Dr. Husam Balkhy, Associate Professor of Surgery at the University of Chicago Medicine, discusses the second part of his lecture, on the minimally invasive and robotic heart surgery program at the University of Chicago Medicine.
[MUSIC PLAYING] HUSAM BALKHY: We can move onto epicardial procedures that are done with the da Vinci robot. We have one of the largest, if not the largest, currently series totally endoscopic robotic coronary surgery here at University of Chicago Medicine. We do the whole procedure with the da Vinci robot, in the majority of cases without the heart/lung machine and without stopping the heart. We can do single-vessel coronary bypass endoscopically. We call it TECAB-- totally endoscopic coronary artery bypass. We can do multi-vessel, using both internal mammary arteries or sequential internal mammary arteries. And we can also do-- and we're starting to more and more of this-- hybrid revascularization, which means utilizing the best of what the cath lab has to offer, which is drug-eluting stents, and the best we think of what surgery has to offer, which is a sternal-sparing, totally endoscopic, off-pump beating heart coronary bypass procedure. And so we have a very, very strong collaboration with our interventional cardiologists. We review the majority of the cath films that come in from the outside or that happen internally for the possibility of a combined hybrid procedure to enable the patient to have a sternal-sparing approach. So the main advantages of this obviously are significant reduction in surgical trauma, as we talked about before, preservation of the integrity of the thorax, and importantly more frequent use of bilateral internal mammary arteries. We've seen that when internal mammary arteries are used, the patient's survival is enhanced. We know from previous surgical data for many, many years that using the internal mammary artery onto the left anterior descending is a very, very strong predictor of long-term patency in coronary bypass. And this study here shows that using two internal mammary arteries is better than one in terms of survival and in terms of re-operation. This is a graph that shows the incidence of use in bilateral internal mammary arteries in the general STS cohort and in a couple of series that use TECAB robotic bypass procedures. And you can see that we're up to about 50% here at UCM with bilateral internal mammary arteries, compared to the STS cohort, which is under 5%. And so the normal bypass procedure would entail a single mammary artery and veins-- unless the surgeon is very geared towards using all arterial grafts-- the majority of people will use vein grafts in robotic coronary bypass if it's multi-vessel. The majority of those patients will be considered for bilateral internal mammary arteries. TECAB in the literature has had excellent success in multiple hands. This is a review of some series of arrested heart TECAB on the heart/lung machine, with very resectable mortality and morbidity rates, a conversion rate about 15%. Some of these were very early series, but also very acceptable morbidity rates as well. This is talking about beating-heart TECAB in the literature. Again, excellent peri-operative mortality at 1%, very comparable to the STS database with a 13% conversion rate and a very low stroke risk, under 1% for this cohort or this multiple studies-- a total of 850 some patients. This is our operative setup for a patient undergoing totally endoscopic coronary bypass. The patient's head is to the right, feeder to the left. And you can see the number of ports that are placed. There are three ports in the left chest, and they port here in the subcostal area just under the costal margin. And then the working port, which as you saw on the mitral surgeries was 2 sonometers, or 20 millimeters, this one is 15 millimeters. And it sits right in the second interspace just to the left of the sternum. We've leveraged a new technology as well in performing totally endoscopic beating-heart coronary bypass. And this is the anastomotic device that we use. It's very similar to an Endo GIA stapler. And it allows us to perform a coronary bypass to all different areas of the heart without having to use a suture and thread. It's a mini stapler, if you will, that allows us to connect the artery to the internal mammary artery. Or if we're using a vein, for example, which we don't a lot, it allows us to connect it to the coronary artery in one fell swoop with the push of a button. And so as you saw in the animation, you load the artery, make a hole in the coronary, insert the anvil, and push the button, and presto it gets fired. This is an example of a procedure being done robotically. What you see there is the internal mammary artery that is skeletonized right here. And we're using it to create a y graft. And so we've divided the distal third of the left internal mammary artery. We're loading it onto this anastomotic device called the flex A. And we're going to create a y by inserting the device into the proximal part