1 00:00:00,390 --> 00:00:11,040 So I sort of have a little. 2 00:00:11,040 --> 00:00:15,240 Morning, everybody, thanks for coming. Thanks for this nice introduction. 3 00:00:15,240 --> 00:00:25,320 Today we are going to talk about the personalised external, the support and in particular the Oxford experience with this technique. 4 00:00:25,320 --> 00:00:33,270 Before going in the specific of the topics, I would like to talk with you a little bit about the complex Tartick surgery programme. 5 00:00:33,270 --> 00:00:41,100 So introduce the team and give you an idea of our work with the complex outcome data and overview of the service. 6 00:00:41,100 --> 00:00:48,490 And then we will go in the specific of the personalised electrode support and will give I will give you an introduction of the stand, 7 00:00:48,490 --> 00:00:58,920 the indication of forco and the conventional treatment, a worldwide clinical experience and the specific products for clinical experience. 8 00:00:58,920 --> 00:01:07,080 So let's start with introduce the team you will recognise as some of the folks here in the room as the two men are disorganised. 9 00:01:07,080 --> 00:01:15,480 Mr. President Mr. Petr is the head of the programme and Mr. Fareed is a consultant who recently joined the team on the senior fellow. 10 00:01:15,480 --> 00:01:17,530 And we work obviously with all the team, 11 00:01:17,530 --> 00:01:27,150 but specifically with Dr. Hill as an anaesthetist that a gene is our top operator that is as a fundamental role in theatre and we go just manner. 12 00:01:27,150 --> 00:01:31,080 He is a surgical practitioner, sculpt as a one of a scrub nurse, 13 00:01:31,080 --> 00:01:42,270 and obviously the team of perfusion is A.P. So is a big team and usually we do our big test on Wednesday and sometimes also on the Monday. 14 00:01:42,270 --> 00:01:50,760 In July 2017, we established a formal complex our the committee, and in the first year we discussed a little 140 cases. 15 00:01:50,760 --> 00:01:55,680 So it was a very, very successful first year of such MDT. 16 00:01:55,680 --> 00:02:02,970 And the aim of this, and it is to have a multidisciplinary discussion that involves a cardiac surgeon, 17 00:02:02,970 --> 00:02:06,960 cardiologists, vascular surgeon, vascular radiologist, 18 00:02:06,960 --> 00:02:17,370 anaesthetic team and to provide the referral pathway for both patients and referral doctors to discuss indication and timing for surgery. 19 00:02:17,370 --> 00:02:26,190 The surgical planning, the follow up and we had built so many learning discussions off the difficult case to see how we can improve the service. 20 00:02:26,190 --> 00:02:36,060 And here you can see all of the, you know, doctors involved in this complex surgery and a reward that's offered our pay. 21 00:02:36,060 --> 00:02:43,760 Tracy, as she does a fantastic job and overview of the patient with three things with this this 22 00:02:43,760 --> 00:02:48,930 this in the in the tableau where you can see the results of our first year audit committee. 23 00:02:48,930 --> 00:02:54,150 So fundamentally, we treat patients with active disease. Our taikonaut is an honourees. 24 00:02:54,150 --> 00:02:58,830 My article, the section acute chronic by Cosby Aortic Valve Syndrome. 25 00:02:58,830 --> 00:03:02,610 We call it the disease, including Marfan syndrome terminal syndrome. 26 00:03:02,610 --> 00:03:09,270 We collaborated very close with Dr. Tamar from that endocrinology centre and realised this syndrome, 27 00:03:09,270 --> 00:03:13,710 patient endocarditis, omnigraffle and prosthesis degeneration. 28 00:03:13,710 --> 00:03:22,590 So the type of surgery we do is our kind of surgery, including elective valve repair, and we just start a programme of suture lacerated valve. 29 00:03:22,590 --> 00:03:27,840 Our third procedure, including total road replacement valve, Spedding growth replacement, 30 00:03:27,840 --> 00:03:32,460 root remodelling and enlargement ascending and outcasts replacement, 31 00:03:32,460 --> 00:03:40,360 including her MI after total heart and helfen trunk descend upon surgery for descending thoracic. 32 00:03:40,360 --> 00:03:48,840 And we way we do a hybrid procedure. The branching and and the vascular treatment in collaboration with the vascular team. 33 00:03:48,840 --> 00:03:56,360 And the complex review procedure. And we treat endocarditis to abscess and holmoe graft. 34 00:03:56,360 --> 00:04:00,840 We looking at our outcome here, I will show you that three here. 35 00:04:00,840 --> 00:04:06,120 So in cardiac surgery, every surgeon has to publish is a result. 