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

1. HEART PORT
Port-Access® Operative Procedure
UCI - Policlínica Gipuzkoa

3. Técnica Heart Port - PG
Port Port: Robot-Assisted
Esternotomía
C.
Endoscópica
Experience
stages

4. Técnica Heart Port - PG

5. Técnica de Perfusión Estándar
PUMP Oxygenator
Lungs
Right Right Left Left
Atrium Ventricle Atrium Ventricle

6. Técnica de Perfusión Estándar
PUMP Oxygenator
Cardioplegia
RA RV LA LV

7. EndoClamp: Cardioplegia y Clampaje
SVC Drainage
Clamping
Right Right Left Left
Atrium Ventricle Atrium Ventricle
Cardioplegia
O²
IVC Drainage

8. Técnica By-pass cardiopulmonar

9. Técnica By-pass cardiopulmonar

10. Técnica By-pass cardiopulmonar

11. Técnica By-pass cardiopulmonar
Canulación venosa
Acceso Femoral

12. Clampaje
Aurícula Ventrículo Aurícula Ventrículo
Derecha Derecho Izquierda Izquierdo
Cardioplegia
O²

13. Técnica By-pass cardiopulmonar
Canulación arterial

14. Técnica By-pass cardiopulmonar

15. Técnica Heart Port - PG

16. Técnica Campo Quirúrgico

17. Técnica Campo Quirúrgico

18. Técnica Campo Quirúrgico

19. Técnica Campo Quirúrgico

20. Técnica Campo Quirúrgico

21. Técnica Campo Quirúrgico

22. TÉCNICA HEART-PORT
POLICLÍNICA

23. Resultados HEART PORT - PG
ü Casos realizados
Heart-Port (2003-2009)
HP
Porcentaje
No HP
Frecuencia válido
Si 192 5,5
94,5% 5,5% No 3329 94,5
Total 3521 100,0
Tabla de contingencia Heart-Port * Año
Año
2003 2004 2005 2006 2007 2008 2009 Total
Si Recuento 14 47 32 24 30 16 29 192
% de Año 2,6% 8,5% 6,2% 5,0% 6,2% 3,3% 6,2% 5,5%

24. HEART PORT
Tipo de cirugía
Porcentaje
Frecuencia válido
Valvular 363 91,4
CIA 23 5,8
Valv-CIA 9 2,3
Otros_Heart Port 2 ,5
Total 397 100,0
"
" 51,6%
Heart-Port
Porcentaje
" Frecuencia válido
Si 192 48,4
" 48,4% No 205 51,6
Total 397 100,0
"
"

25. HEART PORT
"
"
"
"
"

26. HEART PORT
"
"
"

27. Resultados HEART PORT - PG
Periodo: ago-03 / jul-10
Edad corregida (años) Stem-and-Leaf Plot
ü Casos realizados: 200 Frequency Stem & Leaf
10,00 Extremes (=<36)
ü Sexo: mujeres 60% 2,00 3 . 77
7,00 4 . 0112244
5,00 4 . 56679
11,00 5 . 00112223444
ü Edad media: 64,9 años (16::86) 25,00 5 . 5556777778888889999999999
29,00 6 . 00000111111222222233333344444
29,00 6 . 55566666667777888888889999999
34,00 7 . 0000111111111222222223333344444444
ü 2ª Intervención: 7% 31,00 7 . 5555556666667777777777888888899
16,00 8 . 0001111112223334
1,00 8. 6
ü F.E. Media: 62,6% (min. 31%) Stem width: 10
Each leaf: 1 case(s)
ü P. A. Pulmonar Media: 43 mm Hg. (max. 106)

28. Resultados HEART PORT - PG
Periodo: ago-03 / jul-10
ü Casos realizados: 200
ü Sexo: mujeres 60%
ü Edad media: 64,9 años (16::86)
ü 2ª Intervención: 7%
ü F.E. Media: 62,6% (min. 31%)
ü P. A. Pulmonar Media: 43 mm Hg. (max. 106)

