Cox-MAZE IV with Coronary Artery Bypass Graft and Mitral Valve Replacement
In this long and complicated case, Dr. Marco Zenati performs a full, biatrial Cox-MAZE IV procedure with coronary artery bypass grafting (CABG) and a mitral valve replacement (MVR), moving between the three procedures as necessary to minimize time on the ischemic heart. The patient suffers from congestive heart failure that recently escalated from class II to class III.
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TranscriptionsPlease note that, unless otherwise stated, these transcriptions have been auto generated and therefore we can not guarentee their complete accuracy
My name is Marcos Zenati, I’m a cardiac surgeon at the VA Boston. I serve as Division Chief. I'm also a Professor of Surgery at Harvard Medical School and an Associate Surgeon at Brigham and Women’s Hospital. Today's case will be a complex combined procedure including a full biatrial Cox-Maze IV for mitral valve repair or replacement, and a single vessel CABG with mammary to a LAD. So this gentleman suffered from congestive heart failure for, for many years, recent worsening effort intolerance and shortness of breath, transition from class II to class III and he was really keen on getting relief of symptoms and also life prolongation because in the course of the workup but we found a very tight, 95% stenosis of the left anterior descending coronary artery.
So the procedure will involve a little bit of going back and forth between the procedure because we don't complete the full Maze and then move over there to the mitral and the CABG. We can do part of the Maze and then we go back. The reason being that we try to, because there's a long and complex procedure to minimize the global ischemic time to the heart and to do so we are going to do procedure, part of the procedure on the beating heart to prior to stopping it. So of course, you know, this is an open heart surgery; requires a full median sternotomy, requires cardiopulmonary bypass and requires opening of both left and right atrium.
Specifically, the Maze procedure that we going to perform today is the most recent evolution of the procedure that was developed by Dr. Jim Cox, first in the 1980s and then perfected to what we call the Cox-Maze III in the 1990s. Today's procedure is the most recent evolution of the original Cox-Maze III, we call a Cox-Maze IV and the major difference compared to Dr. Cox teaching is that the majority of the lesions that we create on both left and right atrium are created using alternative energy rather than a surgical incision that requires a suture to close it. And specifically we going to be used a combination of radio frequency energy and cryoablation.
The procedure will be a biatrial Maze, both left and right atrium will be treated and fundamentally, there are four components of the Cox-Maze IV: one, which is the mainstay, is bilateral pulmonary vein isolation and this will be performed using a bipolar radiofrequency clamp. The second component is the right atrial lesions of the Cox-Maze which were targeted right atrium and the right isthmus. And the third component is the left atrial lesions of the Maze, the most important part because atrial fibrillation is originating primarily from left atrium and is designed to interrupt large reentry circus [movement]. The fourth component is the treatment of the left atrial appendage. 90% of patients that have a stroke, a cardioembolic stroke, secondary to atrial fibrillation, have a trauma in the appendage, so it is paramount to to treat it. There are several ways to do it. Today we plan to use the a left atrial appendage clip that has to be placed carefully at the base and completely exclude the appendage from the circulation.
So the first part of the procedure, this is a full median sternotomy. The first part of procedure will be the harvesting of the conduit for the bypass so we’ll do the median sternotomy followed by the mammary harvest. And I will do that using skeletonization technique.
[Resident]: And why are we skeletonizing this mammary?
Well it is my preferred technique, I like to do it actually, for everybody but as you… with us yesterday, it's especially important when you do bilateral mammary. I think this is the best technique and I use it routinely.
[Resident]: Especially on a younger patient, or diabetic?
The data supports catheterization, it should be for for all patients.
[Resident]: For all patients?
[Resident]: Even non-diabetics?
[Resident]: It also helps with length, right?
Yeah, so the advantages are length, so you you never have an issue of reaching a distal target. If you have to do a sequential graft or composite, it’s much easier when you have the mammary without any surrounding muscle tissue. And also devascularization of the sternum is, is better.
So what’s this hematoma from? A cath or something?
[Resident]: Maybe. Oh you know what, he had all these hematomas after he had his teeth removed but I don't know what that’s from. Ecchymosis on his cheek and abdomen.
We’re gonna go deeper.
Can you just stay on top of here.
[Resident]: Divide the ligament?
It is the deep cervical fascia, there's no ligament.
[Resident]: So this is an important staple line.
Yeah and I feel the interspace is here as I go down.
Okay saw. The lungs down please. K, lungs up. Tidal volume 450 please. Okay, army navy. Evanko please.
So the next step I will sit down and will perform the left internal mammary harvest using a skeletonisation technique but I prefer technique especially when bilateral mammary surgery is performed. We use a Vancomycin paste as a hemostatic agent and also provide topical antibiotic coverage. Okay good. So if you want to step back and I'll pick a root tract.
So this completes the median sternotomy part of the procedure and now we move to the harvest of the left internal mammary artery. There are two of this mammary artery running inside the chest, one to the left, one of the right, we are gonna mobilize the one in the left. We need a special retractor to expose the internal chest wall.
[Resident]: I’m gonna watch him skeletonize the mammary so I'm going to go to the other side.
The first step is to expose the internal chest wall on the left side. We mobilize this fat and pleura in order to provide optimal exposure. It’s very important to have a comfortable position for the surgeon with the head aligned with the mammary. So we enter routinely the left pleural space. This is the left lung and you can see the inside of the chest, of the left chest. This is the preferred conduit to revascularize the left anterior descending. It's an arterial conduit with excellent long-term patency by 95% to 10 years. So the first step it's to, again provided, a nice dry exposure to the interior chest wall. And we can see now the mammary artery and the two veins that run parallel to it. So normally the harvest, called the pedicle harvest, will take fascia, muscle, and both veins with the artery. It will create a very large pedicle. That is the standard technique. This technique instead harvest the artery itself without any surrounding vessels or tissue. So we start by identifying the artery and then grabbing the fascia right underneath. The bovie is a very low 15 to 20 joules. Then we start by incising the fascia and following the course of the mammary. Keep it dry.
So a very short burst of cautery, then we can use the tip as a spatula once it cools. So we have to be careful not to apply the tip of the cautery immediately after using for cutting to avoid thermal injury to the mammary.
[Resident]: So do you skeletonize also in patients who are non-diabetics?
I do. Because as I said, it does preserve blood flow to the chest wall better and provide extra length, up to an inch extra length. So it allows me never to worry about not reaching my target. We try to avoid to direct manipulation of the mammary as much as possible, use the adventitia. You can see the mammary now starting to show up underneath the fascia. I tried to stop right before to bifurcation between the superior epigastric and the pericardial phrenic because beyond that location, the media of the mammary becomes more muscular while the rest is mostly elastic and that's what the provides long-term patency as a conduit. The fact that there's a little muscular component. And also the mammary has this property of pretty much never getting athersclerotic disease. You can have patients with severe perivascular disease and conditions or severe diabetic disease and pretty much always the mammary is pristine. You have noticed that in your practice, I'm sure. And that is because the endothelium of the mammary has the properties of releasing nitric oxide at much higher rate that's protective. So it is that special, special conduit and that actually provides protection to the distal vessels once it’s used to bypass conduit.
[Resident]: Does the radial artery have the same properties?
To a lesser extent. The radial artery has very thick muscular media so that makes it less desirable. So by far the left internal mammary artery and also the right are better conduit. So I'm using a high-quality micro clip. The first clip, to divide branches, is applied flush with the artery and the other one is a short distance away. Then we use a scissor to divide in between. So this technique allows collateral circulation from the intercostal arteries from different interspaces to be preserved while it is interrupted with the pedicle technique as you know. See we’re starting to develop the artery, there is a branch coming up in front of us. So another clip please. And you see that then my exposure is obtained by grabbing on adventitia, never holding on the vessel itself. A clip nicely applied flush with the artery, another a short distance away and the tenotomy scissors and a nice sharp dissection. So basically it's cut, clip, clip, cut, clip, clip, cut. You see we’re developing and the vessel is coming out by itself without any surrounding muscle or vein. So this is a technique that you have to do but you cannot rush so I would not use it on an emergency case. You have to be able to kinda take your time. Proceed, you know, expeditiously but without rushing because this conduit is very important for the patient so you want to minimize the risk of damaging the conduit. So this technique is more involved. It's a little more complex than the pedicle but can be taught and is very reproducible. It's mandatory if you were going to do multi arterial like bilateral mammary revascularization. If that's your practice you’re going to have to use this technique. Although, as you know, the recent five-year data published New England Journal of Medicine on the ART trial, did not show superiority of the bilateral mammary approach. You familiar with the ART trial? Kelly?
[Trial mentioned: http://www.nejm.org/doi/full/10.1056/NEJMoa1610021#t=article]
[Resident]: I’m familiar with it, but I don’t know the details of it.
