Ohio State cardiothoracic surgeon Michael Vallely, MBBS, PhD, FRACS, explains the advantages of anaortic (aortic no-touch), total arterial, off-pump coronary artery bypass graft (anOPCABG) surgery. In a landmark study of nearly 38,000 patients published in 2017 by Dr. Vallely and other leading cardiac surgeons from Australia, the U.S., Canada and the United Kingdom demonstrated that the procedure significantly reduced postoperative complications as compared to traditional coronary artery bypass grafting.
Read more about Dr. Vallely’s experience with the procedure
here. Okay. My talk today is antibiotic Total material off pump coronary bypass surgery. I could talk about this all days. In a week. I certainly had. This is my little pet projects. And nearly 25 years now, I explained that as we go forward, so a Z I said I was very lucky. I did a PhD around 2000 where everyone was looking inflammatory response and cut it when we bypass. And I did one of my attendings in the hospital happen to be doing off pump surgery like a lot of people were taking up on end up doing a head to head comparison of on pump asses off pump site. I got down to the ground level with science, which was very interesting. And then I I went from that hospital to another hospital just across the the other side of Sydney Harbor on I ran into two people. That was really interesting was two people got called John Barratt, another guy called John Ross, and both of those guys were really interesting off pump surgery, but they weren't interested. Inflammatory response or what they were interesting was the brain, and John Brereton actually coined the term antibiotic. Andi. I made it my mission, which took a lot of cajoling with publications to change it from aortic, no touch to an aortic. And now the world's fair museum chaotic. So that was a little Australian is, um, we put through. But I also realizing at a very young age that the patients just did better if you stayed off bypass in particular. If you stayed away from the scene, the order. And so from the very early stages my night, distilled in training, was an off palm pistol, not in two thirds of my distal coronary. Estimize is is a training off themselves kind of serendipity, right place, right time right, people. But also, I found this eternally fascinating has been a great, great thing to do. I've spent as, uh, Dr Michael Carome suggests, I spent a lot of time writing papers. It's eternally interesting. Field and a lot of people shied away from elderly in high risk patients because they're worried about the risk to themselves. The risk of risk thio results. But I actually thought that the risk was to the patient not having therapy or operating operating on using therapy. That was inappropriate for them. So we did a lot of academia and a lot of cases, um, to data down close to 1300 doctor outside. It's been a really a long, long 15, 20 years or so. The other thing, too. Is that on Pump Lima in vain. This was a surgery that was really developed in the late seventies early eighties, and I'm not that young anymore. But at the time I was in elementary school, and this hasn't really changed that much over the course of time. The proven benefit of the limit of lady is absolutely it's the gold standard in coronary artery surgery people don't get along with during a coronary artery bypass is a lot of our eyebrows raised. We have a fixed strike rate it dependent on you measure strike, but fixed strike rates pretty high on with a new definition to strike if you But I am a lesion on Emery, then you, by definition, had a stroke. And there's obviously the proven long term failure rate of stuff in this vein graft, and we know that coming through the lab, Andi, just generally the advantages of this operation is the liberal idea works really, really well. And collateral ization is the vein grafts file slowly, which means a lot of people don't need re interventional re operative surgery. So there is some benefits. This the biggest issue with all cab is our cab is an incredibly heterogeneous, and I'll talk about that as we go through my talk a lot of very, incredibly heterogeneous procedure. And it's very hard to do head to head trials because what is a knocked up to one person is a different operation to another person on. I think that's when one of the failures of October and in the cab trials status is actually doing the trials appropriate and getting the right information out of the trials. Now the only thing what a cab means is doing currently actually bypass graft surgery without a heart lung machine. And that's really what it comes down to and what a heart lung machine does. For those of you who are not intimately involved with operation in an operating theater setting, Ah, heart lung machine is an amazing bit of kit, and we use it for every single other heart operation that we do on basically what it does is it drains drains blood away from the patient filters. It takes away the waste products, puts auction in and pumps it back in. And this provides support for the heart, a suppressed protection support for the body. So we can't throw the pump away because we need it for all the other things that we dio. But the doc have means is this and I will go through in the subtleties of have through the different through the through the tour. So currently to bypass grafting you can do on pump with a still heart you can do on pump with the fibrillating heart on some of the beating heart. And there's October in October has whole lot of generations within that that I'll talk about the subtle is now, as I said, I've had. It's been really fun in some ways, and then I've come up against so much resistance in my own country internationally. With reviewers ahead of this, my little mission in life was to prove the antibiotic total of two lakh cab is the best for patients, one because our family eternally interesting, too, because it was a pretty steep hill to climb. And, uh, myself and my quite substantial team back in Australian. Also, my international colleagues within this space have ultimately I think we've achieved that. I'm not sure that as we go through now, this is what and I already got cabbies. Really? So you've got a beating heart. You've got nothing in the way you've got. This is a bilateral memory T graphs or just oriented. This is the patient's head. This'd is a left memory, actually. Coming down here. This is the right memory artery going Thio. Collateral War. This is a 91 year old man with calcified circulation. Calcified left main. You're presented with sink A peak. So he was sort of pretty death. Um, taken to surgery. Take memory. Are trees down? Lock him in the heart. He goes, I'm happy. No stroke? No, in fact, etcetera. So this is what an aortic surgeries in its purest form. Um, the number one thing with