Endoscopic Cardiac Surgery in Taiwan

台湾微创心脏手术现况及理念
陈劲辰
亚东医院／台北慈济医院
台湾新北市

Why MICS?
• Minimally Invasive Cardiac Surgery
• Earlier surgery before worse
• Low or high risk?
• Equivalence to conventional open?

MICS in Taiwan
• Non-sternotomy
• Videoscope or direct vision
• Mini-thoracotomy
• Partial upper sternotomy
• Parasternotomy
• Peripheral cannulation
• Robotic, total or assisted
• Endoscopic vein harvest

Taiwan
• Health Insurance
• Cost control
• Market size
• New device unavailable

Pre-Op
• Endoscopic vein harvesting: Vein echo
mapping
• EuroScore-II
• Lung function: one -lung
• Chest non-contrast CT: aorta, anatomy
• Ankle-Brachial index: femoral artery
• Carotid Doppler: stroke risk
• Workup for medical condition

Valves
• Parasternal
– Aortic valve
• Thoracotomy
– Mitral valves
– Others
• Heart echo: confirm, new lesion?

Less Invasive Mitral Valve Surgery

Pre-operative Image
Pleural adhesion?
AP diameter Cardiac axis

Vacuum-Assisted Venous Drainage

Delacroix-Chevalier Instruments

Minimally Invasive Cardiac Surgery
May Offer Better Survival and Safety
Outcomes Than Full Sternotomy –

Materials and Methods
• Hospital-based cardiac surgery database
• 01/2005 ~ 12/2012
• Three approaches: N=821
– Full sternotomy (FST), N=177 (21.6%)
– Mini-parasternotomy (MPS), N=283 (34.5%)
– Mini-thoracotomy (MTC), N=361 (44.0%)
• Excluding high-risk outliers (non-elective,
LVEF<30%, or EuroScore-II>10%), N=722
(87.9%)

Results
• Three approaches (MPS, MTC, FST) had
heterogeneous preop baselines and cardiac
pathology.
• MICS was preferred with lower EuroScore-II,
non-MS MR, and absence of HOCM.
• Cardiac procedures were also heterogeneous
among three approaches.

Preop Baselines Among Three Approaches of Low-Risk Cases (Elective,
LVEF>=30%, and EuroScore-II<=10%)
MPS MTC FST p-value
N 261 324 137
Sex (Female) 59.8% 55.9% 44.5% 0.014
Age* 61 (22) 56 (18.5) 56 (23) <0.0001
DM 10.8% 11.8% 18.4% 0.088
HTN 39.9% 44.4% 35.3% 0.199
Uremia 4.6% 2.8% 2.9% 0.493
EuroScore-II (%)* 1.8 (2.4) 1.4 (2.2) 3.7 (3.8) <0.0001
Non-MS MR 30.7% 70.4% 39.4% <0.001
Non-MR MS 4.6% 14.5% 8.8% <0.001
MS & MR 7.3% 9.0% 11.7% 0.333
Non-AR AS 19.5% 3.4% 12.4% <0.001
Non-AS AR 53.6% 5.3% 24.8% <0.001
AS & AR 18.0% 0.9% 14.6% <0.001
Non-AV MV 34.9% 93.2% 51.1% <0.001
Non-MV AV 84.7% 9.0% 44.5% <0.001
AV & MV 35.6% 8.0% 27.7% <0.001
TR 7.7% 19.8% 21.2% <0.001
Af 14.9% 25.6% 19.0% 0.006
IE 4.6% 7.1% 18.3% <0.001
HOCM 1.9% 0.3% 5.1% 0.002
MPS: Mini-parasternotomy
MTC: Mini-thoracotomy
FST: Full sternotomy
Denominator for all percentages: N of each approach
* Median (IQR)

Preop Variables for Choosing MICS (MPS, MTC)
in Low-Risk Cases (Elective, LVEF>=30%, and
EuroScore-II<=10%)
N=722 OR OR 95% CI p-value
EuroScore-II 0.77 (per 1%) 0.69 ~ 0.85 <0.01
Non-MS MR 1.84 1.06 ~ 3.20 0.031
HOCM 0.08 0.02 ~ 0.30 <0.001
MICS(minimally-invasive cardiac surgery): MPS or MTC
Initial variable set: MR, MS, AS, AR, TR, Af, IE, HOCM;
sex, age, DM, HTN, uremia, EuroScore-II,
Multiple logistic regression with stepwise selection

Results
• MPS had more AV procedures;
• MTC had more MV procedures;
• FST had more complex procedures.
• MICS (MPS or MTC) did not have longer
ischemia time or pump time.