of the left internal mammary artery, and attaching the distal third, and then closing that hole with a little clip. And then, you can see now we have two ends of this conduit. One end is going to go to the left anterior descending and the other to the diagonal branch. That anastomosis was done with the anastomotic device. This anastomosis is being done with a different technique using titanium clips. And you can see the precision that the robot allows us. The heart is beating in the background. And then after it's all done, you can see the Y coming down. And then, we cover it with a blanket of extra pericardial fat. There's another procedure that shows a similar pattern of disease. But instead of doing a Y, we're doing what's known as a sequential, which means that we're going to attach the internal mammary artery in two areas-- one at the very distal end and the other in a side to side fashion between the diagonal and the middle part of the left internal mammary artery. And I think I can make this move a little bit to forward here. These are snares that we use to control the arteries while we're doing the anastomosis. Again, this is all done without the heart/lung machine. As you can see, the heart is beating in the background. The patient is on a ventilator and the left lung is deflated. The patients that are applicable for this approach are patients that have mostly left-sided coronary blockages. We can do the left anterior descending, the diagonal branch, the high marginal branches, the ramus branch. And if somebody also has right coronary disease or distal circumflex disease, they can always get a PCI with a drug-eluting stent. And so here, you can see the distal anastomosis being completed with the flex A devise. Once the anastomosis is finished, we tie the suture, and the hole that we made in the coronary is closed. And that completes one of the two anastomoses. And then, we bring this thing that's moving right now is called the stabilizer, and it's what allows us to do beating-heart surgery. I call it a sewing machine basically, because it's just kind of sitting there stabilizing that area of the heart that is undergoing the procedure. And here, we've taken the internal mammary artery and made us a small opening in the middle of it. And then, we're going to attach this to the diagonal branch to make a sequential bypass. And here, we're just going to start putting in these clips and then carefully apply here. You see that we've opened up the diagonal branch. This little guy here is a shunt. And what the shunt allows us to do, it allows us to provide blood flow into the distal part of the myocardium while we're working on the proximal. You can see that these snares are tightened. This one is here. This on is distal. This one's proximal. The snares are tightened until we get the shunt in. Once the shunt is in, we undo the snares. And now, we have all the time in the world, because the heart is happy. You can see the snares are loose now. And we're taking our time in perfecting this side-to-side anastomosis with these clips. This is a control angiogram of the same patient that was performed after the surgery prior to discharge. And you can see a very nice left internal mammary artery, first to the diagonal branch and then to the left anterior descending. And finally, I'll show you one last video that shows using both internal mammary arteries. These are both accessed from the left side of the chest. And so as you can see, we've come across the midline, taken down the right internal mammary artery, and we're grafting it to the left anterior descending. And it turns out when you don't open up somebody's breastbone, you can use both internal mammary arteries liberally. Because, number one, there's no risk of sternal wound infection. Number two, this is the right internal mammary artery coming from all the way on the right side and being covered with the anterior mediastinal fat to protect it from any kind of future potential sternotomy. But what tends to happen when you don't open the chest is that the right internal mammary artery and the left internal mammary are extremely close to each other. And so there's really no difference between which one you use. When we're doing sternotomy surgery, the right internal mammary artery is always kind of thought of as being far away and can't reach the left side of blood vessels. And that's one the reasons that it's not used. Another reason it's not used a lot is because the majority of the patients we operate on are diabetic, some of them are obese. And if we have risk factors such as those, using both internal mammary arteries can set the patient up for a potential sternal wound infection. So all of that is gone when we do this. So this is a publication that we published in The Annals of Thoracic Surgery back in 2011 on 120 of totally endoscopic beating-heart coronary bypass using the techniques that you just saw. We had a mid-term LIMA LAD patency of 98.2%. There was about I think 45% of these that were multi-vessel and 