an aortic surgeries, you need to understand that patients have to memory arteries one on the left, one on the right. And, as I said, from a surgical point of view way, Concord memory arteries in the eighties with the left memory artery but I think that a lot of surgeons forget that people have a right memory artery on, but most people are right handed, so the right memory artery is usually bigger in most people, and and aortic surgery use the memory. Arteries is in flow coming off the subclavian. This an Eskimo sys, which is, uh produced biologically, is much better than the estimize is that we're surgeons can do. So we used. This is Thean Float, and there's a lot of data now that if you skeletonized memory arteries than the results for the vast majority of patients whose after the same from external mobility point of your Certainly we found that in my own practice, what I'd like to talk about is actually evolution of our cakes. I think one of the things is understanding the history off, especially, but also understanding the reasons that there's inertia. Onda reasons that there's momentum as well within within, especially so back to the sixties, very serious Russian looking guy. He was way before his time. He did a not just a clinical op cavity, that little clinical Siri's. It was widely derided. His local Russian counterparts thought he was wasting his time, his American colleagues a little bit more polite and thought that it was at odds, um, with the current evidence for the treatment of coronary artery disease. And it wasn't really until federal or a couple of years later at the Cleveland Clinic, um, put out a toughness. Bone grafts. Siri's with excellent results, really, that may basically launched coronary artery surgery into the mainstream. The South Americans finally enough for doing. And this is something I did talk, refusing to learn about this. The South Americans. A lot of a lot of patients. Onda had some pretty good results, and then it wasn't really until the nineties that cab took off and that was a knife. First was involved with a cab when I was a junior junior resident, and it was industry. The Octopus eyes, in fact, Medtronics, for the whole Siris of sea creatures, octopus of search and staff is various other things. An industry, really drive this. Remember, there's a lot of push Thio get people to do a cab, and a lot of people do doc cab, and this is really what happened was a lot. A lot of people did not cabin I certainly was in my in my late twenties when this and I was certainly very thing. So a lot of odd cab and there was a whole lot of problems, actually, really good surgeons had a lot of problems a lot of patients actually suffered. I think through this learning curve, and I had got a pretty a pretty bad rap towards the end of the nineties, and lot of people abandoned that on then. Ultimately, there was a group of a group of people that worked out how to do a cab and then October styling, but surely having a pretty decent resurgence. Sure, I think the biggest issue was that people tried to do off pump surgery using on pump techniques. And certainly when I did my fellowship in London, the Brompton and I've done a lot of lot having Sydney, and to their credit, they asked me dio to show me what I was doing. I watch what they were doing. They would literally try and do the operation like you doing on pump operation. But doing enough confession. It just doesn't work and you end up with predictable results. And currently surgeries A very, uh leveling, especially if it doesn't work. It's pretty obvious that doesn't work in. And at the end of the day, you had a damaged heart and even dead patients. So it's a very, very challenging technique. Um, it's very obviously things are going wrong. A few surgeons possessing. As I said, I was just very fortunate in my junior time that I was with two. Surgeon. I think it's really important that was to people in the hospital out of six out of sorry, five surgeons that we're doing it routinely. In fact, we would schedule surgery that wasn't schedules off pump surgery. Just scheduled is a cabbage, and it was assumed that there was a cabbage and there wasn't even a pump in the room that pump in the pump room outside. So these guys put in the effort and did literally thousands of cases and taught people like me, and we went off Thio populate other places. The other thing, without cap. I think I'll cab is a little bit mysterious to some people, but I've always said that where basically where human pump mechanics, I think that's that's absolutely correct, and I think you need toe synthesize things down, Thio the simplicity of what we're doing. But PopCap remains simple plumbing. It's a technical exercise that we do every day, and you saw one little tube from a little, too. That needs to be no leaks, no purse string of the nasty Moses with no twists or not too long, not too short. And once I think you remove that mystery, then if you are able to then see ya care for what it is, which is basically just providing, um, surgical revascularization, but not using a pump and not interfering with the order. And ultimately you need to do it every day. And my my mentor and teacher, Don Ross, said to me the reasons that you needed to what cab every day so that you can do it every day on every person. So when you get the difficult patients, it's not a difficult problem. I think one of the issues with October's that people kept up cab for the difficult patients, and then they would have predictably have poor results for the difficult patients. And it wasn't it was saying that Op Cab was the fault, not the cover. So I think that's really um, important observation. The 2000, which is probably where I came of age surgically, in the sense that I, you know, started my advanced training, finished my PhD, and then I've got to start operating and move through different hospitals in Australia. We trained a lot of different hospitals and that into international training as well. Um, the biggest issue I noticed was that there was the clinical trials and people are doing clinical trials. There was three major clinical trials with the ruby trial, the coronary trial, which I participated in. Uh, in fact, off my coffee this morning in my current chalk up and got cab to the other three major ones. And then there was the real world data, which is people doing work. A lot of people who are committed to what happened certainly committed to antibiotic surgery actually refused to participate in these trials. So ultimately, there was removal of experts, necessarily from some of these trials which I think damage the trials. Now, the ruby trial, which came out in, um, it was around 2000 and eight. I think was a very interesting period. There's a trial done in the U. S. mostly in Va hospitals. A lot