Dr. Guy from Georgia Heart Institute gives a front row seat to a robotic mitral valve case with incredible visual quality and unmatched expertise as he operates on a fellow United States Marine Corps patient.
Right, ladies and gentlemen, let's take our seats. We have um three live cases um simultaneous and as you know, patients are ready to go. So please sit down, enjoy the show. All right. Um What I'd like to do is on uh behalf of my co moderator, uh Mike, Mike, I don't think they've met you yet. So, if you want to introduce yourself, hello, Michael Haco. Uh I'm at Emory University. Happy to be here. Thank you. Yeah, Mike is uh chief of cardiac Surgery at Emory. And um, we're really, really privileged today to also have a, a live robotic mitr case done by Doctor Sloan Guy. Um, we'll have a uh structural, so Sloan is gonna do a robotic mitro Ronnie Ramadan and his team are going to do a percutaneous mitr replacement. Um, and then Falcon Patel Nima Gaza and Glenn Henry are gonna do a complex coronary case. So over the next two hours, we're going to be toggling back and forth across those rooms, but perhaps before we get started, we'll ask our esteemed panelists to introduce themselves and um get the conversation going. Hi, I'm Karen Gersh. I am a currently working here at Georgia Heart Institute and these are my partners. I'm Benita Shaw. I'm an interventional cardiologist at NYU in New York. I'm Raza Boss. I'm one of the interventional cardiologists at Georgia Heart Institute. I'm Sunil around intervention cardiologist at NYU, uh, uh, interventional cardiologist at Brigham and women's great. So, we have, uh, two cardiac surgeons and a few more interventional cardiologists. Um, all right. So, um, without further ado, uh, let's, uh, go to Sloan guy's room. Um Sloan. Um I'll have kind of you and Mike Hall do a lot of the moderating uh in your session. I think uh the, what we're gonna do is have every room, take five minutes and present their cases. Um And then we'll go back to Sloan's room when he gets started. So, Sloan to you, good morning guys. Uh Good morning, Mike. Nice to have you here. Habib, thanks for uh hosting our team to do this uh robotic mit case. Uh We're here at the Georgia Heart Institute at the Northeast Georgia Medical Center in or three live and go to the next slide, please. And uh we're going to show this case here. So, the first thing I'd like to emphasize is the importance of the importance of the robotic cardiac team and that the robotic surgeons in the room understand this. Well, uh we really have an incredible team uh here and I just want to go around and sort of introduce everyone here to my right here. We have uh heather, she's our circulating nurse who's uh really outstanding uh to my left here, we have Missy, who is our perfusionist, uh who's uh really been fantastic. And uh we have Ashley uh here is our scrub nurse as well as SID. Sid actually helped train me in robotics many years ago. So, having him here as my first assistant has been a real blessing. Then we have at the helm, we have Doctor Jason Lemons, the cardiac anesthesiologist with uh Bono uh the anesthetist. And then last but not least we have Chaz one of our circulating nurses. Uh So really, this is a great team. We run this next slide. We run this team very much like uh a team of Navy Seals or any other high performance team. So just to present the case, uh this is a 59 year old male, a former marine. We thought a marine would be a good kit for uh this uh for this presentation. He self referred to me with severe mit regurgitation. He gets short of breath with one flight of steps and has decreased exercise tolerance. So has a class one indication for surgery past medical history is relatively unremarkable. Sometimes a hernia repair can come into play but not usually when he has severe Mr due to P two and P three prolapse with ruptured cords, which we will show you next slide, but just to go through the films, we did not get a regular cat on this patient. For low risk patients, we usually start out with a coronary CT angiogram just to save an invasive procedure. And here you can see the patient has a nice led left Maine. You see the circumplex and as you look around the back of the heart, you can see that this patient has one risk factor. We need to pay attention to which is a left dominant coronary circulation, which will be running very close to the aulus. So I need to be very careful putting those sutures in. Next slide. Here we have a 3D imaging, very sophisticated imaging from a company called Immersive Touch. And this was basically a video of me using VR technology. A VR headset where I can really turn it around and see exactly where that circumplex coordinate artery is. And you can see it's quite helpful. Um It's even more impressive live and 3D. Next slide, the ct of the chest admin and pelvis essentially similar to a tavern we consider to be mandatory. It reduces the stroke risk significantly. And you can see on this study, it's sort of glaring what the problem is. So the challenge is this patient has extremely tortured celiacs, particularly the left, but also the right. So we were a little nervous about that. Um And prepared to use advanced catheter techniques to get our catheters up but didn't have to do that. We're already cannulated you see the ferals are nice and robust. You know, the minimum for this case is probably five or six millimeters. In which case, we would do bilateral cannulation. But in this case, we were able to cannulate the right groin with a 23 French arterial and an endo balloon. And then on the right hand side, you see the operative view and we're able to essentially do a tomogram and see that the diaphragm was really unlikely to be a factor. So looking at this case, our two big glaring challenges are the tortuosity of the iliac. We were able to get all the lines in. Ok. So, so that's sort of behind us. Although seating of the end of balloon to stop the heart could be a little challenging and then the, the circum in the coordinate group next slide. And this shows it in using that 3D VR mode. And you can really study it. And you can see that that internal iliac artery takes almost a 360 degree turn back on itself. So there was a little bit of concern about that. You got to be very careful not to injure the a a with a wire or with your dilator because that could cause a dissection. And then we can see on this film that the patient has normal arch anatomy and we can even, we can even flip the patient over into the operative view and put skin on the patient. This technology is really nice. We hope to eventually be able to actually use it live in the operating room and you can see the rip spaces. Our plan was to put our