Least-invasive open-heart AVR option to date yielded rapid recovery in all cases surgeon looking at small monitor at operating table during surgery
Four patients who underwent
robotically assisted aortic valve replacement (AVR) with transcervical access
were able to resume an active life one week later without any restrictions,
reporting low-level pain during recovery.
Cleveland Clinic cardiothoracic
surgeon Marijan Koprivanac, MD, who performed the operations earlier this year,
announced the results in a late-breaking presentation at the American
Association for Thoracic Surgery annual meeting in May. The series is the first
known report of the clinical application of transcervical robotic AVR.
“We are optimistic that this strategy
could be a breakthrough for offering the benefits of surgical AVR without the
lengthier and more painful recovery associated with current options,” says Dr.
Koprivanac.
Transcervical robotic AVR – an
innovative new approach
Surgical AVR (SAVR) has undergone
rapid evolution in recent years with the aim of preserving advantages of an
open-heart surgical approach — primarily complete debridement and removal of
the diseased native valve, and potentially longer durability of the new
implanted valve — while reducing invasiveness. “Although SAVR via sternotomy is
still regarded as the gold standard for surgical candidates in need of an
isolated valve procedure, currently it should be performed infrequently, if
ever, because of the availability of excellent less-invasive options, including
mini-sternotomy, right anterior thoracotomy, and transaxillary and robotic
SAVR,” Dr. Koprivanac notes.
Robotic assistance for AVR is now in
the vanguard of this evolution, conferring the advantages of smaller incisions,
enhanced visualization and greater precision compared with other surgical
methods. Combining robotics with a transcervical approach — potentially
offering an even less-invasive option — is being explored by a few groups, but
Dr. Koprivanac is unaware that it has been performed by others beyond
feasibility studies in cadavers.
He first took an interest in this
strategy after learning to perform transcervical thymectomies while in
cardiothoracic surgical training. Access is through a small incision in the
neck, without need for a thoracotomy or sternotomy incision.
“The transcervical approach is well
suited to AVR, as it offers an excellent view of the aorta and aortic valve
from above,” Dr. Koprivanac explains.
He developed his novel technique on
human cadavers, in an anatomy lab at Cleveland Clinic Lerner Research Institute,
using a mammary retractor and then a specialized transcervical retractor. He
soon brought in some of his surgical colleagues and team. After demonstrating
feasibility on some 20 cadavers, they started offering the procedure to
patients at Cleveland Clinic.
The procedure and initial patient
experience
The procedure involves four incisions. The main one, for robot entry, is placed at a neck crease to minimize scar visibility, similar to the incision in thyroidectomy patients. Placement of the other three small incisions is detailed in Figure 1. Decalcification and debridement of the aortic annulus is performed as needed, and the new valve sutured in.
The four patients who underwent the
procedure were aged 60 to 74 years. The replacement valves used were the
Perceval L in one patient and the Inspiris Resilia #25 in three patients.
The average cross-clamp time was 140
minutes. Postoperative discharge was at 3 days, 4 days (two patients) and 6
days (in a patient who developed complete heart block and ventricular
dysfunction, requiring pacemaker implantation).
A local anesthetic was injected when
the incision was closed at the robot entry sites. Postoperatively, all patients
reported minimal pain and were managed with acetaminophen and ibuprofen unless
additional procedures were needed. Patients had no restrictions, from a chest
wall healing standpoint, a week after discharge, with one patient reporting
that he had resumed running in the gym at that point. Another patient was back
to his farmwork at week 3 after surgery. “These types of activities are
unimaginable so soon after other AVR approaches, even minimally invasive ones,”
says Dr. Koprivanac.
“This is an important advance in
cardiac surgery — completion of a surgical aortic valve replacement with no
incisions in the chest,” notes Marc Gillinov, MD, Chair of Thoracic and
Cardiovascular Surgery at Cleveland Clinic.
Chair of Cardiovascular Medicine
Samir Kapadia, MD, concurs. “This is a great advancement in minimally invasive
surgical treatment for aortic stenosis,” Dr. Kapadia says. “This surgery may be
preferred by patients if it delivers similar safety and efficacy as other,
more-invasive surgeries.”
Future goals – streamlining and
standardization
Dr. Koprivanac and his colleagues are
continuing to offer this new approach to qualified patients who require an
isolated aortic valve procedure.
“The procedure is getting easier as
we learn from each patient,” Dr. Koprivanac says. “With experience, we are
refining techniques — such as optimal port placement and level of valve
introduction — and becoming more efficient. As we have proved the safety of the
procedure, reducing cross-clamp times is the main goal now.”
He and his colleagues are also
exploring designs of new instruments and sutures — and adapting existing ones —
to facilitate the careful manipulation required in a very tight space.
Reducing the cross-clamp time to 90
minutes — and ideally to around 1 hour — is an important goal, and Dr.
Koprivanac expects they can reach this target once the operation has been
streamlined. “Our first priority is always safety, so we are proceeding
cautiously to ensure a good outcome in each patient,” he says.
He adds that the potential of this
operation is that patients might be able to be discharged on day 2 after the
surgery. Although some patients in this series appeared ready for discharge on
postoperative day 2, he notes, they were kept longer for observation owing to
the novelty of the procedure.
Once Dr. Koprivanac and colleagues
develop an efficient technique they are satisfied with, they intend to
standardize it for reproducibility by other surgeons, but he says this will
likely remain a procedure of highly specialized centers.
“Seeing how these first patients’
experience and recovery were so much better than with current approaches, we
are highly motivated to perfect this technique to benefit more of our
patients,” he concludes.
https://consultqd.clevelandclinic.org/worlds-first-transcervical-robotic-avr-procedures
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