of the surgery is done by residents. A lot of it was a lot of van graphs, and there's a very big disparity between on pump and off some results. But the on pump results weren't that flash either. But unfortunately, Ruby was published in the New England Journal. It was was randomized and a lot of people took a lot of head with Ruby, and I think it really put up. Come back quite a few years. John Puskas, who is a is a friend, and it was being a from the moment he published this this paper in 2004, I took notice he did a head to head trial with 100 on pump 100 off pump and cast everyone with 97% Papacy right in both arms. And I think this is his own Ruby trial, and I think he proved the ruby trial before the Ruby trial came out. And so it shows that cap, I think this trial was was really important trial. Um, we also, if you compare Ruby trial with nine at nine experts and currently trial with experts, you had to have done at least 200 cabs to be eligible for the current trial, and you can see the difference is is you've got equivalency between on pumping off pump. Whereas the Ruby trial there's a stark difference between on popping off company interesting things. Theon pumping off from stark difference started right back at the beginning, which would suggest that there was technical issues with the grafting rather than the technique itself. Yeah, I think this is the most important slide that I've seen in the cab literature. And I think thistles once again, John Puskas for next time in memory huge Siri's 7000 patients needs Group 18 surgeons, so variety of surgeons and I plotted the low risk upto high risk. So low quartile, high risk. And I don't can't remember the last time I saw a patient who was truly in the low risk, low risk quartile on. Then they plotted that to get the STS predicted mortality. What it shows is that on pump, it plots very nicely against the STS that shows the STS is a very robust risk, or but what? It shows that the curse diverge once you start to get in. Even moderate risk patients. October's been is better, and this is a heterogeneous group of our cab, John a little bit behind, um, embracing and Ionic surgeon. There waas patients with side borders and top ends, but this is a really important slide. The problem is, it gets published in the insurgent literature, and not many people read that outside. The surgeons and surgeons get into two categories. Those that believe, not cover those that diamond is not a huge group of people in the middle. So it's appeared this slide didn't get out into the cardiology or water medical literature. John once again has been a surgical leader within three us within the world, I think, is really applied, robust academia, and this is a pretty big statement. It's a 13 or 14 year old statement now, but basically a lot of people towards the middle of the first decade of the century realized that off pump was all about the aorta and protecting the Brian. And there's been a group of a sort of pursuit that with bigger over the last 15 or 20 years or so, we can look at that. There's there's lots of data. You better go looking for it. As I said once gonna usually ends up in the surgical literature, which is quite a cute, I think. Quite a cheeky slide. A cheeky little paper, actually. Where the one of the issues around the syntax trial was that the benefit of PC I vs Cabbage was the strike rate and strike right here, as you can see, is about three fold. And these guys did a little little paper with opt. Have no touch, Andi. Their data azi. You could see it was much better from a death in my colon function. Point of view. Stroke, equivalency, Thio, Syntax PC I and this cabbage PC on the same taxi. Probably more robust. Head to head coroner surgery versus P. C I. And so the data is there. So you go looking on and it's easy. What I wanna talk about is, um, antibiotic surgery on biotic surgery is, as I said, very simple. Based on memory inflows is different combinations is the operation that we've we came up with its bean. I think the advantages I get to in flies and so basically preserve the lame into the day and then you bring a right memory, actually with the radial artery sequential compass of graft behind the order through the transverse Sinus. And this keeps, um, graphs away from the front of the order. It also is makes getting length much easier. It means you control the heart over, and I'll show in Operation a second and do this. And this is an operation that between Marco Wilson, I see new done about 1500 these cases, and I've done a lot of these cases here, the higher state as well. What does it look like? This is a CT scan. In 51 years, you've got a memory to the you've gotta write memory with four distills through the transverse Sinus, and you can see the difference in size the right memories twice the size of the left memory because it's supplying two territories and this, you can see the graph coming around here nicely, and it's a really nice, nice technique. It's actually pretty straightforward thing to do, and it's do it. It's reproducible in the vast majority of patients, so I'll just show you a little video on how we actually do this operation. There's a typical patient triple vessel disease had previous stenting to the right coronary artery. That's the circum flex. That's a totally included right. That's a lie coming down here and you can see the previous stance. So leading Sonata Me, we do bilateral extra pleural takedown. We need to do a escalate knowledge in city memory after you. One of things I've been really impressed with working Ohio is everyone's got really nice, big fat memory after he's here. So it's actually been a pleasure to do problem surgery. Mostly a pleasure. Anyway. We can talk with the letter, but you keep. The important thing is to keep keep the pericardium in tech way immobilized. Need to be able to bring the memory actually through here and wide mobilization of the pericardium to allow the heart to move. And these are the This is the right internal memory. After here, skeletonized, and we do an end to a bevel end to end, to get away from purse training and to prevent the I'm slowing down. I think it's the screen screen is a writer lottery down here? Apologize the screen it's not. For so this is basically a technical exercise of sign. A radiological will come through in a second, Um, radio last late nights. Radial artery keeps the memory. It's a nice city, and you can get away with mismatch issues by using a bevel beveling technique. And this takes 5 to 7 minutes to do this. And you can, because the radial artery is nice and big and fat. Because there's a arterial grafts you can see this is the flow you can put as many distances you like onto the onto this by using sequential grafting. So once again, positioning the heart is really