36 00:04:06,120 --> 00:04:11,250 Every three years they're published from our society and the raw mortality. 37 00:04:11,250 --> 00:04:17,700 For Mr. Petrow, surgery for elective surgery was zero, so it was a very, very outstanding result. 38 00:04:17,700 --> 00:04:22,060 And on the top graphic, you can see that most of a procedure. 39 00:04:22,060 --> 00:04:31,200 There are other procedures, so they are not coronary artery surgeries, isolated, a vital mitral. 40 00:04:31,200 --> 00:04:35,340 So that's going the category really of our tick surgery, most of them. 41 00:04:35,340 --> 00:04:44,040 And from from from the research side of that, we look at retrospective review of at our valve preparation. 42 00:04:44,040 --> 00:04:54,480 Our mortality for isolated reduced aortic valve replacement was zero percent and for review complexity valve surgery, it was 7.7 percent. 43 00:04:54,480 --> 00:05:03,820 And we are talking of of a category of passion that they've got a risk predict risk of men of 11 12 percent. 44 00:05:03,820 --> 00:05:10,510 And so we are you UK, this centre for elective valve repair and valve sparing route to replacement. 45 00:05:10,510 --> 00:05:20,650 And Russ, procedure in introduced populism and personalised our of support to that is what we are going to talk to that in particular, 46 00:05:20,650 --> 00:05:30,280 Oxford had the particularly the role in, you know, in study the role of peers for concomitant mitral valve surgery. 47 00:05:30,280 --> 00:05:34,510 So what did this person Isaacson allow to support? 48 00:05:34,510 --> 00:05:42,730 This is a novel surgical method that for the prevention of our secret dilatation in patients at risk of our sickness S. 49 00:05:42,730 --> 00:05:48,460 So a replica of the patient thought, Dick wrote, and ascending our water is constructed, 50 00:05:48,460 --> 00:05:56,980 combining city MRI and 3D printing technology and the suit and surgical implanted around the host of the patient. 51 00:05:56,980 --> 00:06:02,710 This technique has been developed by a team of engineers and surgeons from Imperial College and Royal Brompton 52 00:06:02,710 --> 00:06:09,760 Hospital in London is an evolution of the robust technique that was the rapid culture at the bar today. 53 00:06:09,760 --> 00:06:20,260 Innovative idea was to use a customised ply on porous match that adapts perfectly to the so the route, the sending out to and most important things. 54 00:06:20,260 --> 00:06:25,750 It becomes completely incorporated in the wall and I will show you the evidence of this. 55 00:06:25,750 --> 00:06:32,830 And so that this concept was introduced for the first time at the forefront 56 00:06:32,830 --> 00:06:39,100 of secession in 2000 and the engineer that is the design of this technique. 57 00:06:39,100 --> 00:06:46,660 Mr Goldsworthy was also the first person to have the stent implanted in May 2004. 58 00:06:46,660 --> 00:06:51,670 So really come out with this idea because he's a smartphone patient and he wants to treat himself. 59 00:06:51,670 --> 00:07:01,570 And it didn't absolutely want the mechanical valve and Andy come out with this clever idea to reduce the risk of the operation. 60 00:07:01,570 --> 00:07:05,710 So the manufacturing process in four involves four man steps. 61 00:07:05,710 --> 00:07:12,100 So we got the imaging of the author, the computer. I decided to created a modelling of the aorta. 62 00:07:12,100 --> 00:07:19,330 Then using a 3D technology, we created a format. 63 00:07:19,330 --> 00:07:25,900 And on top of this format, the stent is is constructed. 64 00:07:25,900 --> 00:07:36,010 So let's be innovative of this stent. The difference is that today that the material that is the same material that we use for conventional graft, 65 00:07:36,010 --> 00:07:39,220 but the conventional graft is a low porosity graft. 66 00:07:39,220 --> 00:07:47,020 So is a stiff graft that as we go through that aspect and allow it to band without the clothing, that is what you want, 67 00:07:47,020 --> 00:07:55,150 really, when you complete the replies as a vessel in this stunt is a neutered, marketable smash. 68 00:07:55,150 --> 00:08:05,200 So it's easy to implant. It's is his core strength that anyway prevent any enlargement of the aorta bicycle micro-parties. 69 00:08:05,200 --> 00:08:14,560 So 0.7 mm. So he's allowed the tissue to grow within the borders, and that's why I get completely incorporated into the article. 