Dr. Taggert actually was a lecturer at Harvard. So it was just published in the New England Journal of Medicine. So they randomized patients to either single mammary and vein or bilateral mammary and vein. And they gonna continue to follow up to 10 years, but the one-year and five-year data did not show a difference for the chosen primary outcome measure, which was a composite of major adverse cardiac events. So that kinda dampened a little bit enthusiasm but we’ll have to see the long term data.
So you can see I'm developing the conduit, you know, I'm always apply indirect tension on the mammary. This is another branch back there. I'm going to clean surrounding issue. Clip please.
[Resident]: So when you take it as a pedicle, you still divide these branches. How is this different from taking it and preserving the blood flow to the chest wall?
Yeah, this is an excellent question. Where you divide the branches would be probably down here as opposed to right next to the artery, so this way this branch and the branch above remain connected to a network based on the intercostal arteries. So intercostal arteries run below each rib and the currently connected to the mammary and to the intercostal artery above and below. If you divide with the pedicle at this level you will interrupt them, if you let divide the branch at this level you will not interrupt them, so that is the difference. Make sense?
So this is the xiphoid and the pretty much at this level you expect the mammary to bifurcate into the two terminal branches, the superior epigastric and the pericardial phrenic so I'm going to go just a little bit more distal here and then I'm going to stop for the distal harvest. See we're trying to keep a dry field, no bleeding, so I have a very good exposure. Another branch back there I'm going to divide. Clip please. So our technique requires high-quality instruments like this so we have dedicated clip appliers and very, the best you can get in order to perform this approach. Sometime the mammaries are routed below the aorta in the transverse sinus and, you know, you have to be really sure the clips are applied correctly because once the mammary is routed the transverse sinus is very difficult to access for repair in case of bleeding. You see the bifurcation here? Superior epigastric gastric and pericardial phrenic so we are going to divide and actually leave this bifurcation patent and divide just above. Make sense? You see the bifurcation, we're going to keep this patent so I'm going to put the clip so that the pericardial phrenic and the superior epigastric will still be in continuity.
So we’re going to move the attention to the rest of the course of the mammary. We’re keeping our field dry, we’re using this lav to have the lung nicely tucked away.
[Resident]: Do you think from being on the teaching side of things that this is more difficult to teach than pedicle?
Well, so requires… its graduate school for mammary harvest, so the progression I teach follows this progression, I first teach the pedicle, of course. Usually in our rotation you learned that from scrubbing with my partners who use the pedicle technique. Once the fellow is comfortable with the pedicle, meaning no injury, harvestime less than half an hour, then I introduce the Hemi skeletonization. The Hemi-Skeletonization is it is a version of this approach that the allows you to have the same length afforded by authorization but with a shortened time. However, the impact on the blood flow to the chest wall is same as pedicle so you would not use hemi-skeletonization technique in a bilateral mammary.
[Resident]: So it’s meant for teaching purposes?
So I progress it that way and once you learn the hemi-skeletonization, then you move to full skeletonization technique. So people like, like at your level Kelly and would have an interest, they would, you know, start like a program where they maybe start taking half of this down, and then progress to do the full technique. So this is very reproducible and then it takes perhaps 5-10 minutes longer than the pedicle. So a very expert harvester would take the pedicle down in 10-15 minutes. For this you're probably adding between 5 to 10 minutes, that's just a little bit of a price to pay. So now we’re moving to the manubrium of the sternum. So far the harvest, I think, is doing well. I see another branch here. Clip please.
Some people use the harmonic scalpel for this harvest, and I have no experience with that technique, though some people swear by it. So you would not divide the branches to the way I'm showing it. Clip please. I tried to use clips on even the small branches. I sleep better at night that way. So we're getting there. So we just transition the angle of Louis so we’re going toward second and first base. There you go, so here’s a mammary. Clip please. It could be intimidating the first time to look at this but don't like him like many things once you start doing it then you realize that it is doable. This was a big, uh big branch. Hopefully, it will be a blow for freedom as we complete the harvest here.
[Resident]: How proximal do you go?
I try to go as high as the first rib, above the first rib.
[Resident]: Do you think if you don't take the first branch that, that creates a potential Steal [Syndrome]?
That is a concern, yes. That has been shown, so you know, I try to go high. Another clip please. So as soon as we completed the harvest, we are going to systemically heparinize the patient. Our perfusionist has calculated the dose and the heparin will be given by a bolus by anesthesia colleagues. And in order to start a heart-lung machine after we can cannulate will require an ACT, an activated clotting time, in excessive 400 seconds. We're getting there. Clip please. I think it’s very safe to go ahead and give the heparin.
[Resident]: So you think the take-home message is a low heat and blunt dissection?
Yeah it’s gonna be a combination of blunt and sharp, yeah.
[Resident]: Bovie no more than 20?
Or 15 or 20, yeah.
[Anesthesiologist]: Give me a thousand heparin again.
Thank you! So we start a timer and in 3 minutes I will check the ACT sample. So this is the first rib right here. A very important here not to move to medially because there's a phrenic nerve and I think it's safer to stay away from the area. So I moved from lateral to medial in my dissection, you can see here, lateral to medial. I think we're pretty much done at this point. We have a, you know, very nice conduit here. So the heparin has been given and we’ll divide this conduit right now, so using medium clip, as I indicated that we would like to preserve the bifurcation so I'm going to leave these two vessels here. There's the superior epigastric and pericardial phrenic in continuity. I'm going to put the clip that allows the two vessels to continue to be patent. We place two clips and then we'll use a tenotomy. And we are observing nice flow from his mammary.
[Resident]: Yeah, excellent flow.
And my technique is, I put a bulldog at the very end. I let this mammary distend under its own pressure and I apply topical Papaverine. Bovie up to 50 please. So this is Papaverine and I'm using this 1mm Olive tip needle which you allow me if necessary to do intraluminal dilatation. Today I will not do that and just apply papaverine topically and then we're going to let this conduit distend under it’s own pressure. So also I avoid bunching it up there. I keep it like this so it will, it will distend under its own pressure. So this concludes the skeletonization harvest. I take a quick look here, make sure the chest wall is dry. With this technique, there's much less potential for bleeding on chest wall. You see, it looks good.
So we changed the gown here because I sat low, there’s potential for contamination. Anymore vanco paste? Okay, I need two of the Vicryl.
[Resident]: Okay, right here.
35:00 Blue rubber ……………..
[Resident]: We had this the other day.
Okay thank you.
[Resident]: I’ll get out of your way in a sec.
We're dividing the remnant of the thymus here and we’re going to expose the pericardium. And then we’ll open the pericardium then access the heart. So this is pericardium. And we’re opening pericardium now. Underneath that we’ll see the right ventricle.
[Resident]: You have another blue dog. Nevermind, we have it.
[Resident]: What’s the bovie on?
[Resident]: You see the phrenic?
Phrenic visualized down there. Down there. Ok. 2-0 papa. So we have divided the pericardium, now we're going to suspend the edges of the pericardium.
[Resident]: Oops, sorry.
Thank you, Jeff. We can see we’re at the right atrial appendage here, fibrillating, if you can see the chaotic motion of the atrium. That’s characteristic. Let me just wait a little bit. Bovie one more time, bovie set.
[Resident]: Short aorta huh?
And take it up to a papa again.
And one more 2-0 papa.
[Resident]: Do you wanna keep this long for your cannula?
No, no, cut it. Actually just pull through, cut it off here. And one more position. Okay, let’s get the A-P aortic ultrasound probe. So this point we are going in preparation for cannulation of the aorta. We're going to perform an A-P aortic ultrasound using a handheld probe, please pass, and kept sterile in the field and this will allow us to examine the ascending aorta which is a blind zone for the transvagial echo. If there is a severe intraluminal atheroma we may have to find alternative cannulation. So provide a short axis view, just proximal to the take off for the innominate artery, and we observed that there is no protruding intraluminal atheroma, there’s normal thickness of the aorta. There's no mobile atheroma either and then we provide a long axis view going into the proximal arch and looks really good. I think it is a CAC zero score. Okay so we're done with this. Yes please. And the next step when we do Maze procedure for patients like this, it was a long-standing persistent atrial fibrillation, we always try to cardiovert and and if we can try it, have the patient in sinus rhythm. So can I have the pedals and we’ll do synchronized cardioversion at 10 joules. We have confirmed with transvagial echo that there is no thrombus in the appendages. That's mandatory because -
[Resident]: Prevent stroke.
Of course. So this will be a step that we would skip if there was thrombus in the appendage.
But there is no thrombus.
[Resident]: Why do we try to cardiovert before the Maze?