cam report in probably the fifth interspace, which is usually where it goes and you can see he's a pretty fit guy, not too obese, so that we've got that going for his next slide. This is the transthoracic echo which were basically normally have normal left and systolic diameter. No problem with tr they read it as mild A I, although we weren't sure about that. And now I'm going to turn it over to doctor Jason Lemons from cardiac anesthesia who is going to show the trans echo. All right, good morning. Um I'm just gonna jump in here and focus on the uh micro valve. Um We, we uh do a full exam but I'm just gonna focus on what we saw with the uh microvalve as well as go through some of the uh risk, the uh sam uh risk factors. Uh Looking at the screen here, we have a a um meso views. This first one is the long axis view. It does show the uh Lale poster leaflet uh with a uh anterior directed jet. The uh uh next image is a two chamber view showing the same thing probably uh P two P three and this is the view at 60 degrees. And then the uh four chamber view looking at a 3d uh image, you can see the sort of medial P uh P two P three flail leaflet. I'm not sure if, if it picks up, but there's also a uh cord, a ruptured cord. And if I put color on that again, you can see the anterior directed jet. So, so as part of these cases, we uh do assess the risk factors for uh Sam. And after measuring the uh an interim poster le leaflet, uh we uh calculate the A LP L ratio for this patient. It was 1.9 A, uh less than 1.3 is considered high risk. So, uh this is a uh low risk so far. Uh looking at the sea sept distance, the um coaptation point to the uh septum, the um distance less than 2.5 is, is a high risk for A AM. And, and this measurement shows uh 3.69 centimeters which is low risk. The uh mitro aortic angle is also something that we measure um less than 1 20 is a, a high risk and this patient was 1 21.6. And then the, the LVN diastolic dimension of 5.1 and the LVN systolic dimension of 3.3 are both low risk factors for uh SAM. And, and uh lastly, the uh basal septal thickness of uh 1.3 centimeters on this patient. Um greater than 1.5 is a uh high risk. So overall, this patient has a uh low risk of um postoperative sam. All right. Excellent. Thank you so much. Uh Doctor Lemons. So now I want to take you over here to see the incisions rich if you could pan over here and show those. So basically what we've got here is starting from the neck down in the neck. You can't see it, but we have a 19 French, the PVI A cable drainage catheter. We use bi cable drainage on all these cases because we're completely endoscopic and we don't want any blood in the heart. We have the 48 millimeter metal robotic ports for the left arm, the right arm, the left retractor and the camera. And then we have an eight millimeter air seal port, which is a unique port used by a lot of other types of surgeons like general surgery, which maintains insufflation while we work through it. And this is pretty much the smallest port set up in the world being used. Then if we go down here to the groin, what is also unique about the way we do it is we have learned from our experience and we do all all percutaneous cannulation. So in the right one, we have a 23 French endo return cannula with this side port on it through which an Endo balloon, which is a long catheter going all the way to the aorta with a balloon there, we're going to blow that up with the liver card. Pleasure. That's how we're going to stop the heart and that's how we're going to get blood into the body. We have a 25 French Venus Cannula in the left femoral, I'm sorry, in the right femoral vein. And that's how blood will return. And that's done all percutaneous. And we've, we've pre closed that with two proglide sort of at 11 and one o'clock. Very identical to what you would do with a tavern. When we cannulate, we do it with high frequency ultrasound, a micropuncture set, we pre close it, we do an aio gram to verify we're in the common from artery and we actually cannulate under fluoroscopy, which I believe is the safest way to do this and particularly with today's case with the tortuous iliac, it was incredibly helpful to have that. So that's our set up based on the echo. Our plan will be for neo cords to P two and maybe P three, probably P three with or without a commis stitch on the right side and a ring. I don't think we have to significantly undersize that ring, but the same risk is low if we feel we need to. So we'll let you go to the other rooms. Uh We'll go ahead and get set up and bring you back inside the heart. Thank you. Great. Well, solo and team Jason. Thank you very much for that. Uh lovely overview. Um And we'll let you guys get to work and we'll probably come back to you in about 10 to 15 minutes. Uh Once we've seen the other two cases, um, obviously Mike, we'd love to hear your insights onto the case as well. Well, listen, uh, gentlemen, ladies in that room. Um I think, why don't we kind of stick to our plan and, and head back towards Sloan's room if they're ready for us. Um uh Sloan, are, are you guys ready? Yep. It looks like they're ready and I'll have Mike really kind of help moderate this part because he's also a robotic surgeon. Hey, hey, how you doing? I'm good. Everything looks uh really nice so far. Um I was watching, I'm sorry, go ahead. Yeah, I was watching as you uh arrested the heart. Uh and you had a great result with the end of balloon uh comment if you can about when you're going to use a transthoracic clamp. If ever um with that much tortuosity, maybe I would have used a clamp but you, you again, you had a great result, the heart arrested quickly, no uh migration or anything, but maybe first comment on that and then uh we see that you're closing the appendage first, but go ahead. Yeah, absolutely great. Thanks Mike. So I, I did think about that, you know, possibly um using transfer acid clamp as a way to deal with the tortuosity, but I was pretty sure we could get the balloon around given that his iliac while tortuous were very healthy without calcification. And um on rare occasions, we would use a cross plant, a trans acid cross plan or shit would plant if we thought we couldn't get the balloon up or we had limited small access. Um say the fem were no good and we were using an axillary approach which we do percutaneously as well. Um to uh can, can, can you guys um sorry to interrupt. Can, can you both just see that you mentioned the transthoracic clamp for those of us that don't use it. Could you all? Yeah, let me, let me show this to you, Habib. Yeah. So here's the balloon. So this is the A ce order here guys. You can see that and that's the balloon blown up there and I'll show you something