important and got some heartstrings, lifting the heart forward down on the diaphragm and prior to this off released the pericardium here and release the pericardium at the top. Here, the SEC. I do respect a lot of appendages. It's very straight for this is the only bit of video that's not edited things. Is a Jurassic State worth removing the left atrial appendage? That's actually pretty straightforward thing to Dio. I don't do it in everyone, but it certainly is a very straightforward thing to Dio. You could do it off pump and that it comes. So then we bring the compass of graph through the transverse Sinus you can see this is for Marie Artery. He left out from images. Go on. As I said, This is the lateral wars. A lot of things you can't graph lateral lateral growth. Really? Is lateral walls pretty easy? Graft? Actually, Just pop it up. I don't use I use inter. Currently, shunts inter coroner shots are really important for three reasons. One is it prevent you getting the back wall so there's there's technical benefits. It provides a pretty bloodless field and also provides district refused. And then you just basically your side to side diamond Eskimo sis UN Division. And you could just keep grafting in this fashion if there was a pasta lateral grafted there. There's an intimate it up here. The graph that as well. And then the shunts just filled out nicely. Tie the graph down and then you just move. Move your way around the heart. This is the inferior walks, is the media. You can see there's not much fly out of coming out of this because it's a totally occluded vessel, and then the shut just pops in nicely, pretty straightforward thing to Dio, and you can see this lovely fat radial artery here. It's very easily so a lot of room. The apex opposition looks a bit funky, but it's a very stable position for the heart. The heart can fill in the heart and empty. That's all the heart needs to do. And you get a really good view here and you can graft necessary. If you have a postural lateral right graph that P B A graph down here. Thio. I used to ride as well using this technique, and as you can see, you get a great view of what you need to do. And there's the technical exercise of hot peppers. Inflexible ization. That's the technical exercise on bond I just kept. There's often and so them off and then the heart gets dropped down, um, in second so the heart comes down. This is the front of the heart. This is the idea. This is the left memory artery here, coming through retro farming tunnel. Once again, um, is a handy having assistance stopped getting blood in your eyes. And I use really long shots for big vessels. And this actually shunt comes up against the lesion up here, and you need to take it out and trim it, Um, but the shunts a really nice to put in and very easy to use. And the longer the shunt for the bigger vessels of causes spasm. And as you can see, we've got a nice Glover's field on D. It's just technical exercise, bringing them to escalate. Nice memory, archery down to the lady and to see the shot just pops out. And then you targeting down and the other thing to have is the use of shunts. The use of intra operative graph testing is really important. This graph doesn't work, We do it again, and that's really that's enough. Have operation and I gotta keep operation. The biggest issue is really co mobility's obesity, metabolic syndromes and aging, and that's been my interest over the last, Asai said. The last two decades, really, there's been a 20 fold increase in octogenarian cardiac surgery in the past 20 years, and I think there's multiple reasons for that. One is the population is aging, it's aging better. The other thing, too, is basically a lot of cardiac surgical work was taken away with standing in the nineties, and I think it was a commercial, a commercial thing that people looking for work instead of saying Are you two officers? People started doing more and more and more elderly more and more high risk people, and then they found that they were getting away with that in doing good surgery. And so, you know, surgery because surgery. So, you know, a seven year old now is not perceived as being old, but by definition they are old. On a 80 year old is actually very old in the 90 year old is very, very old. But I've certainly done several patients in the nineties, and I don't see them as old biology, not their chronology that matters. Um, but with age and with metabolic disease comes authorized protic burden and that can present itself in several ways. Um, these air system random pictures I took in the last week or so from my time here too high states that we do non car and received no so non contrast cts and all patients. And that's really important. This is a patient that doesn't have aortic calcification. You can see it here, patient doing the cabbage on in a couple of weeks, and this is a patient that has aortic calcification. You can see this subtle edge, a subtle edge and without image ing. You don't know that this is here, and we'll talk about what happens if you intervene on patients that have got orders that look like this. You can have more gross imaging. This is bit of a Rogue's gallery of patients I did in Sydney with completely calcified circulations, and this person had critical left Main needed four grass to last for two memories and a radio large when you can sort them out. Similarly here, you can sort out patients like this so you can have subtle or you can have gross calcification. And the other thing, too, is, is this dreaded aortic. After I'm in this flooding after Roma, it's not actually always obvious on C T scans. We can see it at image ing. This patient had critical chronic disease as well, had a created in the directory at the same time and had five graphs, total material, an aortic and got through surgery completely neurologically intact so you can actually get these patients. So if you put this patient on bypass and clamp the order, I think it would be a neurological catastrophe. So we get back to our my old friend on pump labor in vain, which is a very good operation. It's been operations that have been around for 35 40 45 years, but we do know that it has its limitations, and the reasons it has a limitations in these patients is if you clamp a disease day order on bypass or even off bypass with a side butter, you get em blight and m belie. Uh, not that smart, and they go wherever they want to go on. Most patients with envelope goes up their nominal artery and goes to the right side of the brain. And then patients get a non dominant heresy strike, get left arm weakness, left leg weakness and variable issues. Or they get gut problems. Randall problems, etcetera. So that is really what happens if you cross plan a disease. They order Andi. Then, as I said, the emboli aren't that