Well, first of all, because, we want to confirm the diagnosis of long-standing persistent - Are we capturing? Are we syncing? The first reason is to confirm that is long-standing persistent. The second reason is - thank you. Syncing. Delivering. Okay recharge. So failed. Patient is still in a- fib.
[Resident]: Okay, so the goal was not to cardiovert? The goal was to confirm?
Goal was to cardiovert also. Go up to 20. Failed twice at 10 joules so we’ll try one more time. Sync and go up to 20 joules. Ready? Deliver. Okay so he failed the three cardioversions so this confirms that this patient is in permanent or long-standing persistent atrial fibrillation so that also will tell us that once we do pulmonary vein isolation, we will not be able to do exit block confirmation. Exit block required we pace the pulmonary veins and because the patient is in A-fib, we will only be able to entry block. So the next step at this point is to.. We’ll put purse strings in preparation. So this is a the purse string for the aortic cannulation.
[Resident]: Can I have a DeBakey please?
I'm inclined to skip the GPs, what do you think?
[Resident]: Yeah I think so.
This patient is in advanced stage, so I think the contribution of the GP will be minimal. So we're not going to do GPs, Paul. Say again? Yeah, you can open a bipolar clamp, the lighted tip dissector as well. The wolf, okay, another stitch. Do I need to see the pledget and you need to expose the pledget for me so I can go to -
[Resident]: Yep yep yep.
Is a twisted? So just dissecting around here. It's the right pulmonary artery right here. Right PA right there.
[Resident]: Yep. Blood pressure is okay? I'm just pulling a little bit on the aorta.
K. Purse string. So we cannulate directly the superior vena cava so we can perform a full Maze procedure. You take a pledget you can let go of the Tonsil. So for the maze procedure we need to have it bi-cable venus cannulation in order to open the right atrium and so we have to cannulate the superior and inferior vena cava sequentially. So now I need you to expose here for a bit.
[Resident]: Alright, I’m gonna push on the heart in a moment.
I'll take a stitch back in.
[Resident]: Pressure, ah okay. It's going to drop in a minute. Alright but here we go. Watch it.
Give it a breather as soon as I’m retrieving the needle.
Yeah, let go.
[Resident]: Off the heart. And coming back.
Okay, you’re doing it like a heart transplant, very low. Lemme see. That's a very good job you're doing, you know, giving him a chance to refill after. Each bite. Okay, one more. Okay.
[Resident]: Okay I'm off in a second.
Okay, stop circulating. So we completed all the purse stringing. So let's divide the larynx tubing. Tubing scissor.
[Resident]: Okay we're clamped up here.
So, there are three components to the Maze procedure. The first component is the pulmonary vein isolation, left and right PV, that's a mainstay of the entire procedure. So that's one part. Second part, in order of us perform, it is the right atrial lesions and then the left atrial lesions. So 1, 2, 3, and in addition we’ll manage the appendage. So these four components will constitute the full Maze.
So in terms of the pulmonary vein isolation, we’ll start with the right pulmonary veins. There are two ways to do it. If possible, it’d be nice to do it before I go on pump and that's not always possible. So what I like to do is we can try a little bit of dissection. However, in this case due to the severe atriomegaly, I have doubts we’re going to be successful. So we are actually going to go and cannulate first and then go on pump and performed that on the beating heart on pump. So I'll take a Metzenbaum. That's a choice that we make on a case-by-case basis.
[Resident]: So to do the pulmonary vein isolation only -
On pump beating heart versus off pump.
[Resident]: But to that for long-standing persistent A-fib, that’s not enough to do the pulmonary vein isolation?
I just said that's one of the four components of the Maze.
[Resident]: Right, but to just do that part -
That will not suffice, yes, you are correct. Okay, the pressure is good. 11 blade please. So we’re cannulating the aorta. Thank you for managing the pressure.
[Resident]: Um, can I use the pump sucker or no? Okay, where is it?
22 French arterial return cannula, so we have to turn it, as you remember. The blue line in this cannula is to look toward the head. Thank you, hold this please.
[Resident]: Yep yep.
Pick-up please. Try to orient it so that flow is aimed toward the middle of the arch, correct. Otherwise, our anesthesiologist will tell us that there is a bruit then we'll have to reposition. The flow can go preferentially into the nominates. Secure purse string. Tie off Foster please. Give me a lil bit of room here, thank you. So this was truly a long-standing persistent A-fib. See sometimes you know the diagnosis may or may not be confirmed if the patient had converted to the sinus, stable sinus, it probably would have been persistent case. I’ll take a clamp. Okay where at in the process of connecting the aortic cannula to the arterial limb of the bypass machine. Let go. We’re checking to make sure there's no air. 2-0 Papa please. Secure the cannula so it cannot be dislodged accidentally. And a towel trying to put it here.
Okay I’ll take a long Tonsil again. Next, we’re going to cannulate the superior vena cava. Thank you. And you have a forcep next also. Lemme see.
[Resident]: K, the pressure might change a little bit. Pulling on the aorta.
So Jamal, I will need your help. You need a forcep next. Jamal needs to hold a sucker here. I need an 11 blade. Yes.
[Resident]: Can you put the thumb sucker in a little more. Thank you.
Let go. Okay, now grab the cannula and hold it in place. So this is 24 French Pacifico type cannula, that will drain the superior vena cava and will allow us to do total cardiopulmonary bypass and open the right atrium. Okay hold this. You can relieve this. Okay thank you, hold this up. Okay so far so good. Secure the cannula. Okay. I help myself, you just need to suck. Yes. I’m pushing on the heart.
[Resident]: Alright, we’re almost done, hang tight.
Okay stop. I need a Tonsil. Okay good. Let go please. Advance it a little bit. Okay we’re good, we’re good.
[Resident]: We’re off. Back on a little bit.
We’re going to go on in a sec. This was a big atrium so definitely we could not have done it without going on pump. Okay good. Okay, thank you. Good job there. So this is a cannula in the inferior vena cava. This is a cannula in the superior vena cava and we're going to be able to isolate the venous return once we open that right atrium. Can you remove the clamp. Saline. Let go. Okay Jeff, all yours. So you doing a wrap, directory at priming, displace that crystalloid and then go on pump.
The next step for us will be addressing the right pulmonary veins and that once we're on, we're going to have better exposure. The first thing we are going to do, we’re going to open the, into the oblique sinus of the pericardium and then passed the lighted tip dissector, which is this instrument here, that has a light at the tip, with the light and it allows a smooth transition. So this instrument will go just flush inferior of the right inferior pulmonary vein, inside of the oblique sinus of the pericardium, and then it will be turned on and we will reemerge on the roof of the left atrium. So this will allow us to go smoothly around both right pulmonary veins. So we will demonstrate this next, so if you expose for me. I’ll take a pick-up and use the Cell-saver.
[Resident]: Cell-saver please?
Is it ventilation off? Pick-up please. So over here you see the cannula of the inferior vena cava. We’re going to dissect a little bit of the pericardial reflection. Here you see the superior vena cava. Don’t pull on the cannula, make sure you stay away from the cannula. Stay away, wait wait, stay away. See it’s trying to come out so you have to stay away from there. Great, show me here, push. So I have to identify there the right inferior pulmonary vein and then I'm going to divide the pericardial reflection here between the inferior vena cava and the pulmonary vein. That will lead me into the oblique sinus of the pericardium right there. See it right there? This led me into the - put the sucker inside - that is the oblique sinus of the pericardium, so this is posterior left atrium but I’m going to extend this dissection until I see the pulmonary vein, the right inferior pulmonary vein. This will allow me to position the clamp, the bipolar clamp very well. So this is the pulmonary vein here, you see? So we going to dissect this a little more toward inferior vena cava and now let’s dissect here. So this is a right superior pulmonary vein and we are going to dissect between the roof of the left atrium. Ok, suck here. And the pulmonary artery. So this plane is where we’re going to retrieve our lighted tip dissector. The lighted tip detector has this plastic sleeve, so as indicated we’ll introduce it flush with the right inferior pulmonary vein into the oblique sinus of the pericardium, then we going to adjust the tip and we are going to observe into the space that we have pre-dissected. For the lighted tip to, and you can see the light now, you can see the lights right there, you see? So that tells us we are free and we're clear of the superior pulmonary vein and a little bit of more blunt dissection and we're free. The next two we're going to grab this with the Tonsil or forceps and I'm going to withdraw the dissector and pass this rubber across. So this now allows me to have a nice control of both right superior and right inferior pulmonary veins. So now we’re going to exchange, this is a bipolar radiofrequency clamp, with gold plated electrodes on both jaws. And the energy will be contained between the two jaws and so the tissue will be in between and by clamping will allow us the circumferential ablation. So this will be the right pulmonary vein isolation will be done with this device. So this device we connect to the end of the rubber, this way. Okay and then we gently pull the rubber across and we introduced it, following the path that the we have developed earlier until. Use a suction here.