65% that were single vessel. This constituted an early experience. And we looked at patency in all of the IMA grafts at 94%. So it showed that this procedure is reproducible and has excellent early and mid-term outcomes. Our operative times went down significantly over this time frame, beginning at close to about 200 minutes for a single vessel coronary bypass LIMA LAD and came down to just over 2 hours to 2.5 hours for the last series of patients in this cohort above 250 patients. What about redos? Can we do redo operations on the coronaries with the da Vinci robot? Rarely we can. It depends on the situation as to where the target is, how many or if any of the internal mammary arteries are still left that weren't used in the past. This is a man who had a previous sternotomy coronary bypass procedure. And his grafts were a LIMA to the left anterior descending and a radial artery graft to his right coronary. And he came back 10 years later with disease in a marginal branch of the circumflex. And so we brought him in and did what you can see here, these little holes-- 1, 2, 3, 4, 5. And this is his old scar. And we did a single-vessel bypass with the right internal mammary artery onto the ramus branch. And here is swinging a golf club a full swing in about nine days after surgery. We all have our token great outcome patients. I'm not going to show you the ones who didn't swing a golf club at nine days. How about combining? This is a very novel type of an approach that is not normally done. I think this has been done maybe about four or five times around the country. And we've done three of them. But this is a patient who has mitral valve trouble with severe mitral regurgitation, as well as single-vessel coronary disease. And if you put your ports in the right spot and you plan your procedure, you can do everything with these little ports. So he had a mitral valve repair similar to what you saw earlier, and a single-vessel bypass and was home in three days. A young person didn't want to have his chest cut open. And it can be done. It's not for everybody. Not everybody should get this operation. But if somebody needs to get back and back to work, then this is a good option if they have the right set of circumstances. This is just talking about the hybrid opportunity with development of these less invasive techniques. And with also the parallel development of very excellent patencies in the drug-eluting stent world, we can combine the best of what surgery has to offer and the best of what cardiology has to offer in the cath lab. We know that a left internal mammary artery to the left anterior descending is the absolute best thing that we can do for a blocked LAD. We also know that patients do not want their chest cut open. We also know that drug-eluting stents have gotten to the point where they are probably for non-LAD targets as good as a vein graft that we can put on. And so if we have a patient that has disease in an area that can be reached with the da Vinci robot on the left side of the heart, why we can use one mammary artery or two. And if there's other blockages in areas that can't be reached, then we can have the patient get a drug-eluting stent. The order of events can be a point of conversation. Which one do you do first? And our strategy is to pretty much do the more symptomatic blood vessel first. So we've gone from having a standardized therapy for a certain disease that we generalize over the whole population, to customizing the patient, to now customizing the artery. So we look at every artery that is blocked on the cardiac cath, and we customize each artery and say, what is the best thing for this artery. Is it a vein? Is a drug-eluting stent? Is it an internal mammary artery? What is it, and how can we do it? And you can see that when we get up to the hybrid, we get to the highest in efficacy and the least in invasiveness, and this is what we want. With traditional surgery we're over here, with high invasiveness, high efficacy. But it's not what patients want. And with the advent of drug-eluting stents and hybrid procedures, we can do this and be less invasive and very efficacious in treating people's coronary disease. The availability of hybrid surgical rooms and suites-- and we have two rooms in our new hospital with very, very excellent equipment-- can allow us to do these procedures simultaneously. Although it takes a lot of planning and a lot of collaboration, it is the gold standard of what a hybrid procedure should be. This is some data to show that in the syntax trial, the three-year MACE, major coronary complications after drug-eluting stents was 28%, which is right about the same rate of three-year occlusion of saphenous vein grafts. And the majority of these were procedures for restenosis. And so you can see that vein grafts are somewhat morbid and take a lot out of the patient. Drug-eluting stents are probably as good at this point. And if you give the patient the left internal mammary artery, then you've really done them a good service