smart. They can cause trouble. This is in the New England Journal, actually, writes the new journal. Uh, they saw This is a is a an interesting case arrived that there should be a never event. This patient should have been screened beforehand should have had inter operative, um, emerging to show that their disease and they should have had their surgery abandoned. Or they should have had a Nordic approach and they wouldn't have this problem. So these problems are avoidable, the pre operatively or even inter operatively. Um, you can get a Type one neurological injury, which is an obvious injury where the patient, you know, is heavy politic or their physic or something terrible. But I think the more dreaded injuries, the type tune your laundry injury. The so called pump brain on this can present in a whole lot of different ways, from sort of subtle neurocognitive changes people that can't do the crossword anymore. Personality changes, psychiatric issues, long term depression, long term anxiety, other things. This is obviously much harder thio harder to evaluate, but if you go looking, you can find it. This is very interesting paper in Eurovision, which was looking at patients that have had non cardiac surgery, I found that one in 14 patients had this terrible event is actually recent papers that show that 60% of people have a cerebral event after cardiac surgery and these are not benign. It depends where these mbali land as to what happens to you. Most people, the human brains recently plastic, but we do neither. You get increased acceleration of dementia and other sinister issues, so there's not benign and not their asymptomatic, but they're not benign. So basically, as I said, coming back to my my little mission, which has been a fun thing to be doing, is just to try and prove that antibiotic and total material. I talked about the total material element. Second is best for patients. Um, so let's just talk briefly about total arterial revascularization. Once again, getting back to my is that every every human beings, if they don't have one, of has been taken in previous search has to memory arteries, and they're both available for use. And once again, very nice conducts and you can use them in a whole lot of different fashions from photographs inside shoes, extension graphs, etcetera. Um, now this is a really important paper that came out in 2000, and once I was hadn't even started surgical training 25 years ago now, and David Taggart, whose pain I am zealot when it comes to total arterial revascularization and an aortic surgery, and I think he's done a wonderful job academically. He's the professor of cardiovascular surgery at Oxford, and this paper showed so 20 years ago, and this is from paper nineties show that there's a survival benefit for bilateral internal memory arteries. More recent paper from the Cleveland Clinic, which was in Jack a few months ago, would show that if you once again, if you use bilateral memories, you get a benefit and it starts to appear in the 5 to 10 year range for patients. Um, this is a piper from Australia that I was involved with, where we looked at long term outcomes for patients having off pump and on pump, and, interestingly, the outcomes for the same, which I think is interesting. And then they start diverging at the four or five year mark. Now, this makes no sense between on pumping off pump at all, except that those of us in Australia it off pump did mostly an aortic surgeon. Anybody, surgery really lends itself to tailor to your accusation. So what you're seeing here is a benefit off multiple arterial grafts, really not the benefit of on part versus off time. Similarly, another paper. Three or 4000 patients in each group. Single idea graph this is model are photographed of survival, survival versus mortality versus other issues. And once again, multimedia grafting is hardly giving it going forward. More recent paper from a good friend America. Dino, Once again, radial arteries, I think, had a fairly mixed response. One issues with radios is they're susceptible to competitive flow and you need to put them into a significant significant stenosis. FFR has been really imp important, I think, in the use of radial arteries. This is a meta analysis off rally largely versus sufferance vein graft. And once again you see diversions, uh, at the 33 to 4 year mark and then you get a plateau ing of radial arteries going out here is they remain open. Basically, this is van graft failure, which happens in the 3 to 5 year period. This is quite a cheeky paper from Alistair Rice from Melvin Melvin is but a huge, um, experience with radial arteries. He looked it wasn't the number of Rto graphs is whether or not he had a vein graft or not, And he looked at survival benefit of of total material of total Atiyah grafting with a Lima radial Ashley Y graph like this compass of graft versus any other combination. You can see that the QWERTY diverge and this is a survival out to 21 years, and I think this is a really important paper, and I got the the import to deserve the publication in Jack. Now one of the issues really comes down to It is inertia, and it's really a matter of trying toe encourage people to use op cab and once again came back to the thing, which is October is an incredibly heterogeneous, heterogeneous procedure that means different things to different people on this is really the idea that was buzzing around in my little brain in around 2015. I've got a lot of frustration when we're trying to. We're publishing papers. We were writing meta analysis of proving, and I thought it was better. We're doing case series. We're doing cases as well. That's within their own hospital. You have to be in trouble. Brilliant. So basically what I decided we needed to do was to break up cab down into the some of it of its total part. So you have a on pump cabbage here, um, with the cross clamp and and cut it from the bypass. Then you have off pump cabbage using a partial occlusion camp or a side biting clamp with a top end here, a proximal op cab with a heart string or a proximal estimated device on, then an aortic surgery. And basically we knew from our data that there was basically a two thirds or three quarters benefit of strike reduction with the traditional. And as you go down through different lessening degrees of aortic manipulation, it makes sense that you get less m belie and you get less strokes. Now, this is what a sidebar looks like so side, but is handing instrument. The problem is, if you put it on a hospital, order off pump and you can cause some problems. This is what a heart string device looks like. That's what looks like insight. You some patients you just can't do and exotic surgery, so you need alternative inflow, and you do need to put on this is a pretty easy thing to use. You put