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Minimally Invasive&Robotically Assisted Heart Surgery - Dr Mihaljevic

Tuesday, June 2, 2009
Tomislav Mihaljevic, MD

Tomislav Mihaljevic, MD
Cleveland Clinic Department of Thoracic and Cardiovascular Surgery

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Cleveland_Clinic_Host: Dr. Mihaljevic was unable to attend the chat due to an emergency surgical case, however he did answer your questions below. Please note that names were removed if you have included them in the question for posting.

Mitral Valve Surgery

mtpatel_2: Is there any difference in success rate of surgery with laparoscope right thoracotomy mvp repair and minimally invasive surgery through sternal incision?

Dr. Mihaljevic: In our experience there has been no difference in success rate of mitral valve repair with any of minimally invasive approaches compared with the operations performed via complete sternotomy.

Is mitral valve surgery right for you?

coffee: I am sorry an appointment prevents me from getting in on the discussion. I am especially interested in this subject. Is there any way I can find out if the Dr. thinks this less invasive procedure would be advisable for an 80 year old who has both a mitral valve leakage and is in Atril Fibrillation all the time? I will look for the answer on the transcript page.

Dr. Mihaljevic: Minimally invasive mitral valve operation and Maze procedure (for treatment of atrial fibrillation ) can be done in elderly patients. Age is not a contraindication for minimally invasive procedures. In contrary, elderly patients may derive greater benefit from less invasive procedures.

roullac: Since Robotic mitral valve surgery is being conducted as a standard of care at the Cleveland clinic I would be interested to find out should I elect to have mitral valve repair, where and how many incisions would it be necessary for me to have? I assume that the technique used will also dictate the size of the incision or incisions. For the specific technique being recommended exactly how big would the incision size be and indeed how many would there be and where precisely would there be made on my body since I am a petite size lady weighing only 48 kilos approximately? I will be extremely grateful if you could answer my questions.

Dr. Mihaljevic: Incisions for robotic mitral valve repair are placed on the right side of the chest, under the right breast. The longest incisions measures 2 cm in length, there are three additional 1 cm long incisions. In addition there is a 3-4 cm long incision in the right groin crease. Robotic instruments are inserted between the ribs, so that there is no need for rib spreading or rib removal. This approach minimizes operative trauma and blood loss, and speeds up the recovery. This approach has been successfully used in petit patients. However, it is important to emphasize that the final decision regarding the operative approach will be made after through review of the medical documentation and physical exam.

roullac: I am a 53 year old female asymptomatic with myxomatous degeneration of the mitral valve, prolapse of the posterior leaflet mitral valve most likely involving the P2 segment but no chordae rupture. As a result of that I have severe mitral valve regurgitation. My left ventricle is normal in size and systolic function. It measures 5.3 cm (diast.) and systole at 3.6 cm in end diastole. The left atrium is mildly enlarged to 4.5with normal thickness. As compared to my first echo doppler of February 2008 when I was diagnosed with heart disease there is a slight drop in Ejection Fraction 61% and a slight increase in left ventricle cavity (syst.)3.6. Question What is your view? Given this diagnosed condition would you recommend surgery at this point of time.

Dr. Mihaljevic: I would definitely recommend surgery since you seem to have severe mitral regurgitation and left atrial enlargement. This is a condition that will get worse over time if remains untreated. In contrast, surgery is very effective and associated with low risk. In our experience the likelihood of successful repair of your mitral valve exceeds 99%, with mortality risk of less than 0.1%. Repair of prolapse of the posterior leaflet is usually a life-long solution with very low rate of failure. Operation could be performed with robotically-assisted minimally invasive approach, with 2-5 day long hospital stay, and quick return to activities of daily life. More precise information can be given after the review of your medical records.

roullac: If surgery is unavoidable for an asymptomatic patient and is also on an elective basis when would be the right time to elect to have such surgery? Over which time period?

Dr. Mihaljevic: Patients with severe asymptomatic mitral regurgitation should have elective operation. The timing of surgery should be determined after detailed review of medical records.

cudos2you: Dr. Mihaljevic. I am a patient of yours from Wyoming, Pennsylvania. Last year, on July 31, 2009, you repaired my very leaky Mitral Valve using the DaVinci Robot. Today, almost a year later, I have gotten my energy back to the point where I am able to work out 3 times a week and have recently completed a 4 mile walk for the March of Dimes. I have the following questions today: During my Robotic Mitral Valve Repair Surgery, you inserted a 38mm Cosgrove Ring, to hold my repaired valve in place. Will this ring ever need to be looked at, to know if it is still functioning properly? and if so, what type of tests would I need so my cardiologist can ?view? the ring to determine if it is still ?doing its job??