[Resident]: Suction please.
Till we are trying to visualize the the jaw right there, and see the jaw? And we advance till we have to push the heel a little bit. So we trying to try to position this clamp nicely across, yeah. Okay now I'm going to remove the rubber and now you can see that the jaw. Now I’m going to clamp. Clamp, this clamp will allow me to do a circumferential ablation. Take this. Okay, so we ablating currently so you see the energies being deployed through the two anode and cathode of the jaws and there is conductance algorithm and we do 5 of this RF applications. So the purpose here is to obtain a coagulation necrosis that is irreversible. So this device will notify us when no more energy can be delivered. So we stopped the ablation, open the jaws, reposition slightly, you can see the char and reapply. So this is the second application of five.
[Resident]: So what, how did they determine there's five applications?
Well we did an experimental study in the porcine model in my lab and saw that sometimes the thickness of the atrium is such that up to five or six applications are usually necessary.
[Resident]: And do you move it?
I open it and reapply.
[Resident]: But in the same area.
So at the end of this application, we are going to confirm entry block. In this case, patient is still in A-fib so we cannot do exit block or we will confirm entry block, provided that they are sensing to what is operational.
[Resident]: How many seconds does that run?
We let it run until…..
[Resident]:Okay so you don’t set it.
There’s an algorithm that changes the sound and that’s how I know. So this is number three, you can see the nice charring, that's what we want to see. We’re going to put another application, number four. So once this is complete it will allow us to have a complete right pulmonary vein isolation, en bloc.
[Resident]: You're going in the same area, you’re not moving it from side to side?
No, no. Provide that I’m across. You have to go past...
[Resident]: It looks like it’s really burning it, there’s no risk of it going through and through.
This is number five. So even if I don't have any confirmation from the sensing pen, five in my experience is sufficient. So you can see a little bit of char here on the device. This has to be cleaned, but I consider the right side completed. So the next step we going to be doing, open the right atrium and in order to do that we have to use umbilical tape and encircle the cava. So umbilical tape and curved clamp. So we going to go around here, umbilical tape. So let's do this superior vena cava over here. Easy easy easy easy easy, just pull the aorta. Yeah I previously stented it so this should become pretty easy to do. Okay I'm coming down on this SVC let me know if you have issue with a venous return Jeff.
[Jeff]: Nope so far so good.
And you want to make sure the head is not distended. That was anesthesia. I snared the SVC cannula, so make sure the head is decompressed.
[Resident]: That it’s not blowing up, right. Cause we just snared the SVC, so just make sure there is no head edema. Thank you.
And let's go down on this. I'm afraid this cannula is not in the right place. See, this cannula is not going in the right place.
[Resident]: Now is the time to readjust it.
Yeah we need to get adjust this, so I have to readjust the -
[Resident]: Do you have scissors, please?
[Resident]: Er yeah, 15, sorry.
No let me do it, this is a little dangerous move. So Jeff, I have to reposition the IVC cannula because it’s not in the IVC, it was in the atrium. So you might get some air, so leave a little bit in. So just release this, a little bit. It’s nice very tight just control it with your hand. Let me see here, I need to see. K that should be good, okay. Tighten. Empty the heart.
Now hold this cannula, no not good enough, hold this, hold the, hold this cannula please and show me here. Empty the heart. Pull this. The pair of scissors.
[Resident]: I have scissors.
Pull this plastic thing up. Okay, that should be, should do it. Let me see. Okay, Jeff here I'm going down on the IVC as well. How's the venous return?
Same as it was. No problem.
I need the slinky. Tubing scissor. Okay I'll take a - so we’re doing now the right atrial lesions of the Maze, so hold this up. 11 blade. Open the cyro. Grab here. 11 blade. I think a long scissor. Okay, so bipolar clamp, we can shoot, put this here. Yellow up. and atrial retractor. Atrial retractor. So we start on the right side by doing this incision with the scissor which corresponds to the Cox-Maze counter incision and then this will be the longitudinal incision toward the superior vena cava. It’s done where the jaw inside left atrium and the jaw outside toward the vena cava so we going to apply this for three applications. Any luck with the sensing tool?
Where is the new one? Okay it’s on atrial tissue. Okay this is, see the pen, yeah switch it. I want atrial tissue. I’m on the ventricle. Nothing working. Okay so this is the first application. We're going to do, we said three. I need to switch on bipolar RF right now. So this is second application of RF energy. And then we'll do a third one. So this is longitudinal incision of the Maze toward the superior vena cava. You can see entire the, inside of the right atrium. Okay we're going to clean this char. And you have a good venous return, we're looking good? Thank you. See what we needed to reposition the cannula. This is the inferior lesion that is the continuation of this line but instead of doing cutting and so, we will be using radio frequency again. Again, we going to do three application of RF energy, you good? good?
[Resident]: So you would open this and and bicavally cannulate even if you're doing a CABG and a Maze?
[Resident]: And they still would open up this way?
If you choose to do it by, biatrial Maze you may choose not to so. That's a surgeon's preference and we'll do one more ablation. Okay, so we're done with this. Now we're going to do one more lesion toward the tip of the right atrial appendage.
[Resident]: Also three lesions?
Again, this is a lesion with one jaw inside the atrium, one jaw outside the atrium, provides a linear lesion and next we going to use the cry probe.
[Resident]: And the same lesions start with the cryo?
This cyro will be used for a lesion going toward a tricuspid annulus.
You see the nice tissue necrosis here? The very tense tissues takes about 10 seconds. So can you clean the jaws for me and now I need an atrial retractor.
[Resident]: So what if you applied cryo for these lesion sets, does it not have the same effect?
This is faster. So a radiofrequency takes 15 to 20 minutes and each cryo lesion takes 2 minutes so saves time.
Okay, okay so same effect but the difference is scarring.
So now you can visualize. Lift up here. You can visualize the tricuspid valve. This is the septal leaflet of the tricuspid valve and you can see the coronary sinus and we have our suction device there. So this lesion will go from the cut end of the atriotomy toward 3 p.m. on a clock on the tricuspid valve and will overlap slightly with the tricuspid annulus.
[Resident]: So the tip goes to the annulus.
Okay so grab this tissue here for me so you want to make sure that it was it connects, touches the, okay. Freeze. So they probably two minutes for this linear lesion. So as you can see RF is much faster but the reason why we’re using this is you can demonstrate is that it's safe here to use the cryo, even on the part of the valve leaflet. We will not be safe to use radio frequency on the leaflet. And the reason is because cryoablation provides ablation without damaging the collagen and it does not result into scar. What radio frequency provides irreversible coagulation necrosis but heals with a scar so it will damage that leaflet issue where the cryo will not. So this is sometimes referred to as part of the right isthmus lesion and the right atrial lesions were doing were part of the maze are primarily to prevent atrial flutter recurrences. Although some atrial fibrillation cases that I've also component of reentry in the right atrium. It's a little bit unpredictable.
[Resident]: So this this step of operation is not completely necessary for A-fib?
Yeah it is. The data shows that the by in large, the bi-atrial Maze is superior to left atrial Maze only. But it's somehow controversial, there are schools of thought and people who swear one way or the other.
Here’s the cryo probe, make sure it doesn't fly away. 2-0 papa. So we have completed in the meantime the ablation, the lesion of the right atrium for the Maze procedure so that is done. Now we will close the right atrium. I need a straight and then a 5-0 probe.
[Resident]: So we won’t go transseptal for the mitral?
No, no transseptal, just left atriotomy.
[Resident]: So this is an incision here, right and I never go this way.
Okay yeah, they have to reposition. yeah, before it falls in the field. I’ll do the first stitch and then you sew it toward you.
[Resident]: Full thickness.
Squirt. So we're closing now the atriotomy, so you can see that the right atrial lesion so the Maze made in this case was achieved using a combination of cut and sew. So this is atriotomy constitutes cut and sew, radiofrequency bipolar, and cryoablation. So we use basically, it you consider cut and sew energy source, three different energies. And all of this is done on the beating heart. There's no ischemic arrest and that's done on purpose to minimize the myocardial ischemia.
K, scissor please. Cut that. Take this.
[Resident]: Yeah thanks.
Let’s do superficial and close together.
That’s not superficial. We’ll take it but the next one has to be superficial. So we will try to do as much as possible on the beating heart before arresting the heart.
So this so far we have completed 50% of the pulmonary vein isolation which is one component of the Maze we have to still do the left pulmonary vein isolation. However we have completed the right atrial lesions of the Maze so will we still have to do half of the previous isolation on the left and then left atrium lesions. And we will do those after we stop the heart and we open the left atrium.