29. Resultados HEART PORT - PG
Periodo: ago-03 / jul-10
ü Estancia en UCI: 1,8 días / Md:1 día
ü Estancia Hospitalaria: 8,5 días / Md: 7 días
ü Mortalidad en UCI: 2,5%
ü Mortalidad a los 30 días: 4,5% (Media EuroSCORE log.: 6,78%)
Bajo riesgo (ES <= 2.94%)
Porcentaje
Frecuencia válido
No 196 98,0
Si 4 2,0 Alto riesgo (ES >= 10.9%)
Total 200 100,0 Porcentaje
Frecuencia válido
No 164 82,0
Si 36 18,0
Total 200 100,0

30. Resultados HEART PORT - PG
“PROBLEMAS”
ü Entrenamiento / “curva de aprendizaje”
ü Tiempo y Paciencia
Esternotomía Heart -Port
Prueba de muestras independientes
Estadísticos de grupo
Desviación Error típ. de
Heart-Port N Media típ. la media
Tiempo de isquemia (min.) Si 192 89,11 30,141 2,175
No 237 49,86 26,552 1,725 Prueba T para la igualdad de medias
Tiempo de By-pass (min.) Si 192 128,47 35,752 2,580 95% Intervalo de
No confianza para la
240 86,67 28,294 1,826
Diferencia diferencia
de medias Inferior Superior
Tiempo de isquemia (min.) 39,253 33,868 44,637
Tiempo de By-pass (min.) 41,802 35,585 48,019

31. Resultados HEART PORT - PG
COMPLICACIONES - accesos
ü Complicaciones accesos vasculares arteriales: 2%
ü Complicaciones canulación venosa: 2%
ü Clampaje transtorácico - Novare: 8%
ü Adherencias pleurales: 2%

32. Resultados HEART PORT - PG
COMPLICACIONES - globales
Complicaciones Heart-Port
ACVA con secuelas 1,5%
IAM peri-IQ 0,5%
Shock 1,0%
Daño renal agudo (RIFLE) 6%
FRA con TDE ,0%
H. Mediatínica SIN re-IQ 3,0%
H. Medistínica CON re-IQ 1%
Politrasfusión (> 6 C.H.) ,0%
Taponamiento ,0%
* 0% conversiones a esternotomía

33. Conclusiones HEART PORT - PG
ü HP es una técnica HABITUAL en nuestro centro
ü Pacientes seleccionados
ü DIFICULTAD para realizar comparaciones

34. Comparaciones NO significativas
Resultados HP vs nHP: 2003-2009
Heart-Port
Porcentaje
Frecuencia válido
Si 192 48,4
No 205 51,6
Total 397 100,0
Media
Heart-Port
Si No
Prueba de muestras independientes
Edad corregida (años) 65,12 65,96
Fraccion de eyeccion (%) Prueba T para la igualdad de medias
63,01 61,90
95% Intervalo de
Hipertension pulmonar (mm Hg.) 41,97 46,12
confianza para la
Diferencia diferencia
Sig. (bilateral) de medias Inferior Superior
Edad (años) ,511 -,839 -3,344 1,667
Edad corregida (años) ,511 -,8387 -3,3442 1,6667
Fraccion de eyeccion (%) ,307 1,110 -1,022 3,242
Hipertension pulmonar ,109 -4,146 -9,225 ,933
(mm Hg.)

35. Comparaciones NO significativas
Resultados HP vs nHP: 2003-2009
Tabla de contingencia Reintervenido * Heart-Port
Heart-Port
Si No
Reintervenido Si Recuento 13 55
% de Heart-Port 6,8% 26,8%
No Recuento 179 150
% de Heart-Port 93,2% 73,2%
Total Recuento 192 205
Tabla de contingencia Tipo de prótesis mitral * Heart-Port
Heart-Port
Si No
Tipo de Mecánica Recuento 109 133
prótesis mitral % de Heart-Port 56,8% 64,9%
Biológica Recuento 4 21
% de Heart-Port 2,1% 10,2%
Anuloplastia Recuento 63 20
% de Heart-Port 32,8% 9,8%
No Recuento 16 31
% de Heart-Port 8,3% 15,1%
Total Recuento 192 205