Dr. Mihaljevic: I am glad to hear that you are doing well. Anuloplasty rings that are used for mitral valve repair have been in use for a very long time, and represent a durable solution for mitral valve repair. The follow-up of patients after mitral valve repair is relatively simple and involves periodical physical exams and echocardiography.

cudos2you: Dr. Mihaljevic, what is the long term prognosis for having Mitral Valve Repair done as I did, with the DaVinci Robot? Will the repair 'hold' for the rest of my life? What symptoms should I look for to alert me that the repair needs to be done again?

Dr. Mihaljevic: Most mitral valve repairs last a life time. If failure of repair occurs it is most common with the first year after surgery, so that it is very unlikely that you will ever develop recurrent mitral regurgitation. Regular visits to your cardiologist will assure the proper follow-up.

cudos2you: If one starts to have shortness of breath (when exercising) a year following Valve repair surgery, does that mean the valve is regurgitating again?

Dr. Mihaljevic: Not necessarily. Shortness of breath can be caused by very many other factors, however if it persists over longer period of time you should see your cardiologist.

RHAZ77: I have heard that the strategy for asymptomatic patients, ages 50-55, otherwise healthy and with active lifestyle and with moderate to severe mitral valve regurgitation would be mitral valve repair, but if there is prolapse of both leaflets and/or flailed leaflets present that repair should not be done until symptoms appear. What are your thoughts on that strategy and what is it about bi-leaflet prolapse that factors into the course of action?

Dr. Mihaljevic: Bileaflet prolapse usually signifies a more advanced disease. However, patients with severe mitral regurgitation and bileaflet prolapse should have mitral valve repair done before the occurrence of symptoms, provide that repair is done in the center with experienced surgeons. In our experience, bileaflet prolapse can be repaired in more than 99% of patients, with minimal operative risk.

Postponing surgery until development of symptoms is a reasonable strategy if you do not have access to a center with expertise in mitral valve surgery.

RHAZ77: For patients with flailed leaflets and moderate to severe mitral valve regurgitation but who are asymptomatic, does watchful waiting carry any major risks that could be avoided by immediate mitral valve repair? For example does waiting increase the risk of that replacement will be required instead of repair of the mitral valve?

Dr. Mihaljevic: Watchful waiting in patients with severe mitral regurgitation and no symptoms introduces a small, but definite risk of sudden death. Longer waiting does not increase the risk of mitral valve replacement, but does case a small increase in the overall risk of mitral valve surgery. It also decreases long-term survival even in the event of initially successful surgery.

RHAZ77: Can you comment on what you believe are the most important developments in minimally invasive or robatic surgery in respect of the mitral valve that have occurred in the last 2 years.

Dr. Mihaljevic: The most important developments are: reduction of operative times, and simplification of mitral valve repair techniques. The combination of these two improvements allow us to perform.

km1926: Your parent is 83 years of age on June 4th, 2009. She has mitral valve regurgitation, her Left Atrium from medical reports is 4.8cm. ( Additional Cardiology notes: 3 Stents: RCA, 3.5X 13mm, PDA, 2.5X 13mm, Marginal, 2.5X8mm,Non-stented 2 LAD lesions(50-60% occluded), Scar left ventricle, old infarct posterior area of heart, family history of heart disease). How does a family member know if their parent is receiving the correct Cardiology care for Mitral Valve Regurgitation? Thank you, her son.

Dr. Mihaljevic: In order to provide you with an adequate response to that question I would need to review your records. Generally speaking, periodic exams and echocardiograms for the assessment of heart function and mitral valve function are essential for proper care of patients with mitral regurgitation.

valdosta: age is 48 height 5'11" weight 182 non drinker, non tobacco, no caffeine, exercise regular, hx of atrial fibrillation since 2006 4 times. ceased alcohol and caffeine and had no additional occurrences. My cardiologist in Jacksonville FL just performed nuclear stress tests(excellent results 15 minutes up to heart rate of 170. TEE revealed serious Mitral Valve that Dr. stated would be candidate for repair. Will perform heart cath. this thurs. am. at that point we will overnight all films for your review at Cleveland Clinic accompanied by medical records. Would you be the Dr. that performs the minimally invasive heart valve repair? If Cleveland Clinic agrees with my physician could the surgery be performed in early July?