[Resident]: Okay can you cut this? Please, thank you.
Okay I'll give you back the cava so we don't we don't need to have total cardiopulmonary bypass anymore so I'm releasing the inferior and I'm releasing this superior. The next step will require need to cryo I'm going to do part of the left isthmus lesion from the epicardial side. So lemme take a look here. So lemme see. So I’ll take the cryo from -
Okay, so you can see here the corner, this is the POV, this is a PDA, this is the posterolateral branch of the right dominant is the right dominant and you can see the coronary sinus down there. Right there, the coronary sinus, the tip of the cryoprobe is coronary sinus and that's left atrial so I'm going to perform the left isthmus lesion here from the epicardial surface. Freeze please. And this will catch the coronary sinus from the epicardial surface, you can see.
[Resident]: Okay I know and I wanted to take a, I wanted to see where you are, where the tip is.
Okay it’s very important to study the coronary anatomy prior to doing this. Make sure is cryoablation is not over a coronary artery because this cause thrombosis. So this will be a two minutes lesion so this is the left isthmus lesion. Peter, from the epicardial surface, we do a both endocardially and epicardially. It’s a cryoablation a linear cryoprobe. This guarantees that we catch the coronary sinus. Yeah and this is the protocol is 2 minutes. Yeah that is the reason why we added this lesion because of the endocardial lesions were inconsistent and so this this two combined that provides a pretty solid left isthmus lesion which is critical. And again we're doing all this on the beating heart. There's no ischemia so we're on pump with a beating heart.
Okay we're gonna try now to do that left pulmonary vein isolation on the beating heart. This sometimes is possible, sometimes it's not possible because the size of the heart. I believe that it will be very difficult to do today given the size of the heart. So at this point I'd rather move on to place the cardioplegia and cardioplegic arrest unless you want me to try the sensing tool one more time or we're giving it, giving up on that. Okay, pen one more time. So, again this is the right atrium, it should have an electrogram if it works. I'm on left ventricle.
That's why I overkill in a sense I do five ablations even perhaps two or three enough because I don't take a chance and have that cases were I needed all five. Okay so I need a purse string for the interverting cardioplegia without a pledget. So with a pledget, I'm sorry. The pledget. And we have done needle cardioplegia today. Thank you. Okay, you want to flush the cardioplegia. Cut, cut, cut and lighter please.
Flush cardio. Cut. Go straight. Cardioplegia needle.
[Resident]: Ok off.
Hold this in place.
[Resident]: K, got it.
Okay, I’ll take a tie and Foster. It should go down to 32 please Jeff. Okay cut this.
[Resident]: Did we have scissors up here?
Take a tubing scissor. And root vent up. Okay aortic clamp. Cardiac is ready? Okay we're going to go proceed to stop the heart using cardioplegic arrest. Flow down please. Aorta is clamped. Flow back up. Start to integrate cardioplegia. We’ll do some topical hyperthermia with the ice slush. Pressure in the root is good. We confirm that the clamp is nicely across. We take a deep breath now. Relax a bit. Ask a question first.
[Resident]: Is there any absolute contraindications to Maze procedure?
It's it's, well, let me think. I would not, would not do it in a redo operation honestly because you know the previous cardiac adhesions would make very difficult to the the access, although it is not impossible but you know, increase the risk. If you have to do five vessel CABG and double valve I would not add a Maze. I will probably just exclude the left atrial appendage, so it's a judgment call. But as you know, it's, it, it's a Class 1 indication for mitral valve repair/ replacement to do this, because the data supported that there is no additional additional risk.
[Resident]: Yes, however only 60% of surgeons are doing it this way.
[Resident]: and the question is, why do you think that is?
Well it could be in that combination of factors, one is at the training. Maze is not commonly taught in all training programs, so you need to seek education on your own after your training.
[Resident]: So how did you do that?
Had to do a Maze. Had to do course, there’s course, there’s courses. And you have to really develop an interest and an even understanding of the underlying and develop positive relationship with electrologist, that's important. How much cardio in?
[Resident]: So there are no true absolute contraindications, just relative?
I think it was just a relative.
[Person]: How effective is the Maze procedure is?
Oh the success rate, that’s an excellent question. So in the 90s when Cox described his results he reported in excess of 95% success at 10 years but the criteria were a little bit vague, not establish, a little subjective, and since 2007 we have a consensus document with cardiology and surgeons that the criteria for success is much more stringent. How much cardio is in?
[Person]: That is 1100 gram, almost there.
Okay. Group vent up. Off. So for for this procedure I would expect that the six months, off class 3 anti-arrhythmic, success rate of about between 70 and 75%.
[Resident]: That’s pretty effective.
Yeah, well it's not 90 but it is...
[Resident]: I wonder if how long they had it pre-op, has correlated too?
Yeah it’s a risk factor, yeah. The larger the atrium, the lower the success.
[Resident]: So that goes back to the size of the left atrium.
Okay, let’s now go...
[Resident]: Do you have a cut off for the size?
I don't. So let's now turn our attention to the left pulmonary veins and this is a time where we want to isolate them.
[Resident]: Can you turn the table towards Dr. Zenati a little bit? Thank you.
Show me here, sometimes there is a ligament of Marshall. Ok stop. That I try to divide, right here. This is the left superior pulmonary vein, this is left inferior pulmonary vein so I'm going to develop this vein a little bit, if the appendage can get out of my way. And I need a lighted tip dissector and if you can move the other sucker here. I'm going to go with a tip flush with the left inferior pulmonary vein and enter the oblique sinus superior cardium and I'm going to rotate the tip and I'm going to look until the the light appears and see beautiful demonstration of this device. If we use this Tonsil maybe.
[Resident]: Tonsil please.
So now we have encircled both pulmonary veins on the left side and we going to withdraw the device and advance this plastic sleeve until we have the red rubber position across. And next we going to use our bipolar clamp. We're going to use to connect to the jaw to one end and now Kelly if you pull the plastic tabs on your side gently. And I'm going to advance the device. Okay to keep, keep pulling gently, keep pulling, keep pulling, keep pulling, gentle gentle gentle. Now I’m going to try - Ok now here, here I’m across and now pull it hard. And now it pops. Now if can get exposed for me, I'm going to demonstrate both tips are past, past the vein and I'm going to clamp across and we’re going to ablate.
[Resident]: Five times.
Five times. So once we're done with this we’ve completed the bilateral pulmonary vein isolation. Make sense?
[Resident]: Yes. So you don’t have to - well we’re gonna open up the left atrium for the mitral valve but-
The lesions of the left atrium will be done last. This is just pulmonary vein isolation. First ablation.
[Resident]: So we’ll take the appendage?
That’s the next thing we’ll do. There’s two ways to deal with the left atrial appendage. One thing we will be to take a scissor and cut it off at the base and then over sew the stump. Another one is to place a clip so - Yeah, yeah. This is number three ablation. No you either do it inside or outside. We going to be deal with the outside. You have to place it at the base that's important to do complete isolation. So this is number three, so this is number four ablation.
[Resident]: So doing this, pulmonary vein isolation, is not enough to complete a Maze?
No, we’ll have to open the atrium and do an additional lesion and you will demonstrate. It is the last lesion we’re going to do.
[Resident]: I think it’ll be helpful at the end, you know that picture you drew for me? To show me that picture.
Okay so this is done. Okay, now if you take a Resono forceps, Kelly, and grab the tip of the appendage. So this is the - and then take a scissor. Grab a full thickness, we’re going to amputate the tip, now put the sucker inside.
[Resident]: Pump sucker.
Give that to Jamal.
[Resident]: Yeah that’s the left atrial appendage.
Yeah keep it open here for a second. And I’ll - what that lesion is done with a bipolar clamp with one jaw inside and one outside toward, overlapping toward the pulmonary vein isolation. You see this line goes from the stump of the appendage and overlaps with the pulmonary vein isolation. Is that clear? So the lesion goes from stump of the appendage and overlaps with the ablation line we created on the left pulmonary veins. Is that clear? By putting one jaw inside and one outside, we create the transmural lesion.
[Resident]: And what about, does using cryo any difference?
Yes, as we discussed cryo takes 2 minutes for lesion, so I reserve it, you could do it all this with cryo, but it will take you much longer. So, but if, you know, it's not you could do everything with bipolar you frequency or with a cryo. I prefer the combination of energies because each energy at modality has its own pros and cons. Did the one against cryo is time. So this is done. Done three ablation, you can see in the nice line. Now I'm going to start the roofline of the appendage that when you going to put a jaw inside and another jaw outside and the outside jaw is running in the transverse sinus of the pericardium and you can see now below the aorta. And this will be half of the roof connecting line of the left atrium.