70 00:08:14,560 --> 00:08:21,040 The idea of using a mock riposte Mashaba was already described in the early 1890s and said 71 00:08:21,040 --> 00:08:26,350 it was already have it done so that he got completely incorporated in the optic wall. 72 00:08:26,350 --> 00:08:30,520 There are two ship models with the Alaska stand. 73 00:08:30,520 --> 00:08:31,600 We know one model. 74 00:08:31,600 --> 00:08:43,690 The stent was applied to the carotid artery of six in sheep and the wall, and after for six months, the artery were removed and analysed, 75 00:08:43,690 --> 00:08:51,490 and the mechanical evaluations show a five fold increase in maximal tensile strength of the heart out that was covered by 76 00:08:51,490 --> 00:09:00,640 the stent and histological exam showed that the machine became completely embedded in the wall in the second animal study. 77 00:09:00,640 --> 00:09:04,600 The graft was put around the outside of the sheep, 78 00:09:04,600 --> 00:09:09,820 and on your left side you can see a conventional graft so you can see how the graft 79 00:09:09,820 --> 00:09:15,010 created a shell around the water and the space between the nativo water and the stent. 80 00:09:15,010 --> 00:09:19,690 And this is the whole technique with this innovative technique. 81 00:09:19,690 --> 00:09:28,360 The stent that's completely embedded been down off the wall and became a single layer, so there's a massive difference. 82 00:09:28,360 --> 00:09:32,950 So what are the indications for personalised electoral support? 83 00:09:32,950 --> 00:09:40,630 So this procedure is indicated in patient with the rotation of the proximal or incompetent outtake valve. 84 00:09:40,630 --> 00:09:44,920 The large cast of patients treated our muscle and patient in. 85 00:09:44,920 --> 00:09:52,960 I mean, we all know that the medicine patient, our dissection is the most common cause of death in the natural history of medicine. 86 00:09:52,960 --> 00:10:00,790 Patient and and surgical treatment is the most important prolonging treatment that we can offer. 87 00:10:00,790 --> 00:10:10,280 These are by 2014, our thoracic guidelines confirmed also in the 2017 valvular heart. 88 00:10:10,280 --> 00:10:16,490 Is this guidance that established should that replacement of assuming off for Marfan syndrome is 89 00:10:16,490 --> 00:10:25,040 recommended by the when a diameter maximum of 50 or 45 if there are concomitant risk factor? 90 00:10:25,040 --> 00:10:34,260 There are other conditions that kind the person that we also treat the world we can because they are very aggressive disease. 91 00:10:34,260 --> 00:10:39,140 A lower threshold that has been set has been recommended to treat this patient 92 00:10:39,140 --> 00:10:45,020 and is in below this syndrome tunnel syndrome and hairless Donalds syndrome. 93 00:10:45,020 --> 00:10:55,040 The conventional treatment we go really the the the classical conventional treatment is the total root replacement or what we call mental operation, 94 00:10:55,040 --> 00:11:01,320 and we just celebrate the fifth year of this procedure. And so we use a composite graph. 95 00:11:01,320 --> 00:11:05,370 So there's a graft with the valve inside that could be a mechanical Volvo. 96 00:11:05,370 --> 00:11:11,990 Or you can, you know, Taylor by a one with the with the tissue valve. 97 00:11:11,990 --> 00:11:16,820 These is an effective, safe, reproducible and durable operation. 98 00:11:16,820 --> 00:11:24,110 And it can be performed, respectively of the function of the valve, the size of the arrhythmia and is very the symbol. 99 00:11:24,110 --> 00:11:28,970 So there's not much of a of surgeon variability. 100 00:11:28,970 --> 00:11:37,010 But the problem is that you go artificial valve and particularly if you go to mechanical valve in a young person like probably the Marfan 101 00:11:37,010 --> 00:11:45,500 patient with that required of just prophylactic surgery means that this person needs to be on anticoagulation for the rest of his life. 102 00:11:45,500 --> 00:11:47,630 So to avoid this problem, you know, 103 00:11:47,630 --> 00:11:58,520 in the in the early 80s to new technique developed to try to preserve the valve and this other remodelling technique and the implantation technique, 104 00:11:58,520 --> 00:12:03,470 the proper bananas are considered the gold standard for these type of patients. 105 00:12:03,470 --> 00:12:12,080 And we got excellent long term result with valves bearing the root procedure in a very big high specialised our centre. 106 00:12:12,080 --> 00:12:21,650 But surgical registry meta analysis show worrying variability between centre and particularly within surgeon. 