Dr. Mihaljevic: It seems that you have an indication for mitral valve repair, and likely a pulmonary vein isolation at the same time. Pulmonary vein isolation is a relatively simple procedure that regulates heart beat in patients with history of atrial fibrillation. We have several surgeons who perform this type of surgery. Patients can choose their physician. We could certainly perform your operation in July.

valdosta: On mitral valve repair with no complications approx how long will surgery last? How long before you encourage patient to walk after recovery? question from 48 yr old

Dr. Mihaljevic: Mitral valve repair is mostly a solution for life. Very few patients require repeated operation. If the operation is done using a robotically assisted approach the recovery is very fast. Patients can get out of bed a day after surgery, and typically get discharged from the hospital within 3 to 5 days after operation. There are no restrictions when it comes to physical activity after surgery. We encourage our patients to be as active as possible, since moderate physical activity leads to faster recovery. Most patients with severe mitral valve disease are in their late 40s,eager to return back to work and regular activities of daily life after surgery. Most patient return to work within few weeks after surgery.

Aortic Valve Surgery

M1643: I have just been informed that I need aortic valve replacement surgery in the near future. My valve has narrowed to .4cm due to calcification. What is the current status of using robotically assisted (minimally invasive) techniques for valve replacement? Is valve repair a possibility? I am 70 years old and in good health.

Dr. Mihaljevic: You have a definitive indication for surgery. Although robotically-assisted approach for aortic valve replacement is not available there are other minimally invasive options for this operation. We have routinely been using minimally invasive approach through 6-8 cm long incision in the front of the chest since 1995. This minimally invasive approach allows faster recover, with less trauma to the patients. Risk of operation is usually very low (less than 1% mortality risk), with average hospital stay of 5 days.

Annie3: My question is ...Can the Aorta Valve be replaced Robotically?

Dr. Mihaljevic: Aortic valve replacement can not be done robotically, but it can be done through a very small incision (6-8 cm) in the upper part of the chest. This minimally invasive approach has been used extensively with excellent results and a very low operative risk.

Annie3: I have been diagnosed with mild right ventricular enlargement with normal function and the aortic valve is bicuspid moderately thickened and calcified with mild reduced cusp mobility.

Dr. Mihaljevic: Surgery for aortic valve is indicated if the patient has severe aortic stenosis, symptoms and evidence of heart enlargement of dysfunction. We will be happy to review your records and give you a more accurate assessment.

dcaldwel: How does a surgeon decide which form of minimally invasive surgery best suits a patient?

Dr. Mihaljevic: This decision is made after physical examination and review of records. Most patients with heart valve disease are candidates for a minimally invasive approach. We always try to find the approach that best fits an individual patient. One operative approach is not suitable for all patients.

dcaldwel: Do surgeons at the Cleveland Clinic routinely use minimally invasive and robotically assisted heart surgery for aortic valve replacement?

Dr. Mihaljevic: We have the largest experience in the world in minimally invasive aortic valve surgery. More than 70% of patients requiring aortic valve surgery receive, have their operation done via minimally invasive approach.

dcaldwel: What is the advantage of robotic assistance?

Dr. Mihaljevic: Robotic surgery is currently not an option for aortic valve replacement, although we are developing this operation in our research laboratory.

dcaldwel: What is the keyhole approach to aortic valve surgery?

Dr. Mihaljevic: Keyhole approach is the minimally invasive approach through the small 6-8 cm long incision in the upper part of the chest. The aortic valve is approach through partial division of the breast bone. This approach has been used extensively since 1995, and results in faster recover and less trauma to the patient.

dcaldwel: Does aortic valve surgery require stopping the heart?

Dr. Mihaljevic: Yes. The heart has to be stopped during the aortic valve surgery.

dcaldwel: What can a surgeon do to prevent stroke during aortic valve surgery?

Dr. Mihaljevic: Risk of stroke for an average patient requiring aortic valve surgery in Cleveland Clinic is less than 1%. Careful conduct of operation and avoidance of extensive manipulation of the aorta are the most important steps in avoiding the stroke.

Atrial Fibrillation and Robotically Assisted Heart Surgery

Arizona50: Are robotics used in PV ablations for afib or PV stent placements?

Dr. Mihaljevic: Robotically assisted approach is being successfully used for pulmonary vein isolation and Maze procedure for treatment of atrial fibrillation.

Outcomes of Robotically Assisted Heart Surgery

tedlaz: At this time, how many robotically assisted mitral valve repairs are you performing monthly. Also, in a previous web chat I read where the mortality rate is running at 1 in 1,000. What is the present mortality rate?

Dr. Mihaljevic: Last year alone we performed more than 250 robotically-assisted mitral valve repairs. Our mortality for robotically-assisted operations is 0%.

Bypass Surgery

sergiomgomez: Is there any possibility of performing robotically assisted surgery after a traditional CABG?

Dr. Mihaljevic: Reoperative bypass surgery is not possible after previous CABG. However, robotically-assisted mitral valve repair can be performed after previous CABG. There are alternative minimally-invasive approaches for reoperative bypass grafting.