[Resident]: Where are you? Are you inside?
One jaw is in the inside, one jaw is on the inside the transverse sinus of the pericardium. We were in the oblique sinus earlier now we are in transverse sinus.
[Resident]: Can I ask you, does this does this qualify, this is like the following -
It’s half of the roof line, It’s half of the connecting roof line.
[Resident]: Is this considered five-box Maze. Is that a term?
No. The five-box Maze is a procedure done exclusively epicardially using minimally invasive access. And there is few people doing it and it's unclear whether - Because the energies only applied epicardially and as you see the thickness of the tissues really is unpredictable.
[Resident]: Surgical Maze that’s epicardial even though that’s surgically - yeah.
So the one more application and then we're going to put the device on the at the base of the appendage so we choose wear the size for the clip and do we have the new clip. Okay, okay. So we're done with this now let's take a look here.
[Resident]: Can I have a DeBakey please.
Okay can you hold a spot for me. Can you hold a heart for me either 4 by 4. I’ll take the sizer.
[Resident]: Oh yeah, can I have a… I don't know, this Stuttgart was slipping, so I was gonna get a 4x4 from you.
I think a 40 will do, 40. 4-0. And the Resono. 40. So this is the device that is placed at the base of the left atrial appendage. We grabbed the appendage here and then we placed it inside this device, we make sure the entire appendage is caught. It's important to do a complete exclusion of the appendage. So this looks pretty good. I'm going to release it. I'm going to take a look here so I'm happy in this side. Let me see if I missed any, doesn't look like, so I think we're in good shape. What do you think? So 15 blade. Strings. Pickup for a second. So this device will actually seal the base of the appendage. See we left it open in the tip here and this will seal it so it will be no blood going through this. So this takes care of the left atrial appendage which will prevent stroke in this patient. So let go. Now we’re going to do the coronary bypass and then we gonna do the mitral. Can you get the table back to the midline?
[Resident]: Gerald please?
I need the coronary forceps. This is our poor mammary. I need a wet lap. Wet lap. Flow is excellent as you can see. Bulldog. Okay so, Jacobson please. I need a 7-0 ready. You take two forceps and expose one.
[Resident]: Can I have another one please?
K, 7-0. Rubber shot. You can let got there. Okay, pick up. So this the left anterior descending coronary artery. Do you have a blue probe available?
[Resident]: Is your vent on or off?
Jacobsen. So we did an arteriotomy on the coronary that’s about 1.7 mm in diameter. Probe. 1.5. Just wanna make sure I'm distal to the lesion. It’s just the lesion right there.
Check out Beyond it right?
So this is the end to side anastomosis using a 7-0 probe. Can you go down to 32.
Why did you do that?
Why? There’s air, so I just wanna make sure there’s no air. I also make sure it's not twisted.
Last one? One more.
So the mammary to LAD anastomosis is completed. And we’re now going to turn our attention to the left atrium for the mitral valve and the remaining left atrial lesions and we’ll access left atrium through a left atriotomy. Okay cut this.
These two needles goes back to you. Looks good. Okay, alright, so now let’s set up for the mitral. K, take the DeBakey, DeBakey, and then I cut this. Rotate table away from me a little bit. This is too long. Want a regular short.
Can I have a DeBakey please? Long.
Okay, show me down there. Show me 4x4 end. Careful as you descend to stay away from the cannula. Stay away from it. Suck. Suck. Is the waterstone rule develop a little bit? Yeah the veins, I wanna incise right here. It’s pretty deep. 11 blade. Ok so this is a left atriotomy.
[Resident]: So right at the pulmonary vein. Pump sucker up all the way.
Yellow up. Lung scissor. Okay suck inside.
[Resident]: So you go up to the pulmonary vein.
Okay. Let go now. So I'm just get the Cosgrove stuff. So it goes like this.
[Resident]: Has to be loose.
I need to sit down, thank you please. Ice please. Do you have a sponge on a stick. Okay I see about one of these guys.
[Resident]: Put that guy in there and there. Well first you should put that guy there. Good?
Yeah. Hold on to this. Hold on to this. 15 blade. You have to get the forceps and push the cannula in.
Pickup. You have to push that in as much as possible. Push, there you go, perfect nice.
[Resident]: Is the air better?
[Anesthesiologist]: Yeah that's better.
It's when I pull up you know so… Tie and a pastor. Okay, pickup.
[Resident]: Scissors please.
I need the sucker I need a Cell-Saver. Okay. Do you have a valve hook? This has to be deeper, can you release it? Should use a narrow one. Take this out. So this is an anterior leaflet and there is some weird retraction here so this is A2, this is A2. See here, A2. And here's A3 that’s kinda all sucked in, see it’s all retracted...
[Resident]: So it’s tethered.
Well but it’s a primary process. See, the height is very short. The height of the leaflet is very short there. So if there's an organic processes that really I cannot augmenttestlt. See here, A3 ,just like it's a healed rheumatic process. This A3 is much shorter than than here. This is commeasure here, commeasure, so this is A3. See, the A3 quarter, somehow, see how short it is?
[Resident]: Suspectly short.
So I don't think I can repair it honestly. Give me that Resono. See there is some process on the on the anterior. So we going to replace the valve. Do you mind to hold it for me because I don't really have a good exposure here, I'm sorry. So just remove this the other hand held retractor. Yeah remove that. Yeah, that’s better exposure. Yeah hold it there. Hold it. Okay I’ll take an 11 blade. So we’re going to leave the posterior, remove the anterior. Scissor, long.
[Resident]: You’re heading all the way down to papillary muscles.
Yeah for the anterior only. I’ll leave the posterior.
[Resident]: Woah that’s thick. Interesting. So thick here.
I think there’s a ruptured chord P2 also.
[Resident]: And this is the specimen, anterior leaflet of the mitral valve.
Sizer for 27. Let me see. Like that. Have you drain your pan on the right side. There are... okay now it's better. Okay, 27. Okay I need stadium. Let me see if I snare if it gets any better. Any better? Let me see.
[Resident]: See any air up here? Is it a lot of air, Jeff? It looks like it’s from the SVC, but...
Can you check your neck line, make sure there’s no 3 way stopcock open. We’re getting air from the SVC. Looks better here. Make sure it doesn’t fault. Can you hold this here with a towel or clamp.
I need the... so let's do the rest of the ablation so that's done, we don't have to worry about anymore. So I need to cryo. Actually, let’s do the bipolar clamps first, they’re faster. So we’ll do a lower connecting lesion one jaw in one jaw out.
[Resident]: So where are you?
So this is lower connecting between the right inferior and left inferior pulmonary vein. See? Right inferior to left inferior pulmonary vein. Is that clear?
[Resident]: So it’s right to left.
Yeah, one jaw in, one jaw out. So full...
[Resident]: Okay, so three times?
Number four, it’s pretty thick here. I'm losing the... where is it? Where is it? So in terms of the procedure now we're completing the left atrial lesion ablation. We have done both pulmonary vein isolation. So that's completed one part of the procedure. We done the complete right atrial lesion, done. Second part of procedure and we're now completing the left atrial lesion sets of the Maze and we already done the appendage. So this two lesions left are the left isthmus and the roof will completed the full Maze then we'll have to do the mitral valve replacement.
Yeah 27, that’s fine. Can you make sure there's no three-way stopcock open?
[Resident]: So just no more air? Why cause you have enough volume to get it out, or…?
Okay so now I'm going to do half of the left Isthmus lesion. So this is lesion aimed toward P3. Aimed toward P3 and I'm going to go half with a cryo, with the RF, and the rest overlapping P3 with the cryo. This is a half of the left isthmus lesion.
[Resident]: So where are you, are you at the right superior pulmonary vein?
No, inferior. The right, right inferior, right? The atriotomy. Then this is going toward the mitral valve. This is the left isthmus lesion. I need cryo, cryo. And I'm going to complete this lesion going toward the P3. So from where I left off to P3. And freeze. See? So this lesion goes from the atriotomy overlapping part of the lesion that I made and then into P3 so connects with the fibrous skeleton of the heart at the mitral annulus. So this is done, saline. So you know it allows me to take this off faster over here. So we got stuck the tissue. Now we’re going to finish the roof lesion. Freeze.
[Resident]: Overall how many lesion sets are there?
Ten. Some are made into two bites. Some are made proximal part RF, distal part Cryo. So there's a lot of things to do. So we have to be able to move this case along we have to take every chance you have to do things before you clamp the aorta. So you're right, ruptured chord on P2 and then some restriction of the A3 and I didn't feel comfortable repairing so I'm replacing it. We're done with ablation. I think there was a cleft, I think it was a lot to repair and I think in the end the restriction of the A3 would it be in the limiting factor. Okay next I need the stadium and scissors. Expose this mitral thinking valve. Stitch please.