else. You see that green glow that is uh IC G nine firefly technology. It tells us exactly where the balloon is and the balloon is a little lower than I usually have it, although it's not bad. And that's because the, with the tortuosity, you know, we've probably got a little bit of increased, increased slack. Now I'm close, as you mentioned, um I'm closing left at pend and you notice that I'm using a barbed suture. It has these, these barbs in it like a binger. And um this technology has been around a long time and lots of different specialties use it. Um We were the second group to use it in the world. I learned it from a guy in China and what it allows you to do is not have to tie that knot. So we've put one of them here to expose the post your angles. I always close the left atrial appendage first, primarily as my valve exposure technique. And if you're ever, if you need of the cardiologists in the room, if you're ever watching a surge and do a, the way you can tell the amateurs from the pros is the probes will always take time to expose the valves even if it takes a while. What's the cross is? 15 minutes? Yeah. So we're 15 minutes cross by time and that was to close the left advantage and expose it. We really take our time. I'll take the uh suction, right. That's what I want to point out. So now what we're gonna do is kind of a valve analysis. Um Can we get, can we get a laser pointer as you're, as you're showing us point out the uh an interior leaflet, the scallop post? Good point. So let me show you the anatomy here guys. So this is the left, this is the anterior leaflet here. OK. So a one would be over here. A two here. A three here poster leaflet P one P, two P, three sort of the um enter your lateral comma close to your media commas here. And then the Trigo here and here, left and right. Ok. Now the, er, valve is right there, right on the other side of it there. And of course, the circumplex artery is running right here and we got to worry about it today. It's left dominant. So basically, this channel that we've left here is where the circumplex is and we don't want to hit that with any of our futures. And this is clearly the problem here, which is exactly what Jason shared on the echo. Although it seems like it may involve a little bit of comma but certainly more to towards the P three side. And so what I'm looking for, we can start out of analysis at this point is not so much that because I know I've got to fix that, but the other part, so I'm gonna grab this P two part and kind of push it down. And by the way, if you were to fix this with a clip, that'd be the sec, that'd be the segment you want to get. OK. And I can kind of see. So if I push this down, we should get a pretty decent result. There is a little there, but it's really what we've got to do is here. So at the moment, my plan is to do a Neo cos to either side of this and then reassess and then put a pretty decent size ring on this. Um And you can see a one a two A three, p one, p two p three. Uh although it's a little distorted, any, any uh questions, Mike comes up. Yes. So, Sloan also uh just for the audience. So right now, Sloan's testing the valve, he's inflating saline to pressurize the ventricle to uh reass simulate where the source of the leak is. He's looking inside the ventricle. Now, at the PAP muscles, you can see with this approach, the exposure is really unparalleled, unparalleled, you can drive the camera into the ventricle and really get very precise placement of your uh neo cord sutures, the neo cords. I'm assuming you're gonna be using cortex suture. That's what we're gonna, we're gonna use two neo cords either side of this. And one thing I would like to, to mention what Mike just said is, you know, I'm an old college receiver and I'll tell you a good receiver does not in football doesn't have great hands. They have good eyes, your ability to see, to see these things so exquisitely is very high with the robot even better than sometimes open cases. And so that's, that's really what makes this, I think a great operation, not just for minimally invasive but for the repair itself. Now, these are sort of homemade Accords and the Accords are nothing new. They've been around since the seventies. But what we do is we make sort of a homemade version where we tie knots here, sit uh sit our first assistant has done that with a pledget and this is, these are exactly 12 centimeters long on each side. Go ahead. And so, so Sloan Sloan, sorry to interrupt you while you all are talking about that. I wanna make sure our audience um is understanding the sort of the very basics of what we're trying to accomplish, right? You've got this flail posterior leaflet, you've got a cord prolapse. And then, um so the three main things you all do when you repair is sometimes uh you'll, you'll resect a part of the flail leaflet, you'll reattach it together and then you'll do something with the cords and then finally, you'll do something with the annuus, right? So there's an, there's other and chords two principles and essentially you are able to restore or deal with the leaflet pathology. And there's different ways to do that. Habib mentioned it. One is a uh neo coral reconstruction strategy that's very commonly used. That's what Sloan is doing right now. Uh The other is a resection approach, both work. Uh It's depending on the surgeon at different types of pathology will deal with things in different ways. Uh And this help people understand the difference between the two. Let me do that. Let me do that real quick because I can show you here. So I'm putting a neo cord in and the goal is to push that down right now. What I could do and it'd be totally acceptable was I could do a triangle resection. OK, which is popularized um at Mayo Clinic. But you could, you could cut from here to here and then sew it together. You could not cut that out and just put stitches to do the same thing. Traditionally, Dr Caron, sort of the father of all this would have done a quadrangular section here and then either placated these two angular points together or more likely in this case, slid these two points together so you can resect this. Now, I think most high volume uh micro surgeons have migrated more and more towards cords for a number of reasons. One is it preserves coaptation, uh which is the key to this operation. You want more coaptation, the more solid this repair is gonna be. And the second thing is if I screw it up and I'm not happy with it, I haven't, I haven't removed any tissue, I can literally start over. Whereas with the reception approach, if you take out too much, which I, I did early in my career, um then you can, then you're, you know, you're screwed, you gotta, you've gotta