Clara: I had heart surgery 3 years ago and the grafts had filled up 60% 2007. I have been told that I have other arteries that are too small to fix. My left anterior descending artery was 60% at that time too. Is there anyway that I would be a candidate for minimally heart surgery.

Dr. Mihaljevic: Minimally invasive approaches are possible for some patients requiring repeated bypass surgery. We would be happy to review your records and outline the plan of care for your particular case.

cavaneng: I have read that bypass surgery for the LAD has been done robotically. I have two concentric stents in mid section of my LAD. On 12-17-08 , another stent was added to the same area partially inside the end of the other two. At Mayo Clinic, I was diagnosed with coronary artery spasm from endothelial dysfunction. Is it possible to bypass the lesion robotically? There are no other lesions in my entire heart.

Dr. Mihaljevic: Robotically-assisted minimally invasive bypass with left internal mammary to the LAD seems like an excellent option for your case. We would be happy to give you a more accurate assessment after the review of your records.

Aortic Aneurysm

sallydea: My husband recently had an MRI to identify pain in his back from an injury or possibly arthritis related. When the MRI was read he was asked if he knew he had an aortic aneurysm (abdominal) . He did not. Our primary care doctor said that it was only about 2centimeters and they usually didn't worry about them until they were 5 cm. Is that true. He had 4 bypass surgery in 2001. Navel hernia surgery before that. Thank you.

Dr. Mihaljevic: That is true. Small aneurysms do not require any intervention.


Dr. Mihaljevic: Minimally invasive endovascular approach may be possible in your case. Our colleagues from vascular surgery have the word-largest experience in this kind of less invasive treatment of aortic disease. Please send us your records and we will define your plan of care.

Adult Congenital Heart Surgery: Minimally Invasive and Robotically Assisted Heart Surgery

Stephanie25_2: My question for Dr. Mihaljevic and minimally invasive heart surgery is regarding congenital heart defects. I am interested in knowing if there are any minimally invasive procedures (i.e. catheter based, etc.) to repair a VSD (ventricular septal defect) besides the traditional open-heart procedure. If, so-what types of procedures would these be and where could they be performed at? Thank you so much for any insight. I look forward to the response. --Stephanie Arnold, 25yrs, VSD patient from Indiana

Dr. Mihaljevic: Minimally invasive options for VSD closure are possible. Surgery is mostly conducted through a small incision on the right side of the chest or via a small incision over the lower part of the breast bone. Decision about the most appropriate approach for VSD closure depends upon the location and size of the defect.

Percutaneous Valve Surgery

roullac: What is your view to deferring the decision to have surgery for an asymptomatic patient until such time that the Percutaneous non invasive surgery becomes readily available?

Dr. Mihaljevic: Percutaneous aortic valve replacement is currently reserved only for patients who are not candidates for conventional surgery. Currently risks of percutaneous procedures for aortic valve replacement are higher than those of conventional surgery for an average patient. It is unlikely that percutaneous valve replacement will become the standard of care for all patients with valve disease in near future.

Post Surgery Activity

roullac: This question is about people who have previously been involved in physically active hobbies e,g. sporting activities and belly dancing in my case. How soon post surgery and rehabilitation would they be able to resume these physical activities?

Dr. Mihaljevic: Resumption of physical activities after surgery depends upon the type of surgery that was performed. Patients who had minimally invasive robotic surgery can resume physical activities within few weeks after surgery.

August20: How extensive might post-op physical therapy be, and what will it likely consist of?

Dr. Mihaljevic: Most patients do not require any special physical therapy after robotically assisted or minimally invasive heart surgery.

Before Surgery Preparation

August20: I drink a lot of tea, and some beer. How long before surgery should I begin to cleanse my body of the caffeine (including chocolate?) and alcohol? How about afterwards?

Dr. Mihaljevic: There is no need to make substantial alteration in caffeine intake prior to surgery. Alcohol should be avoided for several weeks prior to operation.

August20: What types of foods should I limit or avoid before and after surgery? What should I make sure I get plenty of?

Dr. Mihaljevic: Balanced diet is all that is needed before and after surgery. There is no proof that any dietary supplements facilitate recovery after surgery.

Technology for web chats paid in part by an educational grant from AT&T Ohio and the AT&T Foundation (formerly SBC).

Reviewed: 06/09

This information is provided by Cleveland Clinic as a convenience service only and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. Please remember that this information, in the absence of a visit with a health care professional, must be considered as an educational service only and is not designed to replace a physician's independent judgment about the appropriateness or risks of a procedure for a given patient. The views and opinions expressed by an individual in this forum are not necessarily the views of the Cleveland Clinic institution or other Cleveland Clinic physicians.

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