Op Characteristics Among Three Approaches of Low-Risk Cases
(Elective, LVEF>=30%, and EuroScore-II<=10%)
MPS MTC FST p-value
N 261 324 137
AV Involved 92.3% 4.0% 54.7% <0.001
Combined 46.7% 40.4% 73.7% <0.001
MV Involved 44.8% 94.8% 72.3% <0.001
MV repair 19.5% 54.6% 19.0% <0.001
AV & MV 37.9% 1.5% 34.3% <0.001
TV 10.7% 20.4% 40.2% <0.001
Maze 13.0% 25.0% 18.3% 0.001
Myxoma 0.4% 0.6% 1.5% 0.431
Ao/Root 2.30% 0.00% 5.10% <0.001
Redo 5.4% 12.7% 30.0% <0.001
Pure Fresh AV 48.7% 1.5% 11.7% <0.001
Pure Fresh MV 5.4% 67.3% 18.3% <0.001
Non-MV AV 52.9% 1.9% 17.5% <0.001
Non-AV MV 6.1% 75.3% 20.4% <0.001
Septal myectomy 1.9% 0.3% 5.1% 0.002
Ischemia TIme (min)* 59 (32) 53 (29) 61 (39) 0.008
Pump Time (min)* 94 (46) 98 (47) 109 (52) 0.066
Denominator for all percentages: N of each approach
* Median (IQR)

Results
• Non-AV MV and MV repair procedures
preferred MICS.
• Combined, septal myectomy, TV, Ao/root, and
redo procedures preferred FST.
• MICS had Kaplan-Meier survival benefits over
FST.

Procedures That Affect the Choice of MICS
N=722 OR OR 95%CI p-value
Non-AV MV 1.81 1.03 ~ 3.18 0.039
Combined 0.35 0.21 ~ 0.58 <0.001
MV repair 2.24 1.34 ~ 3.76 0.002
Septal Myectomy 0.13 0.04 ~ 0.43 0.001
TV 0.57 0.34 ~ 0.97 0.038
Ao/Root 0.27 0.08 ~ 0.90 0.034
Redo 0.25 0.15 ~ 0.42 <0.001
MICS (minimally-invasive cardiac surgery): MPS or MTC
Multiple logistic regression with stepwise selection

Survival Curves Zoomed to 1 Year

Results
• Compared with MICS (MPS and MTC),
unadjusted for EuroScore-II or propensity
score, FST had worse non-complication rate,
non-complicated length of stay, non-
complicated ventilator hour, 30-day mortality,
pneumonia, sepsis, stroke, and prolonged
ventilator over 48 hours; non-complicated ICU
hours showed no significant difference.

Postop Outcomes Among Three Approaches of Low-Risk Cases (Elective, LVEF>=30%,
and EuroScore-II<=10%)
MPS MTC FST p-value
N 261 324 137
Non-complicated (NCx) 95.0% 90.4% 83.9% 0.001
NCx LOS# (Day)* 12 (6) (N=248) 12 (7) (N=293) 16 (14) (N=114) <0.0001
NCx ICU Hour* 49.5 (25.3) (N=248) 48.5 (25) (N=293) 61 (30.3) (N=114) 0.316
NCx Ventilator Hour* 12.6 (15) (N=243) 9.6 (15.3) (N=243) 19 (13.6) (N=114) 0.001
30-day Mortality 2.3% 4.0% 8.0% 0.031
Pneumonia 2.7% 4.0% 11.0% 0.002
Sepsis 2.3% 3.4% 11.0% 0.001
Stroke 0.4% 2.2% 2.9% 0.070
Ventilator Over 48 Hrs 7.7% 9.9% 21.2% <0.001
Non-complicated (NCx): survivors with ventilator use under one week or intensive care unit stay under
two weeks
* Median (IQR)
# LOS: Length of stay

Results
• Adjusted for EuroScore-II and propensity score,
compared with FST, MICS had shorter non-
complicated length of stay, lower 30-day
mortality, and less pneumonia.

