: 16-84 years; 29 aged >75 years) underwent video-assisted port-access mitral valve surgery through a 4 to 6 cm anterior mini-thoracotomy. Mitral valve repair wascarried out in 36 patients (36%) and mitral valve replacement (MVR) in 64 (64%). Redo procedures were performed in 14 patients.

Results: Endoclamp occlusion of the ascending aorta was used in 94%. The median intensive care unit and hospital stays were 20.0 ± 30.8h and 7.0 ± 5.9 days, respectively. Hospital mortality was 4% (n = 4). No patient required conversion to sternotomy. There were no perioperative myocardial infarctions, permanent strokes, major vascular complications, or peripheral ischemic events. Among the patients, 63% had no complications at all during the postoperative course, and no wound infections were observed.

Conclusion: Video-assisted mitral surgery through a micro-access may be performed safely, at low risk of morbidity and mortality, and with results and quality standards similar to those reported for a sternotomy approach. Of note, older patients may be successfully treated using this technique.


The Preferable Use of Port Access Surgical Technique for Right and Left Atrial Procedures Gersak B, Sostaric M, Kalisnik JM, Blaumamauer R. Department of Cardiovascular Surgery, University Medical Center Ljubljana, Slovenia.

Results: There were statistically significant differences in cardiopulmonarybypass time (CPB) and aortic cross-clamp time (AXT) between both groups: CPB C versus PA: 98.3 ± 33.5 minutes versus 149.2 ± 44.2 minutes (mean ± sd), AXT C versus PA: 62.9 ± 20.6 minutes versus 88.3 ± 26.8 minutes (mean ± sd). There were no statistically significant differences in mortality and stroke for both the groups There were statistically significant differences in favor of the port access over the classical one for: intensive unit stay postoperative stay in days, blood transfusion, postoperative thoracic bleeding and extubation time in hours. Furthermore, costs analyses showed that the average total patient cost was less for port access. The differences between endo and classical type suggested that the port access type of surgery is 20% cheaper than the classical one.

Conclusion: We may conclude that port access surgery is an acceptable alternative to classical type of surgery, also in complex pathology of the mitral and tricuspid valve.

The Heart Surgery Forum # 2004-1143 8(5), 2005

Objective: To analyze the results of mitral valve operations, either alone or in combination with the tricuspid valve surgeries. Method: From January 2001 till June 2004. The period was divided into two parts, classical sternotomy part (C) (110 patients) and minimally invasive port access part (PA) (105 patients), later being used from December 2002 till now. Also, what we were interested in was the total hospital cost of both types of the procedures and if there are any advantages of port access over the classical sternotomy. The mean age was 61.2 ± 10.2 and 60.3 ± 12.4 (C versus PA) and mean additive Euroscore was 6.5 versus 4.8 (C versus PA).


J Thorac Cardiovasc Surg. 2009

Quality of mitral valve repair: Median sternotomy versus port-access approach. Raanani E, Spiegelstein D, Sternik L, Preisman S, Moshkovitz Y, Smolinsky AK, Shinfeld A. Department of Cardiac Surgery, Chaim Sheba Med. Center, Tel Hashomer, affiliated with the Sackler School of Medicine, Tel-Aviv University, Israel.

Objectives: We sought to compare early and late clinical and echocardiographic outcomes of patients undergoing minimally invasive mitral valve repair by means of the port-access and median sternotomy approaches. Methods: Between 2000 and 2009, 503 patients had mitral valve repair, of whom 143 underwent surgical intervention for isolated posterior leaflet pathology: 61 through port access and 82 through median sternotomy. The port-access group had better preoperative New York Heart Association functional class (P = .007) and a higher rate of elective cases (97% vs 87%, P = .037). Other preoperative characteristics were similar between the groups, including mitral valve pathology and repair techniques.

Results: Operative, bypass, and clamp times were significantly longer in the port-access group. Mean hospital stay was 5.3 +/- 2.5 days in the port-access group versus 5.7 +/- 2.5 days in the median sternotomy group (P = .4). Early postoperative echocardiographic analysis showed that most patients in both groups had none or trivial mitral regurgitation and none of the patients had greater than grade 2 mitral regurgitation. Follow-up extended for up to 100 months (mean, 34 +/- 24 months). New York Heart Association class improved in both groups (P = .394). Freedom from reoperation was 97% and 95% in the port-access and median sternotomy groups, respectively. Late echocardiographic analysis revealed that 82% (49/60) in the port-access group and 91% (73/80) in the median sternotomy group were free from moderate or severe mitral regurgitation (P = .11).

Conclusion: In isolated posterior mitral valve pathology, quality of mitral valve repair with the port-access approach can compare with that with the conventional median sternotomy approach.

HEART PORT: dolor y calidad de vida

Pain and Quality of Life After Minimally Invasive Versus Conventional Cardiac Surgery Thomas Walther, MD, Herzzentrum Leipzig

Ann Thorac Surg 1999;67:1643-7

Objective: To evaluate pain and quality of life after minimally invasive cardiac operations in comparison with conventional cardiac operations. Method: From Oct 1996 to May 1997, a total of 338 patients were interviewed daily using standard scoring systems (myocardial revascularization n = 160; mitral valve reconstruction or replacement n = 58; aortic valve replacement n = 120).

Results: There was no significant difference regarding ventricular function and intensive care and hospital stay. Pain decreased until the seventh postoperative day in all patients. Patients with a lateral minithoracotomy had lower pain levels from the third postoperative day onward. There were no differences in quality of life, postoperative wound healing or stability of the bony thorax.

Conclusion: After minimally invasive procedures with lateral minithoracotomy, earlier mobilization is possible because of a better stability of the bony thorax, resulting in lower pain levels.

Pacientes seleccionados

DIFICULTAD para realizar comparaciones

ü  HP es una técnica FACTIBLE y SEGURA

ü  Paso previo a la CIRUGÍA ROBÓTICA



Gracias


UCI

Canulación arterial femoral EndoClamp

manejo del paciente operados con técnica de heart port en el postoperatorio inmediato

Health & Medicine

tcnica heart port

resultados heart port

media heart

heart portport

heart port2

tcnica by

tabla de contingencia

tcnica campo quirrgico