[Resident]: Oh no, hold on. Nothing, I couldn’t feel that on my hands.
Pick them up naked. What's the question? on the inferior? And what's the question? So they left isthmus lesion I did it - Pull up - half with RF and half with cryo. This is not that short. So deep, crazy.
And now I’m proceeding, counter counterclockwise. So if you could use this tool to somehow push this in like this, I can have better exposure. There you go, less less less less less less less push. Forehand.
[Resident]: Less, less. Sponge there, yeah.
So for this valve, the Magna, you need to know which stitch is at the level of the trigone cause it’s an asymmetrical valve. So I think we're just passing the commissure here.
[Resident]: Posterior medial?
So that's, no anterolateral commissure. So this, the next stitch that will be trigone. Now I'm going to the more anterior. You can see the anterior leaflet that has been resected. This will be trigone. We need a marking pen. Let me see, how to get this. Can I get a retractor, another retractor. No the other handheld. Let’s get this off. Let go, like this. Like this. Next stitch. Give a green, this is fine actually. Backhand.
[Resident]: Yeah we’re good, thank you.
Let me see here, yeah like that. Good. So this is the right trigone. The time on cardio?
[Anesthesiologist]: 1 Hour.
Okay so we'll get, will give a dose in a second. So marking pen here.
[Resident]: Do you always put your pledgets on the atrial side?
Yes, always. Forehand.
[Resident]: Almost there.
Yeah cause you’ll see when they put down the valve and I go to tie, I can see every pledget then by knowing the pledgets is in my view, I know the valve is seated, as opposed to not seeing it and then I have to guess. So it helps in that regard as well. Okay I’ll take ah - you can let go of the heart.
There we go. We’re going to relief.
[Resident]: Oh boy. I know. Is it gonna come out all together?
Leave it there. Let’s give cardioplegia. Distension here. Release distension. Okay, go, start. It's empty. There’s air everywhere. Keep going, keep root vent up. It’s empty. Turn off the root vent. Okay, give cardio, push a little harder. There’s no pressure in the root. There’s some pressure, increase the flow.
[Resident]: There’s something in the well, so it’s going somewhere, ‘cause it’s in the well.
But the pressure in the root is very low. I can’t get it so, I can’t release the tension on this suture absolutely. But then it's going to be difficult for me.
[Resident]: We’re making the valves incompetent.
Anyway, we're giving some because the heart is cold.
[Resident]: It’s super soft.
Okay it’s fine. Alright stop. I’ll take a valve. Okay here, just testing. So this two will have to go into the aveol TC. We have 1, 2, 3, 4, 5, 6, 7, 8, so 4 and 4, I need a holder, for the posterior.
[Resident]: Few more to go. Alright that’s three, the last one. One more after this. One more. Alright snap snap. Cut. Just reset.
Just pull up here. Just pull up.
Okay, 15 blade. It’s important to do the ablation before you put the mitral down because after you put the mitral down you won’t be able to see anymore. Exactly. I scored my hand, so Tonsil, long Tonsil. Let’s see if you can expose for me there so I can confirm. We are indeed down, see there, the pledget, you see where the pledget? That means the valve is all the way down. Squirt. Start rewarming.
[Resident]: So we just have to tie these down and then close the atrium...
And then we're done.
[Resident]: We’re done.
Ah, quick procedure.
[Resident]: Yeah, right. Ten lesion sets. See?
Yeah but for instance to do one we did five application with the energy. So if you count every one we did, there’s more than ten.
[Resident]: Where’s the reimbursement for that, huh? Right? It’s a cost benefit. There’s a big benefit.
Yeah I think that there was a component of really not this procedure getting compensated for the work that goes into it.
[Resident]: Also, but there is a mortality benefit, I mean, money aside.
Yes, the data are pointing in that direction. I think the guidelines are possibly going to play a role in increasing the volume of the cases.
[Resident]: This thing just came out, this hunk. Okay.
See how nice it is to see the pledgets because sometimes this just has to be like that, like that, and this you can just like this, like this.
[Resident]: So has this evolved? Your ten lesion set, as when we were doing it in Pittsburgh? Was it not like this?
Yes, the cryoablation on the epicardial surface for left isthmus lesion, yeah that’s new.
[Resident]: Okay. you’ve added that?
You know the literature, also you know, meetings, discussion. The procedure has evolved, yeah. But I think that is a lesion that not everybody does.
[Resident]: The apicardial?
The apicardial, yes.
[Resident]: Forget it.
Score my hand.
[Resident]: I could tell.
So when you replace mitral valve you always tie the posterior first because that's the weakest part of the annulus. And then you squeeze into the anterior, you force it in. Posterior first, tie it first always. So good idea.
[Resident]: Where did you put your first bite?
Around there, around P3 here. So now we’re going to do anterior.
[Resident]: So you find the taking the bite there helps with exposure.
Well today, yes, the exposure was suboptimal and not your fault at all, but just, I just need to see here. Like this, can you push this thing. Careful of the mammary here and lift this.
[Resident]: Can you see I’m not on it. Can you see?
Tonsil. Tonsil. Leave it here please.
[Resident]: So now even if okay -
So give me a second, I need to visualize this, it’s a little hard. Score please. Okay, getting there. So we’re going to close with that fluoroproline. Can we rewarm all the way.
Okay, Tonsil. Oh those are tight already. Scissor. Okay. So the mitral is done, just going to cut the sutures. Going to remove that plastic component.
Okay, 15 blade. Pickup. Okay, lemme see. Just a quick look, just don't let go. Okay. Okay, I’ll take a suture. 4x4 to deploy.
[Resident]: Can I have a DeBakey.
And we’re going to close the left atriotomy and that will be the end of the procedure. I mean you're just muscling through there or you stopped? Yeah. I'm sorry I don't know what else I could’ve done. Score my hand.
[Resident]: You don’t have a Bane retractor do you?
Have you closed the left atriotomy? Yeah, it can sometimes be tricky.
[Resident]: Yeah, actually this doesn’t look that big to me for some reason.
You were expecting a bigger one...
[Resident]: Yeah, I was, I was.
Okay, another stitch. Backhand please. See there’s was a little bit of a hole here. Just picked up a big bite here. Squirt. He's a little older. Can I have a 5-0 prolene.
[Resident]: What is that?
It’s the right atrium, tearing a little bit. See this purse string here. Can I have a needle holder. Cut. Okay, head down.
Leave some volume in the patient. Table up. 2-0 Papa please. K, root vent up, root vent up! La sala please. Hold it. So let’s open the mammary. Head down.
[Resident]: Head is down.
One more resala, no no no, down to the lungs.
[Resident]: Yeah keep it down.
One more resala. Down with the resala, empty the heart. Flow down, root vent up. Clamp is off. Flow back up. Okay.
[Resident]: Clamp is off and mammary is open.
Okay, another 2-0 papa. What? Yeah yeah sure. Okay, can you adjust the table so it's not so much down.
[Resident]: Head up a little bit.
Head up more. Okay 2-0 papa.
[Resident]: Yeah can you level up the table a little more for us.
Ventilate. Eh, it’s fine. Yes please.
[Resident]: These are open, both of them, yeah. Scissors.
So you guys want to stay the whole thing I mean right now reperfusion the heart.
[Resident]: Why isn’t the right atrium filling up? Is it just taking time or what?
[Resident]: It’s empty.
Yeah because they are draining. What do you mean?
[Resident]: I don’t know.
It’s supposed to.
[Resident]: Scissors. Is there no activity or what?
Do you have pacing ready? That’s the mammary. Pacing wire.
See his heart is starting already. Cut this. A little more level the bed. And down. So pacing cables out I'm going to place him at eighty. Do you have cables?
[Resident]: No. Do you have a set of cables for us, okay so here’s a V wire for you.
Give me a sec. Scissor here. Cut this. Lower the bed a little more please.
[Resident]: Take this needle, here you go.
Wait a minute.
[Resident]: The ground is negative.
No, the ground is positive. Negative is always the one on the heart. This is ground positive. Pace at eighty please.
[Resident]: Okay where’s your ground. Here’s your ground. Ground is positive. Okay, giving em back to you. Try that. That’s just a V.
Okay, I’ll take another set of cables and 6-0 Proline and another pacing wire. So HR is not doing anything see which is good good. Yeah start us on some inotropes.
[Resident]: So do you always put atrial wires no matter what?
[Resident]: Can I have a DeBakey please?
You have the lead the with without the needle. Why so short? Ah, it’s okay. We’ll make do.
[Resident]: Scissors. Metz.
Cut this. Can I get another empty needle holder, I can give you one needle. Okay, can I have a 10 gauge needle. Cut this. Yes sir. Okay I’ll take another ground wire.