107 00:12:21,650 --> 00:12:29,600 And this is probably because this procedure is very technically demanded and is based on our own surgeon 108 00:12:29,600 --> 00:12:37,550 experience and the stress of judgement that technical skills are largely based on the surgeon's experience. 109 00:12:37,550 --> 00:12:40,940 So here is where the peer scam really is. 110 00:12:40,940 --> 00:12:49,800 So the piece is a just prophylactic surgery, so it can be done just before the 100sqm got too big or the valves leaks. 111 00:12:49,800 --> 00:12:55,250 And so it's usually offered to young active, active symptomatic patients. 112 00:12:55,250 --> 00:13:05,180 So the high means that to offer a safe, reproducibly operation to prevent our dysfunction and the risk of the dissection, but to avoid also the risk. 113 00:13:05,180 --> 00:13:09,680 Cholera with complex elective surgery like prolonged cardiopulmonary bypass 114 00:13:09,680 --> 00:13:15,290 early recurrence of Arctic good need for the operation of thromboembolic events. 115 00:13:15,290 --> 00:13:20,250 As for October 2017, 120% has been treated worldwide. 116 00:13:20,250 --> 00:13:27,770 So with this technique and the large cohort of these patients who are Marfan syndrome oh one 124. 117 00:13:27,770 --> 00:13:36,650 Question three were converted to conventional route surgery four and due to intraoperative funding and one patient died. 118 00:13:36,650 --> 00:13:39,350 And this is the city's kind of a patient that died. 119 00:13:39,350 --> 00:13:48,590 You can see that he had the very distorted demand for me with the severe practise and during the mobilisation of the tissue to implant the graft. 120 00:13:48,590 --> 00:13:50,960 There was a dominant of the last month's time. 121 00:13:50,960 --> 00:13:58,160 The patient I was obviously put on bypass so Nachman and actually recovered well after three or four days. 122 00:13:58,160 --> 00:14:08,450 But unfortunately he had the intracranial bleeding five day post-surgery and died and three female from patients had thought uneventful pregnancy. 123 00:14:08,450 --> 00:14:14,770 This is very important because pregnancy is a big risk for my son patient because it's been noticed that during pregnancy, 124 00:14:14,770 --> 00:14:19,460 the size of the aorta increase under the risk of dissection during pregnancy. 125 00:14:19,460 --> 00:14:26,240 And one patient had the reoperation six year after. In this patient, he had the same M.O. dynamical instability. 126 00:14:26,240 --> 00:14:33,170 In it, you lofted the first implant of appears so that the the stent was release on the proximal 127 00:14:33,170 --> 00:14:37,520 around the sinus because they were worried about compression of coronary artery. 128 00:14:37,520 --> 00:14:43,850 And actually, what's happened is that few thereafter come back because there was a dilatation specifically of that sinus, 129 00:14:43,850 --> 00:14:49,760 though this this kind of a natural experiment to show that in that patient, they added, it wasn't covered by the stent. 130 00:14:49,760 --> 00:14:56,000 Actually, the disease progressed. One patient presented with angina seven year after surgery. 131 00:14:56,000 --> 00:15:00,770 This is his coronary, and there the region of the corner is completely free. 132 00:15:00,770 --> 00:15:10,250 And the problem was a lesion on their lady at Wolstanton. So it wasn't correlated at all with with the with a stent implant. 133 00:15:10,250 --> 00:15:17,390 This is probably the most important appearance we go so far that the president of the foreign and I fear from the implant died, 134 00:15:17,390 --> 00:15:25,820 and the post-mortem examination showed no sign of our section, no complication correlated with the stent implantable. 135 00:15:25,820 --> 00:15:31,880 The problem was probably a cardiomyopathy content academy party that is often associated with Marfan syndrome. 136 00:15:31,880 --> 00:15:36,600 So this is the only relates to pathology funding. We're going to human, 137 00:15:36,600 --> 00:15:43,880 and this is important because we confirm what we saw in the XI for the graft to get completely disbanded the in the in the off the wall. 138 00:15:43,880 --> 00:15:48,050 But the most important thing, too, is the the structure of the media. 139 00:15:48,050 --> 00:15:57,650 So on the on the Figure B, you can see the classical degeneration of the media that is characteristic of the muscle in the patients. 