36. Comparaciones NO significativas
Resultados HP vs nHP: 2003-2009
Tabla de contingencia IAM peri-IQ * Heart-Port
Tabla de contingencia Shock * Heart-Port
Heart-Port
Heart-Port
Si No
Si No
IAM peri-IQ No 190 203
Shock No Recuento 189 199
99,5% 99,0%
% de Heart-Port 99,0% 97,1%
Si 1 2
Si Recuento 2 6
,5% 1,0%
% de Heart-Port 1,0% 2,9%
Total 191 205
Total Recuento 191 205
Tabla de contingencia H. Mediatínica sin re-IQ * Heart-Port
Tabla de contingencia FRA con TDER * Heart-Port
Heart-Port
Heart-Port
Si No
Si No
H. Mediatínica sin re-IQ No 185 197
FRA con TDER No 191 205
96,9% 96,1%
100,0% 100,0%
Si 6 8
Total 191 205
3,1% 3,9%
Total 191 205
Port-Access®: tiempos de isquemia y CEC más prolongados

37. Comparaciones NO significativas
Resultados HP vs nHP: 2003-2009
Tabla de contingencia H. Medistínica con re-IQ * Heart-Port
Heart-Port
Si No
Tabla de contingencia ACVA con secuelas * Heart-Port
H. Medistínica con re-IQ No 189 195
Heart-Port 99,0% 95,1%
Si No Si 2 10
ACVA con secuelas No 188 194 1,0% 4,9%
98,4% 94,6% Total 191 205
Si 3 11
Tabla de contingencia Politrasfusión (> 6 C.H.)
1,6% 5,4%
Total 191 205 Heart-Port
Si No
Politrasfusión No 51 50
(> 8 C.H.) 100,0% 92,6%
Si 0 4
,0% 7,4%
Total 51 54
Tabla de contingencia Taponamiento * Heart-Port
Heart-Port
Si No
Taponamiento No 191 201
100,0% 98,0%
Si 0 4
,0% 2,0%
Total 191 205

38. Comparaciones NO significativas
Resultados HP vs nHP: 2003-2009
Heart-Port
Porcentaje Tabla de contingencia Mortalidad a los 30 días * Heart-Port
Frecuencia válido
Si 192 48,4 Heart-Port
No 205 51,6 Si No Total
Total 397 100,0 Mortalidad a No Recuento 184 194 378
los 30 días % de Heart-Port 95,8% 94,6% 95,2%
Si Recuento 8 11 19
% de Heart-Port 4,2% 5,4% 4,8%
Total Recuento 192 205 397
48,4% 51,6% 100,0%
Tabla de contingencia Alto riesgo (ES >= 10.9) * Heart-Port
Heart-Port
Estadísticos de grupo Si No
Alto riesgo (ES >= 10.9) No 159 121
82,8% 59,6%
Desviación Error típ. de Si 33 82
Heart-Port Media típ. la media 17,2% 40,4%
EuroSCORE Log. (%) Si 6,5582 Prueba de muestras independientes Total
8,37325 ,60429 192 203
No 10,4865 9,05432 ,63549 Prueba T para la igualdad de medias
95% Intervalo de confianza para la
Diferencia diferencia
de medias Inferior Superior
EuroSCORE Log. (%) Se han asumido
-3,92828 -5,65610 -2,20045
varianzas iguales

39. Comparaciones NO significativas
Resultados HP vs nHP: 2003-2009
Desviación Error típ. de
Heart-Port N Media de muestras independientes
Prueba típ. la media
Estancia Media (días) No 205 3,91 8,582 ,599
Prueba T para la igualdad de medias
en UCI Si 192 1,86 2,147 ,155 95% Intervalo de
confianza para la
Diferencia diferencia
Sig. (bilateral) de medias Inferior Superior
Estancia media (días) ,001 2,048 ,828 3,267

40. Conclusiones HEART PORT - PG
ü HP es una técnica HABITUAL en nuestro centro
Pacientes seleccionados
DIFICULTAD para realizar comparaciones
ü HP es una técnica FACTIBLE y SEGURA
Bibliografía