replace that valve and then really a replacement in a valve like this would be considered a complication. It's one you want to avoid, um especially in, in a young person. But um that's the difference. Does that answer your question? Yeah, I think it's definitely helped me and I hope it's helped some of the audience too. Thanks for that. And so we've just put one set of the accords from the anti ladder pillar muscle up to the um uh up to the sort of the left side of P two or whatever we wanna call, that prolapse segment said, open, close thick. You have to be very careful, by the way, removing needles inside and out, you can drop them in the chest. So I'm not going to adjust that yet, but you can see we're set up. OK. And I'll take the next uh set of Sloan while you're doing that. Uh just to again, touch on the other uh components and you mentioned them, you know, we want to address leaflet pathology totally acceptable to do resection approaches totally acceptable to do neo cords. It depends on how much tissue you have. In this case is what Sloan's doing. Really, the pathology is limited to that one segment, the P three P two segment. But in a lot of patients, Barlow patients, the entire valves will be billowing and prolapsed. And you can use a combination of approaches, you resect a portion of the posterior leaflet, you put cords in the anterior leaflet um to get the optimal results. So address leaflet pathology with a multitude of uh different techniques. Um remodel the annuus. That's the key uh for a durable repair that Sloan mentioned. Uh not to undersize aggressively in a patient with degenerative disease or prolapse disease, but to restore what would would be a normal size of the annual. So that's what the ring does. Uh And then finally, is that ring, you are trying to achieve an optimal area of coaptation so that the anterior poster leaflet will overlap enough. Uh so that you minimize any uh central jets or leaks after the procedure. So hopefully, with what loan is showing you, you could see really clearly um that you have a variety of options, but key is that you can really see inside that ventricle uh into those pai muscle bundles uh to place those cords in. And um, you know, so far, so everything looks really nice. Yeah, I think it's, it's, you know, it's a good, a good plan. The only question is, you know, am I gonna have to deal with that commissure over there? Um uh prolapse always bothers me, but it seems like maybe this is normal, this little short P three segment. So hopefully we'll see. It's, it's, it's fascinating to me, right. So we have several people in this room and in that room that are really, really expert in examining the mit valve without any movement, right? And I, I'm looking around the room at our panelists including Karen, who's, who's done a good bit of this. And, you know, for us, cardiologists are used to looking at echoes and Ts and, and functional. It's just mind boggling that you can take this still anatomy and then derive. So much information from it. Any comments from the panel on that front, either Karen? Do you have any comments in general? Hey, Sloan. Um Quick question. Do you, do you want to comment on uh premade chords and your pros and cons of using those? Because I think that's a go to, to a lot of the folks in the room. Um What is your, what is your thoughts on that? Yeah. So premade cords essentially are where either by echo or live, you sort of estimate the length of your cords. And you know, it has some appeal uh particularly um for those who don't do a lot of micro repairs clothes because it's, it's simple, essentially what you would have. Instead of these going through the leaflets, you'd have little loops and you just simply attach the loops uh to the um uh to, to the leaflets. The downside of it is you can't adjust it. And I'm going to show you in a minute why I think, you know, most really high volume micro pair surgeons don't like that. And it's because I'm gonna want to dynamically adjust this with two goals in mind, one to create a decent cooptation zone. But the second will be to um to prevent SAM because the way the out tract is right underneath this anterior leaf in here. So I need crup to occur posterior here. And the more I tie these down, the better I, by the way, just eyeballing this. I bet I'm gonna end up putting a stitcher right there. You'll see. Suction Irrigator. Right. On another, on another note, can you kind of after you fill the heart? Because another important thing is the suction Irrigator. So you can really get good distinction of the ventricle when you're in this. And just if you can kind of let the crowd know how when you look at the anterior leaflet relative to the poster leaflet with the heart arrested like this and you're uh such suction Irrigator installation of um volume of the ventricle. Tell him the uh the the height of the anti leaflet relative, the poster leaflet for, for potential for potential Sam. So if that poster leaflet is high, you know, that's a, that's a problem, that's a risk factor for Sam. So, Sloan is in inflating the ventricle with saline. So he can test his core to see if he's uh adequately reduced the height of that uh prolapse segment of. I mean, the only question is, what do you think, Mike? I, I think I might be OK as is, you know, it looks, it's interesting because this, this sort of pulled this leaflet way over there. So where I thought there would be a problem, there's not. But the question is, do I need to push that down as a sand reduction? I'm thinking not, but maybe, you know, not undersize that ring. What's your opinion, Mike? So I, you know, I think you, it looks good. I tend to when I'm using cords in the posterior leaflet. If I'm gonna to err on the side of how long those strings are, I'm gonna make them a little bit shorter. I would probably cut. Right. Would, I would probably leave everything else alone for now until I put the ring on. And then that right there is, is interesting. Now, um, a lot of surgeons will, um a lot of surgeons sit, get down there, please. A lot of surgeons will uh leave these cords to the final um uh adjustments until basically, um until basically the ring is on and that's fine. That's a good technique. I, I'd like to get him out of the way now. Um And I haven't seen any real problems doing that, but the, the one advantage to that of course is that you can really make fine, even finer adjustments, but I'm pretty happy with this as long as I don't go overboard with my ring side. Like I say, the only thing I might, may or may not do is put AAA core there, but I, I kind of like it the way it is. Sid, what do you think? I think it's perfect. Well, Sid thinks it's perfect and, and Sid is never