140 00:15:57,650 --> 00:16:04,420 And and this is a sample of the art of the past that is not covered by this type in the figure. 141 00:16:04,420 --> 00:16:08,180 Do you see the delta that is covered by the stent? 142 00:16:08,180 --> 00:16:13,970 And there's there's a sign that the media within the implant recovers? 143 00:16:13,970 --> 00:16:20,390 And we think that this is because the tensest stress has been removed that's been supported by the stand. 144 00:16:20,390 --> 00:16:29,910 And so there's no pressure on the media and not not disintegration of the fibre to MRI study has been done. 145 00:16:29,910 --> 00:16:35,930 And I'll just go quickly to this one to show you that that there has been proof that 146 00:16:35,930 --> 00:16:41,810 the stent reduce the peak stress at the level of the sinus that is the green hot air. 147 00:16:41,810 --> 00:16:47,030 So the first call Omni's that pre-op MRI. The second call on is Hadley. 148 00:16:47,030 --> 00:16:50,150 MRI was the implant and the third colon is a light, 149 00:16:50,150 --> 00:16:58,640 a mirror and you can see that the green hot air that is the peak of the stress disappear from the sinus because it's been supported by the stand. 150 00:16:58,640 --> 00:17:05,000 But there's a risk that this can be a little bit dislocated just after the nominator. 151 00:17:05,000 --> 00:17:11,000 So that is exactly where the heart finish the idea that this stent coma. 152 00:17:11,000 --> 00:17:13,670 These are the publications so far. 153 00:17:13,670 --> 00:17:24,620 So we go the nine year outcome for the first 30 patient and there was no event correlated to the to the outer valve related events. 154 00:17:24,620 --> 00:17:32,030 And so initially, this technique was perceived very critical, particularly from the big American unit. 155 00:17:32,030 --> 00:17:37,820 But the main issue was that they did not represent the difference between using 156 00:17:37,820 --> 00:17:42,710 this kind of stent or using the whole vascular grafts to do the proper wrapping. 157 00:17:42,710 --> 00:17:47,480 And the most frequent concern were migration of the stent thinning of the rock, 158 00:17:47,480 --> 00:17:54,470 the vote out to the section within the support to the dilatation beyond the support. 159 00:17:54,470 --> 00:18:01,130 So the publication of these long clinical results are changing the view of the surgical community on this technique 160 00:18:01,130 --> 00:18:07,550 and this ongoing discussion about the need to reconsider the decision making process in Marfan patients, 161 00:18:07,550 --> 00:18:11,900 and particularly in view also of the Montgomery case. 162 00:18:11,900 --> 00:18:19,790 Now we are, we are obliged to our patient to discuss with them more on every, every option we got. 163 00:18:19,790 --> 00:18:25,670 And and for a young man from patient, the priority is to have a low risk operation, 164 00:18:25,670 --> 00:18:32,270 to have a healthy lifestyle, to be off of anticoagulation, to be allowed to get pregnant. 165 00:18:32,270 --> 00:18:38,240 And so this is actually is a very is is a could be an ideal technique. 166 00:18:38,240 --> 00:18:44,070 And the main Oxford contribution was in our study, the role of peers concomitant Mahto surgery. 167 00:18:44,070 --> 00:18:52,940 So we come with our through our experience. So a total of seven patients receive an x of uske stent within our team. 168 00:18:52,940 --> 00:19:00,980 Five procedures were performed at the Ratcliffe's hospital and two in the UK centre as part of our proctoring service. 169 00:19:00,980 --> 00:19:07,670 Three patients underwent isolated the stent implant and four concomitant mitral valve repair. 170 00:19:07,670 --> 00:19:11,660 All patient had done this to some Marfan syndrome. Two were five femur. 171 00:19:11,660 --> 00:19:18,170 They were a very young patient population with the midnight of 33. So the procedure is done in mediastinal. 172 00:19:18,170 --> 00:19:22,610 To me, they are still routine, dissected down to the level of the Honolulu's. 173 00:19:22,610 --> 00:19:27,020 The left and right coronary artery are cut off full circumnavigated. 174 00:19:27,020 --> 00:19:37,310 And so the x of uske stent that is been constructed, as we say specifically on the city of that patient is brought to the table. 175 00:19:37,310 --> 00:19:46,010 We go to size one one on the percent and one ninety nine 95 percent reduction of the diameter of the narrative aorta. 