41. HEART PORT ¿Factible y Seguro?
Ann Thorac Surg 2002;74:660-4
Minimally-Invasive Mitral Valve Surgery: A 6-Year Experience With 714 Patients
Eugene A. Grossi, MD, New York University School of Medicine. New York, USA.
Objective:
To analyze a single-institutional experience with minimally-invasive mitral valve operations of 6 years, reviewing short-term mortality and
morbidity and long-term echocardiographic data.
Method:
Between Nov 1995 and Nov 2001, 714 consecutive patients had minimally invasive mitral valve procedures. 561 patients had isolated mitral valve
operations (375 repairs, 186 replacements) . Mean age was 58.3 (30.1% > 70 years) and 15.4% had previous cardiac operations. Arterial
cannulation was femoral in 79.0% and central in 21% with the port access balloon endo-occlusion used in 82.3%. Cardioplegia was transjugular
retrograde (54.1%) or antegrade (29.4%). Right anterior minithoracotomy was used in 96.6% and left posterior minithoracotomy in 2.2%
Results:
Hospital mortality for primary isolated mitral valve repair was 1.1% and 5.8% for isolated mitral valve replacement. Overall hospital mortality was
4.2% (30 of 714). Mean cross-clamp time was 92 minutes and mean cardiopulmonary bypass time was 127 minutes. Postoperatively, median
ventilation time was 11 hours, intensive care unit time was 19 hours and total hospital stay was 6 days. Complications for all patients included
permanent neurologic deficit (2.9%), aortic dissection (0.3%), no mediastinal infection (0.0%). Follow-up echocardiography demonstrated 89.1% of
the repair patients had only trace or no residual mitral insufficiency.
Conclusion:
This study demonstrates that the minimally invasive port access approach to mitral valve operations is reproducible with low perioperative
morbidity and mortality and with late outcomes that are equivalent to conventional operations.

42. HEART PORT ¿Factible y Seguro?
The Journal of Heart Valve Disease 2008;17:48-53
Video-Assisted Mitral Surgery through a Micro-Access: A Safe and Reliable Reality in the Current Era
Ernesto Greco MD, Juan M. Zaballos MD, Luis Alvarez MD, Stefano Urso MD, Ivana Pulitani MD,Rafael Sàdaba MD, Arantxa Juaristi MD, Juan J. Goiti MD
Policlinica Gipuzkoa, San Sebastian.
Objective:
To describe the author´s experience with video-assisted mitral surgery through a micro-access.
Method:
Between September 2003 and September 2006, 100 patients (mean age 65.7 years; range: 16-84 years; 29 aged >75 years) underwent video-
assisted port-access mitral valve surgery through a 4 to 6 cm anterior mini-thoracotomy. Mitral valve repair wascarried out in 36 patients (36%) and
mitral valve replacement (MVR) in 64 (64%). Redo procedures were performed in 14 patients.
Results:
Endoclamp occlusion of the ascending aorta was used in 94%. The median intensive care unit and hospital stays were 20.0 ± 30.8h and 7.0 ± 5.9 days,
respectively. Hospital mortality was 4% (n = 4). No patient required conversion to sternotomy. There were no perioperative myocardial infarctions,
permanent strokes, major vascular complications, or peripheral ischemic events. Among the patients, 63% had no complications at all during the
postoperative course, and no wound infections were observed.
Conclusion:
Video-assisted mitral surgery through a micro-access may be performed safely, at low risk of morbidity and mortality, and with results and
quality standards similar to those reported for a sternotomy approach. Of note, older patients may be successfully treated using this technique.

43. HEART PORT ¿Factible y Seguro?
The Heart Surgery Forum # 2004-1143 8(5), 2005
The Preferable Use of Port Access Surgical Technique for Right and Left Atrial Procedures
Gersak B, Sostaric M, Kalisnik JM, Blaumamauer R.
Department of Cardiovascular Surgery, University Medical Center Ljubljana, Slovenia.
Objective:
To analyze the results of mitral valve operations, either alone or in combination with the tricuspid valve surgeries.
Method:
From January 2001 till June 2004. The period was divided into two parts, classical sternotomy part (C) (110 patients) and minimally invasive
port access part (PA) (105 patients), later being used from December 2002 till now. Also, what we were interested in was the total hospital cost
of both types of the procedures and if there are any advantages of port access over the classical sternotomy. The mean age was 61.2 ± 10.2
and 60.3 ± 12.4 (C versus PA) and mean additive Euroscore was 6.5 versus 4.8 (C versus PA).
Results:
There were statistically significant differences in cardiopulmonarybypass time (CPB) and aortic cross-clamp time (AXT) between both groups:
CPB C versus PA: 98.3 ± 33.5 minutes versus 149.2 ± 44.2 minutes (mean ± sd), AXT C versus PA: 62.9 ± 20.6 minutes versus 88.3 ± 26.8
minutes (mean ± sd). There were no statistically significant differences in mortality and stroke for both the groups There were statistically
significant differences in favor of the port access over the classical one for: intensive unit stay postoperative stay in days, blood
transfusion, postoperative thoracic bleeding and extubation time in hours. Furthermore, costs analyses showed that the average total
patient cost was less for port access. The differences between endo and classical type suggested that the port access type of surgery is 20%
cheaper than the classical one.
Conclusion:
We may conclude that port access surgery is an acceptable alternative to classical type of surgery, also in complex pathology of the mitral
and tricuspid valve.