a van graft onto the top And then you can actually put a free memory on other T graft here to deal with the lady then, obviously, but antibiotic surgery eso one of these is I had was trying to get things published. Coming from Australia was difficult. So I was walking to my office one day and I literally had a conversation with myself. And I'm not I'm slightly crazy. I'm not completely crazy. Literally said, If you wanna play Madison Square Gardens, we need the Rolling Stone. So I asked David Taggart and John Poskus and unite Irani and Andre Limit to join. We'd written the paper. We just needed to come on and endorse it for us. And I think that was the key to get to get in this paper across the line. And so we published this paper and added all the papers that we published that I've been involved with. This is the one that's probably had the biggest impact on me. Personally, I suspect I'm sitting here in a higher because of this paper and also the biggest impact, I think, on the off ramp and currently actually surgery literature in the last couple of years, and so this has been a fun thing to do. So basically, what we did was we looked at all the all of the papers that have done using all these different techniques as a head to head between things. And we did a very smart millennial, probably millennial student who was a absolute wizard statistics. And he put all the statistics together for Thailand, sad statistics at all. But it worked. And basically, as I said, we showed that with decreasing the gray of biotic manipulation, you get a decreasing degree of strikes down to a 78% strike production for an hour, and I already have versus on pump and in every other parameter f renal failure, mortality, bleeding, etcetera on aortic surgery was better. So through this very rapidly, which was really interesting was this paper was adopted by the Europeans are a little bit quicker, I think, to adopt this. I think also having people like Mario and David in the within the David Taggart thistles and minimization of aquatic manipulation is now a class one indication for coronary artery service. So minimization versus elimination, two separate things off pump perfectly. No touch by experience operates things really important recommended patience with significant atherosclerosis of the old. That's a class one indication and off pump should be considered for subgroups of high risk patients by experience, off pump teams as a class to indication Thea thing tools. We'll talk through this. This is what modern or accepted practice cardiac surgery should bay is that minimize aortic manipulation, utilizing bilateral memories? If there's a low, if there's a lower risk of sternal complication, there are some patients that you should just not dio bilateral memories on certainly a beast. Diabetic females. I think it's a really dangerous thing to do, and you all I should use the organization on table graft assessment is really important. Uh, in fact, I think it's mandatory and it's now guidelines. That's not something next to shy away from and obviously using radio larger. So this, I think, is what, what our current idea and pleasingly before, before the before this last week. This came out last Thursday as a scientific statement. It's not a guideline yet, but it will be a guideline, I'm sure is this paper was central to this guideline, and the other thing, too, is as I said, it was our mission. Thio show that an aortic surgery, and they've actually used the term antibiotic, which is very kind of them, since determined my my old Boston now colleague and friend John Barry to come up with. And you can say that the there's multiple iterations for an aortic surgery and this scientific statement, which I would recommend all of you rating highlights the fact that strokes are benign. That asymptomatic brain in Bali is not benign in patients Thio suffer, and also that the use of trilateral grafting lends itself. And I certainly antibiotics. Surgery lends itself thio total at your grafting, at least multi up to your grafting so you get a double benefit of now. I only touching, plus multiple Atiyah grafting, using product from memories and already lotteries. So then I came to a higher and it's been great, actually, has been absolutely fantastic. One thing is, there's been no inertia here whatsoever. It's been unbelievable from the get go anesthetic, receptive colleagues, receptive cardiology, receptive patients receptive when it's been, absolutely, from my point of view, being absolutely wonderful. Um, and from the get go, we found patients. I wouldn't go looking for them. They just were there and because we have a policy in the department where we scan everyone's chest a pride of surgery find I already calcification and at least one patient awake that I'm operating on has the order calcification this week. There's been three on there. There. If you're looking, you will find it thes air. Some of the patients you've done This is an interesting patient that had more Amoyal disease and it had bilateral internal quality artery thio brain bypasses. And obviously she is very high risk. Had standing previously unstable angina had a unusable radial artery. In fact, I found a lot of patients here, more so than in Sydney had unusual radial arteries. And we did a total uh, sorry by that. Remember, this is a van graft extension, Four graphs and sorted her out. That was a very good result. This is another patient with a completely calcified circulation, had multiple stents with high grade left man and then high grade left side of coronary disease. He's got something very interesting in that I had disease and a big diagonal and disease in a big lady. And so this is a writer largely graph coming to around one intermediate toe a diagonal, and then I take it down to the distal lady and then I put a a labor day under here is well, so the patients are There have been very interesting lots off them. The other thing, too, is that before I came, the endoscopic harvesting here is absolutely fantastic. And, um, it's been embraced. We've got Greg, Greg and Greg. Bigelow and his team have really jumped on board with this and provided unbelievable support. And from a mobility point of view, but also from a cosmetic point of view, are my lovely boss in London, John Pepper said he didn't think that people should have Thio advertise, advertise their illness. And this is what it looks like the end of an operation. This is a the surgery four weeks. You could put a watch over this and you can't see the scars. You can walk around, advertise, you've had a raid last recovers, and I think this is absolutely fantastic. Thea thing we've done is well is patients with high greats of clothing. Synthesis of vascular colleagues have standard a T least a couple of these forests to allow us to