176 00:19:46,010 --> 00:19:53,510 And there are two marker that mark the site of a coronary artery and that the stent is placed around there, 177 00:19:53,510 --> 00:19:58,580 sending out tiny root and proximal to the region of both coronary artery. 178 00:19:58,580 --> 00:20:10,740 So is this really speaks at the level of the nominator Austrian proximal at the level of the all of the economists using a 95 percent stent? 179 00:20:10,740 --> 00:20:20,600 The native author can help in supporting the healthy controls and reduce the risk of further Arctic regurgitation. 180 00:20:20,600 --> 00:20:24,830 When you use this technique in combination with mitral valve repair, 181 00:20:24,830 --> 00:20:32,480 the big the big one advantage is the most of a preparation for the routine plant is done before going on cardiopulmonary bypass, 182 00:20:32,480 --> 00:20:40,220 and the actual implant is done have to release the cross clamp, so once the ischaemic time on the on heart is finished. 183 00:20:40,220 --> 00:20:45,950 And so this technique is a very little impact on the ischaemic time, 184 00:20:45,950 --> 00:20:53,360 and this means that allow the surgeon to dedicate a long time to the mitral valve technique. 185 00:20:53,360 --> 00:20:58,610 So the first three patient, as we say, had isolated the stent implant. 186 00:20:58,610 --> 00:21:10,010 The second patient had the previous tiver for abdominal thickness section, and she developed dilated our throat and showed the standard implant. 187 00:21:10,010 --> 00:21:15,020 And the first patient is the first one that had concomitant mitral valve repair. 188 00:21:15,020 --> 00:21:26,270 So was that P2 scallop resection and the implant of a 36 mm range was used to support today to to to perform the mitral repair. 189 00:21:26,270 --> 00:21:37,040 And this patient had a mild central air that improved after the position of a stent and obviously a successful mitral valve repair. 190 00:21:37,040 --> 00:21:42,320 This is the second patient who had combined procedure that you can see the monster, 191 00:21:42,320 --> 00:21:51,410 a good titration and the posterior to intraoperative to the show, a nice, competent mitral valve and cut deeper. 192 00:21:51,410 --> 00:22:02,480 My bypass standard was 140 minutes. And this is a passion that we help to do in Bristol, and this is a possibility of chest X-ray. 193 00:22:02,480 --> 00:22:12,410 I put that to show you that the chest of this patient and how challenging could be and and actually he underwent too much above repair. 194 00:22:12,410 --> 00:22:18,890 But after the repair, he developed what we call some systolic continuous motion movement. 195 00:22:18,890 --> 00:22:21,410 And there is a quite common complication, 196 00:22:21,410 --> 00:22:28,610 particularly more from patients because of that mitral until you leave the mitral valve, that often is very large. 197 00:22:28,610 --> 00:22:37,310 So this question required a second round of cardiopulmonary bypass and a bigger ring was implanted and the same mechanism was abolished. 198 00:22:37,310 --> 00:22:43,490 So it was extremely long cardiopulmonary bypass and cross clump of 100 minutes. 199 00:22:43,490 --> 00:22:50,900 So I think if an operation like this, you won't even perform above valve spreading root procedure, or it will be a very huge operation. 200 00:22:50,900 --> 00:22:57,770 So in particular, in pressure like this, the stent is really, really an ideal technique. 201 00:22:57,770 --> 00:23:07,850 And and the last question that we treat, we treat in Adeyemo and that he this patient had severe genre classification. 202 00:23:07,850 --> 00:23:14,210 So again, that approach was uncomplicated but was quite challenging due to the Onalaska classification, 203 00:23:14,210 --> 00:23:19,100 and they require quite a high number of TEACH- to plan their families. 204 00:23:19,100 --> 00:23:27,320 So a review of all our little Sidious showed that to all the patient underwent successful stent implant, 205 00:23:27,320 --> 00:23:31,550 all that required that had the person I was out to support. 206 00:23:31,550 --> 00:23:36,320 The procedure was performed without requiring any cardiopulmonary bypass. 207 00:23:36,320 --> 00:23:41,930 In the first case, the where we had combined mitral valve repair the the average quadruple, 208 00:23:41,930 --> 00:23:47,570 my bypass was 145 minutes and the cross clamp around 90 minutes. 209 00:23:47,570 --> 00:23:52,550 We had no significant residual Omar in all the patient in one patient. 210 00:23:52,550 --> 00:24:03,860 The degree of our improved after the implant of a stent and no patient required blood transfusion clotting factor, I had major complication. 