wrong. Yeah, I, I don't disagree with shit ever. Right. But it's, it's, it's fascinating. So, Sloan um let me, let me just make sure that and I think I mean, I think there's a huge amount of, of learning that's going on right now and just absorbing, let me add like, um either Benny or um Benita or someone else who's kind of looking at this from the cardiologists perspective and see if you guys have any other questions that you think either yourselves or the audience would like to hear. Yeah, I mean, one of the challenges we have with my work is that um it's so hemodynamic dependent, like, so when we're doing clips and the patients are under anesthesia and their blood pressures are a lot lower. You know, we sort of expect at times depending on, on what's going on and, and what the patient's co morbidities are that perhaps their Mr will be a little worse once they're excavated and they're back to their usual routine. Obviously, medical therapy plays a huge role for that in terms of blood pressure control. Um But I i it's a little difficult when you're in a somewhat artificial setting. Um I'm curious to know how you test that here and, and yeah, good question. So it is true that when we're um when we're repairing this valve, we're essentially repairing it in a diastolic state, right? That the heart is relaxed and so that can throw you off a bit. There's no question. And I think one of the advantages of, you know, trans cap repairs ultimately will be the ability to adjust these live with the heart beating and full of blood. And I have no doubt that in 10 or 20 years from now we'll be able to do a procedure very similar to this percutaneously. Although I actually think it will be with robotically controlled catheters that can make it very fast and efficient. But, but it's sort of an art form. Um, it's the, you know, it's the art of, of understanding these, um, relationships into as compared to Sicily. Um, but there's no doubt it's, it's a disadvantage of doing it with the heart, uh, arrested. Yeah, it's, it's, it's such a, it's, and I'm looking around the room love to have any other comments, but it's such an aha moment, right? I mean, we know you guys do this all the time. Um, and we cardiologists kind of understand what you do but when you watch it like this, the, the, the artist as, as it were of being able to extrapolate kind of this diastolic resting state and then doing it so well and getting that experience that, you know, I mean, Mike, how much have, I mean, is this part of the reason why there's such a huge learning curve for doing these? Yeah. So there's two learning curves here. One is the minimally invasive or robotic approach to anything in cardiac surgery. But then the other is how do you fix valves? How do you know what to do? Um, and it takes time just like anything uh transcatheter uh approaches um uh interventional cardiology. So there is definitely a learning curve. Um I think the younger generation of trainees is coming out with a lot of minimally invasive exposure and experience. And so the uh the onus is on uh us to train how to do the valve repairs surgically because to your point, I mean, these are tested under diastolic with the heart arrested, it's not beating. And so you, but we are anticipating that as we're repairing this, knowing what we need to do to achieve that result. And, you know, sometimes we got to go back and make some adjustments. So in addition to what Sloan, you know, we're gonna see how this goes. But, you know, I know he's thinking, yes, I'm gonna deal with the obvious pathology at hand, but he's also at the end, going to look at every segment of that valve and be thinking, you know, what is at risk for becoming a problem in the future, 10, 20 years down the road like that P two area that maybe is showing some signs that it could be a problem in the future. And how do I do some uh maneuvers to almost preventative man maneuvers to prevent that from being a problem in the future? I think that's a good point, Mike, because a lot of times, you know, many of us myself included, we focus on today and obviously that's, that's the priority today. But, but the durability of the valve repair, you know, is this repair gonna be ok? You know, 10 years from now. Um and is, is also important and it's, you know, it's a balance like everything else. There is a failure rate by the way and anyone who says differently is, is not telling you the truth. And um it's about, it's 5 to 7% at 20 years. Got it, Karen. Yeah, I I was still want to point out to our co cardiology colleagues, how important preoperative imaging is for us, surgeons. Um And I know sometimes we're a little picky about tee measurements. I need this, I need that. But you can see why now why we need to see this dynamically on the echo and be able to have measurements of our annuus, our leaflets. No sam. We also need to have a good idea of our, our coronary anatomy. So we're, we're a little bit uh needy, but there's reasons for it. So we're a little bit needy. OK. You know, I have to say, you know, watching you work here is like is mesmerizing. And I, I might ask a little bit of a naive question, but it's, you know, how do you with this robot? You know, I would imagine that when you're working with your hands, you have some sense of what the tactile feel of these. I mean, how do you, how does it translate with the, there's no tactile feedback in the current generation robot. However, if I push this tissue, see me doing that. OK, I push that tissue, I see that tissue deform. And so what happens is by the way, this is our size or regular sizers won't fit through our eight millimeter port. So Ashley may be ahead of time or, and um but, but I see virtual um I see visi visible deformation of the tissue and, you know, having operated a lot, I kind of know, um I kind of know uh let's see, a 34 I kind of know uh what the tissue's characteristics are, the physical properties of the tissue. So my brain is, since I can feel, I can tell you, I can feel this. No, it's virtual in my mind, but it's based on the visual feedback. So our brains are trained to make up for sensory deficits and my brain is no different and the lack of actual tactile feedback is made up by watching the tissue deform. As I see again, I cannot stress in surgery. How important the eyes are just like in cardiology. The imaging is, you know, it's the same deal. I'm thinking of 34 Mike. What do you think? Sometimes I'll test the valve uh to distend the ventricle, but I'm thinking 34 as well so far. Are we talking 34 miles here? Ladies and gentlemen. So talk about the, talk about the size of the, that you're gonna use Yeah. So we're gonna use a um a Metronic semi plus which is a flexible band, which is