[Resident]: Do we have the cables for the A wire. Okay here's your A wire.
Okay, no no no. Of course. And 18 gauge if you have it. No no, we’re not connected yet.
[Resident]: Do you have a stitch?
Lift some volume in. See there’s some here. See, look.
[Resident]: Oh yeah. Sometimes we put a syringe on it and lift it up, lift it up and pull?
Put the sucker in there. Do you have the ground here? Kay, level the bed now. Level the bed. And down all the way. Down. Okay, try it again. Raise and lower it again. Okay, pace at atrial, at AV. You’re connected now, you’re connected now. So Calcium in, and half flow. I took a lot out.
That’s call the Pittsburgh squeeze.
[Resident]: Are you pacing your atrium? Okay, it doesn’t look like it.
But it’s not fibrillating, that’s good. So we're coming off cardiopulmonary bypass, we’re letting the heart take over the work of pumping. So the atrium is not fibrillating anymore and so that's encouraging. It’s being paced which is normal in this situation. A little too full here, can you empty out? Yeah. Looks pretty good. Look see, capturing the atrium. So this by definition means we don’t have A-fib. We’re able to capture the atrium, that means A-fib is gone. You’re at two liters, go down to one. So this is actually news. So AAO is ideal in this case. K, once you come off, give me a hundred. Yeah turn it off. Nice!
[Resident]: Good job.
How's the mitral valve? Hundred.
[Resident]: What is pacemaker rate after this, the pacemaker rate?
A permanent pacemaker? Oh that’s variable in the literature, you know. That’s one of the concerns. A large series can go up 7-8%. Give a hundred. Yeah those generic statements here they are not helpful heh, so you have to take into context everything. So is the preload not pumping well, is not helpful in this situation. So well, you have to discriminate between contractility issue or preload. Is it empty, as what Dr. _____ was indicating, but we're very sensitive for what you said, because I will give one example for teaching purpose. The circumflex runs right where they posterior annulus is, right? So a very deep bite there could compromise a sert so if we have regional wall motion abnormalities, lateral wall down, that’s bad. So I’m very sensitive to anything that you say. Anyway so the RV looks great, look at this. So we’re pacing the atrium so we’re very happy at this point overall. Look there's no regional wall motion. So I just need to know if the mitral valve is okay. Well okay.
[Resident]: Okay well how much more volume do we have? Where’s your pressure? Can we get some more volume?
Can we get a 100. So let's get rid of this, 15 blade.
[Resident]: 15 and Debakey.
Nice. 15 blade please. You want to do something with that thing right. You’re here waiting for me.
Okay so let’s-
[Resident]: DeBakey, alright. I can pull it out.
I'm not going back for that, I'm sorry.
[Resident]: Maybe it’ll get better with the reversal. Okay. We’ll reassess that.
Yeah, I appreciate that.
[Resident]: You ready?
Go ahead and coming out.
[Resident]: Your SVC is out. Can you take it please.
Hold it, hold it.
[Resident]: Please, thanks. Do you have a squirt? Thank you. Let’s take a little look.
It’s good. 15 blade. 15. Lemme see.
No no, not yet let me see. Let the pledget. Pull. Don’t pull the pacing wire, just the cannula.
[Resident]: K, it’s out. Your IVC is out.
Whenever you're comfortable start programming. Is something bleeding here? Lemme see for a second.
[Resident]: Oh your pump suckers are off? Oh not yet.
I’m gonna test on the line ridden for a second. Okay it’s on its own. It’s in sinus rhythm. Look at that. Look at that.
[Resident]: What. It’s off?
It’s off. It’s not pacing. I just disconnected here. Sinus rhythm. It's a beautiful thing. Mike knows what that means. No but we shocked him three times earlier and you know, so it's not just luck. Success, in one word, right? Look at his atrium, it’s kicking.
[Resident]: But what is the true definition of success?
No no, early success though. The textbook success is 6 months off antiarrhythmic but this is encouraging.
[Resident]: This is encouraging, alright.
[Resident]: Have you given the protamine yet?
Starting. 15 blade.
[Resident]: We’re getting ready to lose your vents.
[Resident]: Is there a pump sucker on? Ready. Okay your vents out, your root vent. Yep. Scissors please.
So we demonstrated on the atrial electrogram that on the pulmonary vein side, on the right side, where we ablated, there was an electrical silence, and on the non-ablated side there was sinus activity so we documented that. Unfortunately, it wasn’t working earlier. 15 blade. So we’ll have two curved 32 and 36 straight. 15 blade.
[Resident]: It looked like he had the room. Stitch please.
K scissor. Protamine, restart protamine. Not working. Keep going.
[Resident]: Is your Cell-Saver on guys?
It’s working, it’s working.
[Resident]: Oh okay.
Just died. Ah, much better. See Harvey.
[Resident]: That’s on Epi?
Lower the bed again, raise it and lower it. Still not working. Just level the head. Keep going with the protamine. Yes. You going to spin the rest. Hold this cannula in place and 15 blade. Find a right angle. Again, when you turn the knot, I don’t wanna see any tension in the aorta, it’s important. Really important. When you are gonna be independent, you want your assistant to do that.
[Resident]: Yes. Don’t pull. Got it.
Go ahead and go down. And now outside. Okay, cannula is out. Thank you.
[Resident]: Can you wipe my left hand please?
So it’s now decannulated. And now basically we just need to do hemostasis and closing the chest. And it stayed a nice sinus rhythm we can actually see P-waves that's really satisfying. So ideally, the pulmonary vein isolation has to be confirmed with an objective approach which is confirming that he has bi-directional block, okay. This patient, because it was in they said that we could not convert, could not be a bidirectional block confirmation, only uni-directional because the exit block which is pacing across the test that involves pacing across the ablation line because the patient is in A-fib. So the only test left in order to confirm trans morality is the entry block test which requires recording atrial electrograms and relies on this tool to work. However, my approach of doing five liters no matter what kind of, you know it's kinda carpet bombing. It's like you know I overkill so I almost never have to do go back and do additional lesions. Generally, only do one or two lesions you taking a chance then you should prove it so my approach does not rely heavily on on this system to work but it's nice to have it documented and give it to the cardiologists, to the patient. So it's it's a scientific approach.
How does it look? Nice and dry.
[Resident]: Just wanna look over there, make sure there’s nothing on their side. Looks like something stuck in the well.
Cannulation here looks good. FS 37. I’m looking at the left atriotomy looks pretty good, 37. Okay, scissor.
[Resident]: Alright I'm closed.
So 2-0 Micro. So this was a difficult to, you know, get back in sinus. We cardioverted him three times, the size of the atrium. Okay 2-0 Micro.
[Resident]: He’s young so are you going to reapproximate the pericardium a bit?
[Resident]: Alright do you have Army Navy, thank you.
Tonsil, chest tube.
[Resident]: Can you put the - can the table go down? I think you just have to put the head down, and then put the table down. I think the back is up. I do think the back is up. So… yeah let’s do that. Yeah see, see what I’m saying. Yeah.
Nice. Thank you.
[Resident]: Thank you.
Knife for a second. 36 straight.
Bovie on 50. All the papaverine is in?
Not that I'm seeing a lot of clots. I don't see much clots. You wouldn’t happen to have any leftover vanco paste? Oh okay. Look at P wave, nice!
[Resident]: So proud. Definitely cool for me to see this you know. Is that lap out of that. Hold on, suction. I don't like all the blood. Trocar? That was just this top guy here.
A type IV, there was a perfusion. Yeah a type IV, those are big cases. Wow. Oh man.
[Resident]: That’s insane. Thank you.
I mean a CABG, you know, is 3 hours skin to skin, a AVR is 2 hours. This is a big case you know we did CABG, Mitral and Maze.
[Resident]: Needle back. A wet and a dry please.
Alright thanks everybody, I enjoyed the case. Bye everybody. Everybody good job. Thank you T. Thank you Jeff. Thank you Jim.
The procedure was, I believe successful. We were overall very pleased with the outcome. The Maze procedure, which was full a biatrial Maze, resulted in normal sinus rhythm leaving the operating room which is very rewarding and it not always a guarantee, even with a very good quality procedure because patient had long-standing persistent atrial fibrillation have sometimes what we call sinus note stunting. So the sinus note, not having work for a period of time, sometimes year, required a period time to go back and function. So we were lucky that today the sinus note picked up right there with an excellent rate in the eighties. The left atrial appendage exclusion was also successful in the criteria we use is on the transvagial echo, a complete exclusion, there was no residual appendage was left behind, so that also we're very pleased with that. The mitral valve have to be replaced and we use a bioprosthetic valve and the coronary bypass surgery was successful with a mammary to the LAD.
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