211 00:24:03,860 --> 00:24:08,960 ICU length of stay was one an off day in hospital stay well, six days. 212 00:24:08,960 --> 00:24:16,100 So very, very smooth. Postoperative day and just one patient that had a previous history of Biafra was discharged on warfarin. 213 00:24:16,100 --> 00:24:21,150 Otherwise all these patients were free from any anticoagulation. We did. 214 00:24:21,150 --> 00:24:28,350 The MRI scan follow up saw the men of nearly four years and the for the first five patient, 215 00:24:28,350 --> 00:24:35,660 and all the scans showed that to the size of the aorta is stable and there's no significant progression. 216 00:24:35,660 --> 00:24:40,880 And that puts you. This is delighted. As I said, you had the previous tiver. 217 00:24:40,880 --> 00:24:49,070 So definitely high risk for the section and the proximal part of the auto stable after five years from the implant. 218 00:24:49,070 --> 00:24:57,420 And and this is question three, and this is the first patient who had concomitant mitral valve repair. 219 00:24:57,420 --> 00:25:04,760 And obviously, we did also transfer Rosica account that confirmed a successful mitral regurgitation motor repair. 220 00:25:04,760 --> 00:25:10,020 And you can see also that the. 221 00:25:10,020 --> 00:25:21,020 Diameter of the ventricle are the ventricles getting smaller with the follow the repair of the mitral and this is the fifth patient. 222 00:25:21,020 --> 00:25:27,080 This is a quite interesting case because it is coming out as a routine scan and we found 223 00:25:27,080 --> 00:25:33,350 incidental funding of a torpedo section in a patient that was completely asymptomatic. 224 00:25:33,350 --> 00:25:36,050 That the section originated just below the arch. 225 00:25:36,050 --> 00:25:43,460 So we don't think it's correlated with the stunt because we say that maybe the aura can be can be high 226 00:25:43,460 --> 00:25:51,470 risk after the stent is just one distant finish that it will be so after the nominal study and and edits. 227 00:25:51,470 --> 00:25:59,960 And so extend this for six seven mm this dissection and reach a maximum diameter of 43. 228 00:25:59,960 --> 00:26:07,460 But I mean, we know from the natural history of this and patient that this is a study up to the mark from patient today. 229 00:26:07,460 --> 00:26:16,910 The main issue is also after so conventional surgical repair. They have the kind of other dissection, another part of the aorta. 230 00:26:16,910 --> 00:26:21,440 And actually remember, this supports the idea that this person's shoes are quite high risk of the section, 231 00:26:21,440 --> 00:26:26,870 and the proximal bit has been as been supported by the stand. 232 00:26:26,870 --> 00:26:30,470 She's she's sorry this one hundred thirty three kilos. 233 00:26:30,470 --> 00:26:37,490 So she's she's a very basic patient, so we are keeping an eye and try to be as conservative as we can. 234 00:26:37,490 --> 00:26:41,480 And and and this is the Bristol patient. 235 00:26:41,480 --> 00:26:48,160 Again, very good follow up at City Scan that the horror show the region of a coronary artery. 236 00:26:48,160 --> 00:26:54,800 And and and again, the mature repair is very successful. 237 00:26:54,800 --> 00:27:02,780 So just just to summarise, so much of dysfunction is the second most common cardiac manifestation in one patient. 238 00:27:02,780 --> 00:27:11,750 So I think it's its role is quite underestimated. Six 80 percent of patients have a muscle with muscle pain syndrome, 239 00:27:11,750 --> 00:27:18,260 mitral valve prolapse and one you need to develop a moderate to severe mitral regurgitation at the age of 30. 240 00:27:18,260 --> 00:27:22,100 So much, so much. Fran syndrome is not just about the disease. 241 00:27:22,100 --> 00:27:30,050 There's is a big component, also the other major disease and and these these matters four are very technically referred to, 242 00:27:30,050 --> 00:27:32,840 usually because it's by leaflet prolapse. 243 00:27:32,840 --> 00:27:41,150 The characteristic are elongated to rupture, cause thin leaflet and so very dilated and the classified the Honolua. 244 00:27:41,150 --> 00:27:46,790 So we know that we can achieve from some study from the centre. 245 00:27:46,790 --> 00:27:56,420 We cannot succeed with long term durability of the Repat, but the best management of the root in this patient is controversial, 246 00:27:56,420 --> 00:28:01,820 and maybe the personalised electoral support may represent an ideal solution. 