sort of an anti A uh band. And the measurement distance is basically either inter trigonal distance or a P distance depending upon how you think about it. Um But the bigger the distance uh and that's in millimeters, the bigger uh the angle. So I think this is about a 38 millimeter uh valve and a P distance. What did you get? Uh What did you guys get from the bond? And so would you guys get to a P distance? All right. Well, we're gonna come back. Yeah, we're gonna have to come back to you uh Sloan, we're gonna have to come back to you because we, we need to get to the other rooms um and then bring it back to take a look. OK. Fantastic. Well done. Really amazing exposure that visibility is like mind boggling, right? We thought it would be amazing for all the cardiology community and our nurses and techs and the whole team to see that unparalleled um teaching experience visibility. We asked for several million dollar robots right here. All right, well said, well said, um all right, ladies and gentlemen, let's go to the or and see what doctor guy and team have been up to. All right guys, we're back, show us, show us the test, right? So, so here are the two cords that we put in and I'll tell you more and more of this is looking like obviously more of a P three problem. We've used those same barb sutures to put the annual Plasty Ring in. We've been very careful to stay away from the circumflex. I always put this additional e pledgeted suture here in the middle for extra support and we're gonna show you what it looks like, Missy, you can turn the, um, root off and we, we've already tested once, but we're pretty happy with it. Um This one area here is that area that, that, that we were, we're a little bit concerned about, but I really think that once the heart drops, it won't be an issue. You can see it kind of runs out. Plus we are pushing, pushing this back. So I think that will go away. Um Sorry when you said once the heart drops, I wanna make sure everybody else. Well, once, once, once the, the order drops on top of it and this poster part is pushing up, I think it'll be fine and it's one of those judgment calls where I could put a suture in there. But I think I'm more likely cause harm the good and just based on experience. So this is the answer that the clarification is post here away from the outflow track, which is over in that direction. OK? And I think it'll be fine. But again, that's just sort of a judgment call I've made, I've gone both ways before where I put a stitch in there and made it worse and, and put a stitch in there and made it better. It's just hard to know, but I think it will be fine. Um, and, um, so now I'm gonna suck it out. Root, put it back on. Ok. So now we've sucked that out. Now, the other thing we noticed, which we didn't see guys on the, um, on the preoperative echo is we actually have a PFO. So you cut right? There's actually a PFO right there. You see it going through there, it's a PFO and so these are very easy to close uh no big deal and we routinely close them. Um, you know, you've got to imagine that it may have some benefit in terms of stroke and whatnot. But any time we see a PFO club and again, I use the same um suture. We used to use regular old fashioned suture and that's fine, but this stuff is just super, super fast and you don't have to tie knots or anything. And um also, I'm not as reliant upon sid, you know, following things, it locks itself. And I just thought since there's a bunch of cardiologists in the room, you might like to see a PFO closure. Um um the um wait, where's the device? Yeah, exactly. Usually. Well, I, I come from teaching institutions like Cornell and others and um I would let the fellows close this, but I'd usually have to leave the room because I couldn't stand watching them go so slow. But I'd let them close these and, um, as sort of their starter portion of the operation and then if they did this, well, you know, I'd let them do more. Um, but actually getting aside just from a surgical technique standpoint, what are you just, is this kind of a running? So this is a double layer running suture with um with a barbed suture? Ok. And basically, it won't go in back in the other direction. These barbs make it so it only go in one direction. And so we're done and this is really in improved the operation quite a bit for us. I have a question uh uh uh for our surgeons actually. Um what, how do you decide what kind of ring to put in? And is there ever any consideration and not have to talk like an interventional cardiologist? But is there ever any consideration about putting in a ring that may be favorable for a val and ring procedure similar to what we saw with Ronnie's case in the future? Of course, your valve is never gonna fail. So this doesn't pertain. Yeah, of course, but it will never fail. Uh No, it could fail. You make a good point. And I've considered that, you know, there's a physio ring, which is a complete ring which we put in sometimes with restricted disease and there's no doubt that would be more favorable. Although I think I'll take the next dish, I think with the across the, I think with the advances in transmit replacement, I think that will become less and less of an issue. I think if you're looking at current technology, you know, putting a safety in, in there. Yeah, I think that is, but I think we'll have a whole lot more devices than that, that if anything the will help because you know, these will be devices that can go into a native, which honestly, there's really not much of an ambulance. I mean, that's what makes a more complicated from a brick standpoint than the uh than the Arctic belts. Now, here, I'm closing the left atrium root v off and, and um, again, we use this barbed suture which, you know, obviously you can tell him very enamored of it while you're, while you're doing that and while you have this wonderful exposure again for you and Karen and Mike, this is kind of you do this all the time, but for the rest of us, we're I and I've been to your room a couple of times and it's amazing. Uh tell us a little bit about kind of your interest or the opportunity to also do sepal reduction um operations through this. So I, I got into this because of a couple of heart failure, cardiologists that sent me some cases and um uh all vent off and um and doctor Randy Chitwood, who's one of Karen's mentor and really a mentor of mine as well. Just vicariously, I didn't train with him, but Karen did um had had done some limitary reports on going through the micro valve robotically. And um it had been done minimally invasive and actually through stoy and dichotomy in the past. But essentially what I do for a Holcomb case is I, I detach the an inter leaf of the mit