use memory in flight, and this is a patient from Sydney, and this is a subclavian standard a year with a memory coming around to the L. A. D. So if you go looking for these patients, we can actually tune them up beforehand on doing operation for them on aortic by fixing their brutal bastard disease using a multidisciplinary approach. Another multinational post has done a couple of these now, which is common. Anybody got Kevin Tavis, a patient had this week, actually had previous stenting had unstable angina, had aortic stenosis, had a scheming march regurgitation, um, gets really vessel antibiotic caps, sorted out the ischemic Marshall regurgitation with radicalization and put in a trans catheter valve. And I think that if you go looking for, these patients will find this has been a fantastic a fantastic program to have started here, having done a few days in Sydney as well. The other thing, too, is a lot of these patients have high grade prodded lesions as well, and we did a Siris in Sydney of around 50 patients. It'll be published soon, and we've done a couple of those patients here in Columbus is well, so it's a multi disciplinary approach to the cardiovascular issues these patients have. And if you have expert product surgeon during the crowded first you have expert anesthesia providing stable blood pressure, but not too hard not to lie. And then you have expert on aortic surgery. I think you could get these high risk patients through without a brain injury, which is the ultimate ultimate for these people, Really. Thea thing, too, is my colleagues. I haven't worked in a department that's his collegiate with this ever not even close. And from the get go, it's been embraced. Azzan particularly, has jumped on board with this, and we've done at least 10 cases together now. And he's to the point where almost like flying. I think you'll be flying solo pretty soon, maybe with me next door for a few cases. But ultimately, I think it proved the techniques reproducible. Um, everyone does all caps surgery here, um, in some form another And the other thing, too, is my colleagues believe in October surgery on have embraced it, which has been absolutely fantastic from my point of view and residents as well. We've got escalating his memory artery harvesting. We've got some distance and other things happening. So it is a teachable technique, and that's been a lot of Santa Marta. So the question is, Why do you need to do? And nobody got cab on every case and why do you need to be next week? This is a little black Edward when he got his first set of golf clubs and golf and surgery is very similar on operation takes about four hours. Golf takes about four hours, and ultimately you can control most things that most the time you've got to control yourself. There are variables as wind and rain and other issues and difficulties, and that's how you make those decisions, which, which could be the end of it. So, as I said, you can progress and you can do simple things and that there was obviously a great technique. But ultimately you goto work, and you don't know when these type of patients sharp and I hope sharp regularly. And as I said, with scanning and with eco on the C T, they're out there, and I'm seeing a patient a week myself, and I don't go looking for them. There's a bunch of get referred specifically, I would suspect that they really are just out there. And ultimately, if you've gotta work and you you don't do and I got a surgery, you don't get a place like this is gonna be very, very difficult for me. Oh, a The Tokyo is the same in surgery. As I said, it's four hours. It's difficult. But I also think the other thing the doctor have surgeries. You have to actually love it. Uh, some people hate it. Some people are indifferent about another. People like myself love it. And I do think that if you do it every day and you do it, you're on you out, you get better and your team gets better and you get better outcomes. And ultimately, that's really what's happening with without caps surgery. And as I said pleasantly my mission waas toe to show that an aortic technological surgery is better for patients. I think we've done that guideline on. It's a term and it's becoming mainstream. Sorry. That's it. Thank you, Mike, Thanks so much for that superb lecture. I'd like Thio open up the floor for questions. Morning, Dr. Benson can Yes, we can hear now. Okay, this is rested from epi. So it's a wonderful lecture. And actually, I had experience with one of my own. One of my own patients, who was 85 years old, referred from outreach facility and he had this op cab, and next morning he was sitting in the chair. I was so excited that I called the referring and told them and send him a picture. So my question for Dr Valley is that what is the reason that we still do own pump cabbage? Is that just because of the volume? Or is it Is there any selection criteria? They're not why everyone gets up camp. That's a very good question. Uh, the answer. Them election, the realities. As I said, I think there was. There's a is understanding in these institutions rock, and that's why I was high. They knew that they needed someone that was gonna drive this program, and under the leadership of off Hussian and and everybody else, we knew we needed to do this thing. Issue comes down to the fact that it's like a lot of things in life is you have toe know how to do it. It has to be good and a good on pump operation is much better than a bad off pump operation. And I think the reality is that there's just not a huge volume of people that can actually do this operation. So my job now is not to do lots of operations. My job is actually to train other people to do the operation, and then we need Thio. Ultimately, we would like to have a advanced super fellowship in advanced coronary surgery so we can try and people. That's really the answer is that this is not it's. It's a difficult technique. It takes a toll east 100 cases, I think, to get remotely comfortable with it. And and that's really what it comes down to is and also the lack of understanding. So I meant what I said. A lot of surgeons don't understand the subtleties of rock Cab. Even even compared toa cardiologists and certainly not primary care physicians and patients. It is just a very nice technique. Okay. Thank you. Um, I got Romesha always interesting. I learned something when I hear you talk. So Thanks. Um, do you think you know, one of the things that didn't get mentioned some of the physiology associated with going on bypass on in, particularly the pledge A that is used, Um, have you looked into anything in terms of the myocardial protection and particularly on the right ventricle side with this technique? And if so, does this open up the opportunity for surgical revascularization for some of the other