247 00:28:01,820 --> 00:28:07,850 So why? Because we show doesn't have the significant complexity to the surgery. 248 00:28:07,850 --> 00:28:10,880 It doesn't impact on the surgical ischaemic time. 249 00:28:10,880 --> 00:28:22,400 And so this means give more time to the surgeon to dedicated for complex mitral valve repair technique and potentially can can give some long term 250 00:28:22,400 --> 00:28:33,980 benefit in terms of reduce the risk of our Typekit in the detection of dissection and need for the operation or for the treatment of the proximal. 251 00:28:33,980 --> 00:28:42,350 And obviously avoid anticoagulation and support thoughts of the analysts and prevent the Delta Valve regurgitation. 252 00:28:42,350 --> 00:28:46,010 Obviously, a large number of patients are required the longer follow up. 253 00:28:46,010 --> 00:28:50,440 These are just our early results, but they are very encouraging. 254 00:28:50,440 --> 00:28:57,170 And I would like to thank Mr Petru for sharing these extensive experience with this technique and 255 00:28:57,170 --> 00:29:03,710 with all and all his articles appearance and support my career and my research projects so far. 256 00:29:03,710 --> 00:29:11,150 And I would like to invite all the students, a junior doctor and senior colleagues with an interest about surgery to contact them, 257 00:29:11,150 --> 00:29:15,860 visit our team will come to you are welcome to come to our theatre. 258 00:29:15,860 --> 00:29:21,200 As I say in many ways that we do this big our decays and these are the contacts. 259 00:29:21,200 --> 00:29:34,130 If you want to contact us, many thanks. Thank you very much. 260 00:29:34,130 --> 00:29:40,550 And, Mario. So I'm going to take a few years back and review my age, unfortunately. 261 00:29:40,550 --> 00:29:51,320 1988, I was a registrar in cardiac surgery in Sheffield, and there was a symposium where Donald Hall was chairing Magdi Akume. 262 00:29:51,320 --> 00:30:01,850 Was there Tom Pleasure, you know, to the guys and they were talking about the water surgery. 263 00:30:01,850 --> 00:30:06,560 And I can tell you the mortality at the time was two figures. 264 00:30:06,560 --> 00:30:11,840 Your results are spectacular when you quote a zero percent mortality. 265 00:30:11,840 --> 00:30:14,690 Why is that? Are you a better surgeon? 266 00:30:14,690 --> 00:30:26,420 Or is it the technology or is it the support and the the the the physiological conditions with bypass doing things without that? 267 00:30:26,420 --> 00:30:31,880 What is it? What's made the difference over a period of 30 years? 268 00:30:31,880 --> 00:30:38,900 Thanks for the question. And obviously, you mentioned some great grace our surgeons saw. 269 00:30:38,900 --> 00:30:44,090 I do think the differences in the surgical skills. 270 00:30:44,090 --> 00:30:46,430 The question is the now the system is different, 271 00:30:46,430 --> 00:30:55,310 it will work in a big team and the MDT discussion is very important because we plan our surgery very carefully. 272 00:30:55,310 --> 00:31:01,190 We do a lot of redo operation and the preoperative C.T. scanning is changed a lot. 273 00:31:01,190 --> 00:31:08,510 That result because we are able to access the risk of free access to the chest and 274 00:31:08,510 --> 00:31:15,230 use the other strategy to avoid the risk of major complication during the reopening. 275 00:31:15,230 --> 00:31:28,970 That is a big part of our activity and the role of intraoperative toys, fundamentally because fundamental because we have a constant, 276 00:31:28,970 --> 00:31:33,650 we have a good planning, intraoperative last minute planning for what we have to do. 277 00:31:33,650 --> 00:31:43,100 We check our our quadriplegia distribution. That is very important because MyoKardia protection is very important and we we check the results of Iowa, 278 00:31:43,100 --> 00:31:47,750 oh, our operating theatre and we are able to fine tune the repair. 279 00:31:47,750 --> 00:31:56,960 So is is really is is a team effort and we found it's very important to have a team and the, you know, 280 00:31:56,960 --> 00:32:06,720 expert scrub nurse and assistant and anaesthetists to optimise the blood management is the teamwork and the cardiologist before. 281 00:32:06,720 --> 00:32:11,870 Very, very, very helpful to to to perform the surgery. 282 00:32:11,870 --> 00:32:18,650 Thank you both very much. It's the first time I hear surgeons talk about physicians to say that they are health. 283 00:32:18,650 --> 00:32:25,576 Okay, thank you.