as well. This is an example of somebody who had a hybrid operation. And you can see that they had a left internal mammary artery here to their obtuse marginal branch and a right internal mammary artery to the left anterior descending. They also had some right coronary blockage, which was intervened on afterwards. It was a little less important. You can see here tight, but not critically right. And so this patient came back and had a drug-eluting stent successfully to their right coronary. All right. Now, switching gears completely from all this, we can talk about another set of illnesses that we manage with the da Vinci robot at University of Chicago Medicine. Atrial fibrillation is a topic near and dear to my heart. I've been interested in the surgical therapy of atrial fibrillation for many, many years, and over the last six or seven years interested in and leveraging robotics and less invasive approaches for patients with atrial fibrillation. The da Vinci robot is very facile at allowing us excellent visualization to perform pulmonary vein isolation, ligation of left atrial appendage in patients with chronic and longstanding persistent atrial fibrillation, performing as close to a normal maze procedure as one can get. In addition, if we're talking about arrhythmia and EP type procedures, placement of leads is also another procedure that we can do-- placement of leads on the left ventricle for BiV pacing or on the right ventricle-- can also be done. And then, finally, drainage of pericardial fluid. Constrictive pericarditis is a major problem-- not very common-- but can be effectively managed with robotics to allow a release of pericardial constriction. When we look at the atrial fibrillation setup, the patient gets five ports. The largest is 12 millimeters and the smallest is 8. In this approach, using an epicardial approach for patients with paroxysmal afib, or if we're doing hybrid afib ablation, this is done off-pump on the beating heart without a cardiopulmonary bypass. So in this example of epicardial ablation with the using the da Vinci robot, as you can see in the video here, the ganglionated plexi have been removed from the dome of the left atrium as well as from the interatrial groove. And what we're doing here is we're driving these magnetic routers around the four veins-- one through the transfer sinus and one through the oblique sinus. And these routers, they are tipped with a magnet. And the two magnets are going to meet behind the heart on the left side. And then, we're going to pull these guys back out and have one continuous catheter that basically surrounds the four veins. And this allows us to now insert the ablation device, which is a radio frequency-based device in this case. And as you can see, the two magnets met, and now they're being pulled. And this is the ablation device. And what the ablation device does basically very simply is it tries to isolate the four veins where we think the majority of triggers that create atrial fibrillation occur in patients with paroxysmal afib. This has the benefit of being able to really go after the target with a lot of energy, because the energy is directed inward. There is less risk of injuring surrounding structures. It also allows us to get, like I said before, the ganglionated plexi, which are very important in this disease. And so this patient will end up-- as you can see, that's the lesion that's created as a continuous circle around the four veins. And with this white probe, we're testing to see the efficacy of our ablation. And then, once we're done, we're going to take a stitch and close the pericardium backup and and isolate the lung from the heart to minimize scarring. And after that's finished, we go to the left side and using an endoscopic approach with three 5-millimeter ports, we basically ligate the left atrial appendage. The left atrial appendage is implicated in the causation of strokes in patients with afib. And that's why they take coumadin. And here, you can see the left atrial appendage. They come in all various sizes and shapes and forms. And we're using an endo loop device, basically a knot-tying system that is kind of encircled at the base of the appendage. And this is all done with the heart beating and under transesophageal echo guidance. And in a minute, you'll be able to see with the echo what happens to this appendage on the inside. And it becomes completely flush with the wall of the left atrium. The reason that the appendage is implicated in stroke is because of its corrugated and irregular surface on the inside. And so when the atrium is fibrillating, which means it's like a bag of worms just fibrillating, the potential for clot to form is highest in the left atrium appendage. And so here we finished ligating it. And we are emptying the sac. This is an older video. Today, we just take scissors and cut that tip of it and then put some more ligatures on to completely isolate it and make sure that it's completely gone. There's a lot of interest right now in the left atrial