valve and then I resect the septum which is staring you right in the face. It's, it's actually really easy to do the septal myectomy part. And then we either close the intra leaflet primarily or we put a little patch on it occasionally, a big patch shot it depending upon the size of the inch of your leaflet. And, and that's a great way to do it. We're also doing other procedures. Obviously, a mix would be easy to do this way. Uh We have done a handful of, of robotic aortic valve replacements where basically we just put a clamp here and go right there and replace the tic valve. Um You know, you can do the Tricuspid, you can do redo, you know, there's a, a whole variety of cases with this. Well, listen, um I think uh thank you so much for showing us that. Um and we got to pop over to the coronary room because there's been a lot of developments there. Um So thank you so much for that. Let's, let's give you a hand for the display. Uh It sounds like Karen says, can we go back to doctor Guy's room just to see the te on the valve? Jason, you're up. Hey, we're back. Just uh walk us through the, walk us through the tee images. We got about 60 seconds. OK. 11 quick picture of this groin. If you see it, you can see it's percutaneous. We're gonna close that and now we'll go to the attic, go, go ahead, Jason take, take them to it. So, so if, if we look at the uh meal uh view views here, um Looks like there's good coaptation. I'm just gonna rotate through needle for a view. Everything looks good. I don't see any uh micro regurgitation memories. Torture the 90 degree view two chamber looks good. And then the long axis view clearly there's no Sam nice and there's 300 per significant. If I jump just real quickly to show everyone a 3d view of the uh valve, pick it off. I think we'll end with that and then rotate for the surgeon view there, right? I mean, I'll call you and then I'll like uh add some color there and there's really no, no significant uh re regurgitation. So um looks like a great repair. Thanks. I, I did pay him $20 just to do that. Um I was gonna ask Doctor Clifton Hastings as our floor moderator. And as all of you, many of, you know, he's um head of cardiac surgery for us. Um Obviously, he's been around for a long time, super experienced. So Clifton, we we can you make some comments on sort of this uh you know, the two mit cases we saw, right, the the sort of robotic uh elective patient that came in but everything we learned and all the innovation that goes into doing that procedure versus this uh cardiogenic shock patient that was stabilized and then underwent the percutaneous procedure. What are your comments? Any reactions, advice? Uh First off, I'm, I'm just thrilled to be here and to see the progress that we've made over the past several years in developing and growing the heart team, which is the key component to this. Because if you have one component of the heart team that's excelling and the other is not, then you really run out of options. So this is just a great example of that. I mean, to re operate on a 92 year old and try to fix the issues that she had um would be a surgical disaster. On the other hand, to have the ability to do the minimally invasive approaches that Sloan is doing, doing complex uh repairs. So I think it just underlines the importance of the heart team. And that's the the the greatest achievement that I think we've achieved over really the past 2 to 3 years is the growth and development of that and having all those opportunities available to do that. And II, I think that's the thing I'm proudest of. And uh so, uh that's kind of my comments on that. Great. Um All right. Well, as we get comments, let's go back to the Coronary room. Um and then um any other comments from either the floor or the panel? Um I think we're managing our time pretty well. We have another 10, 12 minutes. Um So um Karen, any uh comments from you, I mean, you've been on the surgical side, super innovative uh kind of as Mike He coats has with uh collaborating with us plumber guys, you know, and gals. Um so talk a little bit uh while they're showing us how they're finishing the both of your vision for kind of hybrid coronary vascularization, which is something you both have been very interested in. I think Mike and I doing this for quite, quite a number of years. We're getting old, I think like. So uh we earlier today, we started off the conversation about care uh and quality and what does that look like? And we now as our, as our group, we look at uh revascularization in a little bit different set of eyes where we can bring a hybrid approach to these really sick patients. And as I see in the future, a comprehensive complete revascularization with mental invasive robotic assisted um port access, uh Lima to the L AD or a right internal memory to the L AD and a left internal memory to the OM and then a stent revascularization with um our drug loading stents to the right coronary or to an too marginal artery. I think that's a very, very good surgery in procedure. Right now. We have folks coming in with stem and the culprit lesions treated with PC I and we bring them back and do a hybrid revascularization with an I MA L ad with assurance for the quality of that artery. And this, these folks I've done a couple here now, I'm pretty new here, but they go home on post op day three and they're back to all normal activities, driving, lifting, pushing, pulling, excavate it really quickly. Um So I think we, as we learn the, the dynamics uh flow dynamics of the coronary vasculature, which I don't think any of us have really good grasp on. I, I do think that less is gonna be more as far from a surgical perspective, not for everybody but for a lot of patients. And that's the, that's the hybrid team approach where we get sick, people out of the hospital quickly with complete organizations and a spared sternum. They don't come back with sternal infections. So that's pretty good. So, Mike, any words? Yeah, I just think, uh you know, interventional cardiologist, surgeons, you, you, I think, you know what you uh bring to the table. Uh, what you can offer with one of the best parts of surgery. I think most surgeons would agree. It's the, and an interventionalist would agree. It's the Lima to L AD and that may be when we put van graphs to the om vessels in the right. That may not be as advantageous as, as we once thought. Uh PC I, I think is a great option. Um Sometimes multivessel PC I including the led is a great option. It just depends on the patient. But I think when you get the both groups in the room, same thing with aortic valve disease, microvalve disease, kind of talk through the options, figure out with each individual patient, what those options can