44. HEART PORT ¿Factible y Seguro?
J Thorac Cardiovasc Surg. 2009
Quality of mitral valve repair: Median sternotomy versus port-access approach.
Raanani E, Spiegelstein D, Sternik L, Preisman S, Moshkovitz Y, Smolinsky AK, Shinfeld A.
Department of Cardiac Surgery, Chaim Sheba Med. Center, Tel Hashomer, affiliated with the Sackler School of Medicine, Tel-Aviv University, Israel.
Objectives:
We sought to compare early and late clinical and echocardiographic outcomes of patients undergoing minimally invasive mitral valve repair by means of
the port-access and median sternotomy approaches. Methods: Between 2000 and 2009, 503 patients had mitral valve repair, of whom 143 underwent
surgical intervention for isolated posterior leaflet pathology: 61 through port access and 82 through median sternotomy. The port-access group had
better preoperative New York Heart Association functional class (P = .007) and a higher rate of elective cases (97% vs 87%, P = .037). Other
preoperative characteristics were similar between the groups, including mitral valve pathology and repair techniques.
Results:
Operative, bypass, and clamp times were significantly longer in the port-access group. Mean hospital stay was 5.3 +/- 2.5 days in the port-
access group versus 5.7 +/- 2.5 days in the median sternotomy group (P = .4). Early postoperative echocardiographic analysis showed that most
patients in both groups had none or trivial mitral regurgitation and none of the patients had greater than grade 2 mitral regurgitation. Follow-up extended
for up to 100 months (mean, 34 +/- 24 months). New York Heart Association class improved in both groups (P = .394). Freedom from reoperation was
97% and 95% in the port-access and median sternotomy groups, respectively. Late echocardiographic analysis revealed that 82% (49/60) in
the port-access group and 91% (73/80) in the median sternotomy group were free from moderate or severe mitral regurgitation (P = .11).
Conclusion:
In isolated posterior mitral valve pathology, quality of mitral valve repair with the port-access approach can compare with that with the
conventional median sternotomy approach.

45. HEART PORT: dolor y calidad de vida
Ann Thorac Surg 1999;67:1643-7
Pain and Quality of Life After Minimally Invasive Versus Conventional Cardiac Surgery
Thomas Walther, MD, Herzzentrum Leipzig
Objective:
To evaluate pain and quality of life after minimally invasive cardiac operations in comparison with conventional cardiac operations.
Method:
From Oct 1996 to May 1997, a total of 338 patients were interviewed daily using standard scoring systems (myocardial revascularization n = 160;
mitral valve reconstruction or replacement n = 58; aortic valve replacement n = 120).
Results:
There was no significant difference regarding ventricular function and intensive care and hospital stay. Pain decreased until the seventh postoperative
day in all patients. Patients with a lateral minithoracotomy had lower pain levels from the third postoperative day onward. There were no
differences in quality of life, postoperative wound healing or stability of the bony thorax.
Conclusion:
After minimally invasive procedures with lateral minithoracotomy, earlier mobilization is possible because of a better stability of the bony thorax,
resulting in lower pain levels.

46. Conclusiones HEART PORT - PG
ü HP es una técnica HABITUAL en nuestro centro
Pacientes seleccionados
DIFICULTAD para realizar comparaciones
ü HP es una técnica FACTIBLE y SEGURA
ü Paso previo a la CIRUGÍA ROBÓTICA

47. Gracias

48. Técnica By-pass cardiopulmonar
Canulación arterial femoral
EndoClamp