appendage and in our ability to exclude it in order to prevent the risk of stroke. This is an example or a diagram of the device that we use today for atrial fibrillation ablation using the da Vinci robot. It is a dual-energy device that has bipolar and monopolar capabilities, which adds to the efficacy of the ablation. Here's another example. This just shows the left atrial appendage ligation in another patient here and shows a little bit about what the procedure looks like from the outside. And as you can see very similarly here, this video has a clip of the echo, which I kind of wanted to show. And it'll come up in a second here. It's very similar. We finish the procedure. We come around to the left side, three 5-millimeter ports. We have to isolate the lung when we do this. So here is the echo. You can see the appendages right here. And as the snare is coming down, these two come together and the space is completely obliterated. And then, once we're done with that, we incise the tip and then put a couple of more ligatures on to completely isolate it. We've studied some of these patients. And this is an example of a CT scan that was done on a patient, where the left atrial appendage was supposed to be right about here and is now completely gone. Some more examples of procedures that are done with the da Vinci robot in cardiac surgery. This is a patient who requires pacemaking and unfortunately has a totally occluded superior vena cava, and was unable to receive a transvenous approach, and was referred for placement of epicardial leads using an endoscopic approach. And you can see here this is coming in from the right side. And we've put two epicardial leads on the right atrium. Not a common thing, but definitely something that we can do. The more common lead that we put in is a left ventricular lead, when the patient requires BiV pacing and the coronary sinus for some reason is unavailable or the patient can't have transvenous coronary sinus catheter. How about aortic valve surgery with the robot? Not currently performed with the da Vinci robot. It is performed minimally invasively though. We do a port-access aortic valve replacement through a right mini thoracotomy in the second interspace. This is enhanced by sutureless aortic valve prosthesies, which are coming hopefully soon to the United States. They are approved in Europe, but not yet in the United States. Obviously, transcatheter aortic valve is something that is on the rise. And we perform a lot of those procedures as well in collaboration with our interventional cardiologists here. This is one of the very few aortic valve procedures that were performed using the da Vinci robot. And as you can see, the instruments here are a little bit different. We are looking at 5-millimeter pediatric robotic instruments. We developed this procedure with multiple surgeons around the country and came to the conclusion that given the majority of aortic valve disease as calcific-- not like this. So this is an aortic valve that's being resected that's not terribly calcified. It would be better to wait until we had more robust instruments and the sutureless valves to be able to proceed with aortic valve replacement. But we did do some procedures using robotic technology. And this is an example of one of them, a patient who had severe aortic insufficiency. And we used a stentless valve that does not have a rigid stent. And so we're able to use a running suture for this. This valve is made out of pericardium and, as you can see, the exposure with the da Vinci robot is very, very good through a small little 2-sonometer incision in between the second and third interspace. And here, we are situating this stentless valve on to the aortic annulus after. The benefit of doing surgical aortic valve replacement compared to transcather-- one of the benefits-- is that you are able to take out all of the calcium from the annulus and allow for a potentially larger prosthesis to be placed. Obviously, it's significantly more invasive than what a transcatheter valve would be. In the meantime, until robotics become available for the aortic valve, this is the approach that we use with a very small incision-- as you can see here, in between the second and third rib. We use a knot-pushing device to tie the sutures. And in this case, what you saw in this panel was a valve that had a stent-- an aortic valve prosthesis that had a stent that was placed through this very small incision. The patient has to get cannulated in the groin, similar to mitral valve surgery. And this is a man who you can see from his body habits would definitely benefit from not having the sternum cut open. So this is a preview or a brief overview of some of the procedures that we perform in the minimally invasive robotic heart surgery program at University of Chicago Medicine. We're always learning, and we're always advancing and using new technologies to try to benefit our patients, minimizing the trauma while at the same time maximizing the efficacy. Thank you very much.