be. Uh It just offers the, you know, best approach for each individual patient. And it's nice for CTO S of the L AD because sometimes the, these CTO S they don't appear to be easy to tackle as a cardiac surgeon. I think that would just be anxiety provoking for me. But if I can drop an I MA to an L ad, that's, that's pretty low hanging fruit for us surgeons. And that gives you guys a lot of options at that point going forward. So, wow. Well, listen. Um Absolutely fabulous work um with all 33 teams. Um I think we're just gonna have to wrap up this wonderful session, three live cases for you. Ladies and gentlemen, to my trolls going head to head in a way a relatively elective patient but with very complex um robotic repair, relatively complex robotic repair, excellent result, a cardiogenic shock, severe Mr patient, elderly patient Calvin valve with a percutaneous mit valve and then uh eventually uh a retrograde CTO after having gone through the hybrid algorithm with a little distal hematoma that they're, they're working on but uh fully uh revascularized so big hand for the three teams. Um maybe we're a couple of minutes over but any uh final thoughts or comments by Mike or the team, nothing new from my side. Uh Thanks for having me and uh congratulations to all the teams with uh great results. I, I just had a quick question. I'm sure doctor guy is gone now, but um we don't do a lot of robotic at our institution. So, what is the expected discharge time for this patient? When do you tell them they can get back to normal life? He, he slumps out a couple of guys to go home the next day and get back to playing golf within a week. So usually it's about, you know, it depends on the complexity of the case and the severity of illness of the patient. This guy probably will go home one day three. Yeah, it's amazing. Yeah. Well, very well. Um I think we have a break now for uh 20 minutes. Uh Let me just take a quick peek before I let you all go. Um Yes, 20 minutes, please uh visit the exhibit, stretch your legs, get a drink and then we're gonna um have the coronary and valve therapy session, incredible speakers. Um Our own doctor Sunil Rao will be here and um Greg Stone is talking and then we'll have Azim Lati and Vino Tora, really world class speakers. Um So we look forward to it, but the surprise is as I mentioned that we're gonna have Doctor Sloan Guy um come up and give an update on um his patient, the robotic mitro patient that he did yesterday that you all saw following that Sloan is gonna take about four minutes, 4.5 minutes. And then doctor Ronnie Ramadan is going to give an update on his patient with percutaneous mitro and then Doctor Patel is gonna talk about his patient. So Sloan, thank you so much. Good afternoon. Um We do have a special treat for you. Uh We have Mr Tony Turner uh with us today live. Can can you put him up there? So Tony Tony, can you hear me? Yeah, can you hear me? We're having trouble hearing him. Um Maybe you could put the microphone up to him um in any case uh Mr Turner was the gentleman. Oh, that's better. Can you hear me? Yeah, I can hear you, Tony. Great. Thanks again. Thanks again for being willing to talk to these folks. Um Yesterday. Uh as you all know, Tony underwent a robotic endoscopic micro valve repair, uh all percutaneous cannulation, eight millimeter ports only. He also you didn't see this, but he received proud therapy to the nerves to the right chest, which probably has decreased his pain quite a bit. We put a ring around his mit, we closed his left atrial appendage. We closed a Peyton frame in oval Tony. I forgot to mention that it's a small hole between your right and left atria that people have. And, uh, and we, and we put a ring around, around the uh valve with the neo cords and the valve looked perfect. Um, we got an echo and it looks absolutely perfect. You probably had another echo this morning. I'm guessing. Um, we or we ordered it in any case. Um Tony, tell us, tell the folks here how you, how you're doing and uh why you thought about having robotic surgery and how it went for you and how you feel about that decision. I, I feel really good. I mean, that was a very short time ago that I was operated on and I'm feeling fine. I think I'm going home tonight and we've already gotten up and walked around the, the quad here a couple of times. Um, sorry, we, uh this all came about because my doctor in North Carolina, Doctor Kemp had found a murmur in my heart and I was getting really, I used to run a lot and I had a hard time running after like age 55. And he said, you've got a, you know, microvalve problem. You need to find somebody that will do a, uh, robotic. You don't wanna cut your chest open. And so we just, my wife actually went and Googled, um, uh, robotic microvalve surgery and you're the first one that came up. And so we watched all your videos and I said this is the guy. So you're a victim of Google. Uh So, yeah, well, that's that, that's amazing. Go ahead. I was, I was very impressed with all of your knowledge on it and everything. And so I felt really comfortable going ahead and coming down here. And so, and it's worked out perfect so far. Wonderful. I think, I think one of the reasons I wanted folks to meet you, Tony was that there's really a paradigm shift in open heart surgery and this is still open heart surgery because we still opened your heart. We put you on the heart lung machine. We actually stopped the heart all that. And, um, you know, we've gone completely endoscopic where patients can really recover much earlier. There's a lot of folks that have done minimally invasive procedures with fairly large incisions, those patients don't recover this quickly. And, you know, to my knowledge, uh I think there's only two surgeons in the US that have been able to send home patients the day after open heart surgery as you will be doing. And that is um I think it's because we're the two that are doing really, really tiny incisions, not, you know, spreading the ribs and all that. So it shows you what's possible. But I think for most of the folks in the room, it's probably a new, um paradigm new, you know, new way of thinking that an open heart patient could go home on post op day one. I, I don't, how many people in the room thought that was even possible before today. Yeah, my partner Karen, she's also a robotic heart surgeon. Um So we, we really appreciate it. You know, Mr Turner is also a marine, so marines are built tough. That's one of the main reasons we uh we picked you and, and we're, we're glad that you found us and we're glad that you, you know, looked out for yourself and that your cardiologist looked out for you. So thank you so much uh for doing this for this uh group of folks.