Effect of MICS Choice on Outcomes and Complications*
Adjusted for EuroScore-II and Propensity Score
Endpoints MICS Effect Statistics 95% CI p-value
K-M Survival HR 0.40 0.16 ~ 1.01 0.053
NCx LOS (Day) Beta -4.66 -7.43 ~ -1.88 0.001
NCx ICU Hour Beta -3.23 -12.40 ~ 5.91 0.486
NCx Ventilator Hour Beta -0.65 -6.77 ~ 5.47 0.835
30-day Mortality OR 0.36 0.14 ~ 0.96 0.041
Pneumonia OR 0.25 0.08 ~ 0.72 0.010
Sepsis OR 0.36 0.13 ~ 1.01 0.053
Stroke OR 0.40 0.09 ~ 1.85 0.241
Ventilator Over 48 Hrs OR 0.62 0.28 ~ 1.35 0.229
* FST as the reference group
K-M: Kaplan-Meier
HR: hazard ratio
All regression models adjusted for propensity score and EuroScore-II
NCx: non-complicated; survivors with ventilator use under one week or intensive
care unit stay under two weeks
LOS: length of stay

Conclusion
• In optimally-selected cases, MICS can offer
better survival and safety outcomes than full
sternotomy
– Shorter length of stay
– Lower 30-day mortality
– Less pneumonia
• Efficacy outcomes of MICS need to be
addressed in the future.

2004-2012
MICS= parasternotomy + thoracotomy
Total case number=677
60

Reference list
Abbreviation Cited Article title
MICS
Case
number
Impact
factor
(2012
JCR)
ATS 2013
Ann Thorac Surg 2013
(Epub ahead of print)
Minimally Invasive Mitral Valve Surgery:
Influence of Aortic Clamping Technique on
Early Outcomes
n=103 3.454
ATS 2006
Ann Thorac Surg 2006;
81:1599-604
Minimally Invasive Versus Standard
Approach Aortic Valve Replacement: A Study
in 506 Patients
n=232 3.454
J Heart Val
Dis 2004
The Journal of Heart
Valve Disease
2004;13:887-893
Propensity Score Analysis of a Six-Year
Experience with Minimally Invasive Isolated
Aortic Valve Replacement
n=233 1.51
J Card Surg
2003
J Card Surg
2003;18:133-139
Prospective Comparison of Minimally
Invasive and Standard Techniques for Aortic
Valve Replacement: Initial Experience in the
First Hundred Patients
n=30 1.071
JTCS 2002
J Thorac Cardiov Surg
2002; 50: 337 – 341
Midterm Results and Quality of Life after
Minimally Invasive vs. Conventional Aortic
Valve Replacement
n=70 3.526
EJCTS
1999
Eur J Cardio-Thorac Surg
1999; 16:647-652
Minimally invasive aortic valve replacement
(AVR) compared to standard AVR
n=29 2.674

62
0.0
0.5
1.0
1.5
2.0
2.5
3.0
ATS 2006 JTCS 2002 亞東
Mortality (%)
Ann Thorac Surg 2006; 81:1599-604
J Thorac Cardiov Surg 2002; 50: 337-341

63
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
ATS 2006 J Card Surg
2003
JTCS 2002 EJCTS 1999 亞東
ICU stay (days)
Ann Thorac Surg 2006; 81:1599-604
J Card Surg 2003;18:133-139
Eur J Cardio-Thorac Surg 1999; 16:647-652

0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
ATS 2013 ATS 2006 J Heart Val
Dis 2004
J Card
Surg 2003
JTCS 2002 EJCTS
1999
亞東
Cross-clamp time (minutes)
64
Ann Thorac Surg 2006; 81:1599-604
The Journal of Heart Valve Disease 2004;13:887-893
J Card Surg 2003;18:133-139
Eur J Cardio-Thorac Surg 1999; 16:647-652

98.0
100.0
102.0
104.0
106.0
108.0
110.0
112.0
ATS 2013 J Heart Val Dis
2004
J Card Surg
2003
JTCS 2002 亞東
CPB time (minutes)
65
Ann Thorac Surg 2013 (Epub ahead of print)
J Card Surg 2003;18:133-139

0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
ATS 2013 ATS 2006 J Heart Val Dis
2004
亞東
Permanernt stroke (%)
66
Ann Thorac Surg 2013 (Epub ahead of print)
Ann Thorac Surg 2006; 81:1599-604

0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
ATS 2006 亞東
Pneumonia (%)
67
Ann Thorac Surg 2006; 81:1599-604

0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
10.0
ATS 2006 J Card Surg 2003 亞東
New renal failure (%)
68Ann Thorac Surg 2006; 81:1599-604
J Card Surg 2003;18:133-139

0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
ATS 2006 J Card Surg 2003 亞東
Atrial fibrillation (%)
69Ann Thorac Surg 2006; 81:1599-604
J Card Surg 2003;18:133-139

Endoscopic Cardiac Surgery in Taiwan

Endoscopic Cardiac Surgery in Taiwan

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