The Future of Minimally The Future of Minimally Invasive Cardiac SurgeryInvasive Cardiac Surgery

Marco A. Zenati, M.D.Marco A. Zenati, M.D.Professor of Surgery and Professor of Surgery and

BioengineeringBioengineering

University of Pittsburgh School of MedicineUniversity of Pittsburgh School of Medicine

Hans JacobeusHans JacobeusPioneer of Thoracoscopy Pioneer of Thoracoscopy

(Stockholm 1910)(Stockholm 1910)

Modified Cystoscope

Jacobeus HC. The Cauterization of Adhesions in Pneumothorax Treatment of Tuberculosis. Surg Gynecol Obster 1921:32:493-500 (40 patients)

Thoracic Endoscopy Thoracic Endoscopy Pioneers in PittsburghPioneers in Pittsburgh

1993 -1993 -

Landreneau

Luketich

From MIDCAB to TECABFrom MIDCAB to TECAB

Dexterity EnhancementDexterity Enhancement

““Intuitive” Surgery:Intuitive” Surgery:Can You Beat a Fifth Grader?Can You Beat a Fifth Grader?

Computer Motion’s ZEUS1999-2002

Intuitive Surgical’s DaVinci2004-

Robotic Surgery in PittsburghRobotic Surgery in Pittsburgh

April 5April 5thth, 2001 , 2001 University of Pittsburgh Medical CenterUniversity of Pittsburgh Medical Center

First U.S. Robotic First U.S. Robotic Off-Pump CABGOff-Pump CABG

Cardiac Surgeon: Marco A. Zenati, M.D. Patient: 63 yo JAC

Day of discharge home: April 8th, 2001 POD#2

Level 4 MIS for MVRLevel 4 MIS for MVR

““Ideal”Ideal”Minimally Invasive Minimally Invasive Surgical ProcedureSurgical Procedure Single PortSingle Port

Access ANYWHEREAccess ANYWHERE Local vs General Local vs General

AnesthesiaAnesthesia No need for No need for

unnecessary unnecessary invasion of pleural invasion of pleural spacesspaces

Minimize painMinimize painNEJM 2006;354:20

MIS Tools Constrained to MIS Tools Constrained to Pivot at the Body Entry PointPivot at the Body Entry Point

The New York Times May 2007

HEARTLANDER

HeartLanderHeartLander

Bilateral VATS for Bilateral VATS for Pulmonary Vein Isolation in AFPulmonary Vein Isolation in AF

SUBXIPHOID ACCESS

Patient-Specific Strategy for AFPatient-Specific Strategy for AF

Ganglionated PlexiGanglionated Plexi

Armour Anat Record 1997

Rigid Endoscope Rigid Endoscope and Instrument Arm and Instrument Arm ShaftShaft– Unable to navigate Unable to navigate

complex 3D geometry complex 3D geometry spaces (e.g. pericardial spaces (e.g. pericardial space)space)

Ann Thorac Surg 2007

LAA

RAA

Through Transverse Sinus

Entry point: Subxiphoid

RSS Design -Current Prototype-

RSS Design -Current Prototype-

Cardiac Surgeon Cardiac Electrophysiologist

Direct Endoscopic SVPVisualization

FluoroscopyContinuous EKG and hemodynamic monitoring

NAVx 3DImagingStJude Med

HYBRID INTERVENTIONAL SUITE

Subxiphoid ApproachSubxiphoid Approach

Myocor COAPSYSMyocor COAPSYS

Common Lesion Sets Common Lesion Sets Employed in AF AblationEmployed in AF Ablation

Cox-Maze IVCox-Maze IV

Future Clinical “Battlefields”Future Clinical “Battlefields”

Heart FailureHeart Failure– Ischemic Mitral RegurgitationIschemic Mitral Regurgitation– Prevention of Remodeling after MIPrevention of Remodeling after MI

Atrial FibrillationAtrial Fibrillation

• 8 Fr. catheter with an irrigated radiofrequency tip (Biosense Webster) •60ºC, 40 watt, 15 seconds × several times

Ablation procedure

Pathway

Closed Chest Epicardial AblationClosed Chest Epicardial Ablation

Subxiphoid Videopericardioscopy Subxiphoid Videopericardioscopy for CRTfor CRT

Lead

Zenati et al. Circulation 2002

Epicardial Lead Placement for CRTEpicardial Lead Placement for CRTwith DaVinci Robotic Systemwith DaVinci Robotic System