patients we deem high risk, such as those with reduced ejection fractions? Um, Cem pulmonary hypertension? Those types of factors? I think the short answer is yes. This there's, too. The two things is modern. My kind of protection, I think. And if you do a quick in operation and grasses e particular the number one issue with Octavia Scalia. Meagley Putting hypertension not so much particularly for my hypertension ischemic, because you can actually gently roll the hard over, and you can really pasteurize the front of the heart with a brain. A rival extension graph D on. Then everything shrinks. Everything's better. So cardio Meagley is really it's not reduced ejection fraction the size of the heart and the other two. If you add cardio mega lead to obesity, which is what I've discovered here in Ohio, forget it. It's it's impossible. You have to You have to do on pump surgery for those people. And I think beating heart on pump is in how they call that issues with my kind of protection. The short answer is yes. The right ventricle is problematic. If you've got a blown out right ventricle that's permanent than any form of revascularization is highly difficult whether the on pumper off pump. So I think it's a case by case basis. Cardiac memorize, absolutely imperative. You need to distinguish between unknown a scary comment, cardiomyopathy, and and the person has happens to have concurrent current altri disease. Then you have to have a difference between that in this game, and democracy is very different. So yeah. Hey, Mike, this is Dean. Excellent lecture and echo what everyone said. I always learn, uh, when you when you when you talk. So thank you so much for that Ah, question for you, uh, particularly for ah, minimal approach. Uh, I'm specifically referring to the hybrid approach because there's quite a bit of data suggesting really the survival benefits really coming from the Lima since it superior former revascularization and also uh, feeds over 50% of my Oh, cardio. Um you know, we've been involved with a couple of studies with your collaborator here to Ohio State with Puskas with a hybrid approach, that's, you know, suggested Lima minimal, invasive and in stents to the other artery, Cirque and RC. What are your thoughts on that approach? Absolutely, I think I think that's important. You know, Brian's on a bunch of robotic cases. He had done quite a few mid Captain. See, I don't like MidCap particularly. And, ah, high population doesn't lend itself to mid cap. How I think it has to be done with the robot. And so that's part of you know. You come to teach, but you also come to learn. And that's the next thing I need to learn to. Is these reinvigorate my interest in the robot? But I absolutely agree with you. Certainly a discreet right. I'm still my jury is still out on. I think total material grafting to the left system is actually probably better. I think with a robot we can actually get to memory. Arteries down are pretty easy. And I think we could probably re vast arise the left system through a nonstarter. Me approach, and that's that's probably the next thing we need to be talking about, but certainly a limit. The lady understand to the writers and excellent is an excellent operation. The right coronary arteries a different, different based, the less system. And I suspect it doesn't really matter what you do to the rock Army in many ways, whether it by a graft, a standard for not your overdraft a song as you deal with it appropriately, yes, I absolutely great. It also brings us together, and this comes to the point where we talked about this. We need a heart team approach thio the management of a scheming heart disease of which currently surgeries one aspect off. So currently, intervention is one aspect of the management of escaping heart disease, and that's something we need to do. 50% of our work is the economy is currently work, and it's the only MBT that we don't have that some of it put out there on the ground around setting with a big audience. We need to have this as a focus to deliver the best, the best, the best procedure for the best for the patients. Have you noticed using the's procedures and techniques that there has been a significant reduction and post Cory Autumn Ishaq syndrome. It doesn't exist, really not. Unless unless you get a system, there's a benign. And is this, in my mind PhD with systemic inflammatory response? Because that's what everyone was doing. You get a self limiting Veysel pledge, which I think is really interesting. But I think that's got to do with tissue trauma and probably re profusion as well. You gotta re profusion of ischemic segments, but the heart the heart is instantly happy. Um, you graph the heart on bond patient Yesterday, Big Heart, former impressions of 60 did lame to the idea. A photograph radio because he was a base with diabetic with a missing a leg and him alone. And I want to say, a 10.5 so pretty static patient. And by the end of the operation, a half two thirds the size the formerly pressures air in the thirties. So instant benefit without cab without the scheme. Very profusion. Injury s Oh, yes, the postcard economy shop, I say bars a pledge IQ shot from peripheral resistance issues, but I've never seen carry your post Carry on me shocked with our cat ever. Unless there's a problem. Uh, yeah. Thank you. Any further questions? Dr. Valley Pump. How to start Recall Question. How is how possible is it to Dio? I've kept in any patient who's had a prior cardiac surgery? No, a couple of them. It just depends. It depends what operation they've had. Um, if someone's got Peyton disease vein grafts, I think it's a really bad idea because you end up trashing the small vessel, so their patients that have and also depends what conjured you've got. I've done a handful of off pump readers once again read the coronary surgery is not that common because most people get a memory to the lady, uh, and then and then they get stencil other issues or they don't have any and journal issues because the memories got collaterals. I've done a bunch of patients through the left chest. We've got rid angina. I've got a patent memory. You can actually put a a graph from the descending to rest Gatewood across the lateral wall that's really straightforward on That's really good operation, but as I said, it's a case by case basis But once again, you shouldn't manipulate or touch paint disease vein grafts at all. So you need to arrest the heart and disconnect the van grass to stop my cardio attraction. Um, yeah. They say that the technique doesn't lend itself to that. Hey, well, I want to thank Dr Valley again for our first grand rounds of the new academic season. Thanks for everyone's participation and see you next Friday for for our next lecture and have a good day and a good weekend.