So I sort of have a little.
Morning, everybody, thanks for coming. Thanks for this nice introduction.
Today we are going to talk about the personalised external, the support and in particular the Oxford experience with this technique.
Before going in the specific of the topics, I would like to talk with you a little bit about the complex Tartick surgery programme.
So introduce the team and give you an idea of our work with the complex outcome data and overview of the service.
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,
the indication of forco and the conventional treatment, a worldwide clinical experience and the specific products for clinical experience.
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.
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.
And we work obviously with all the team,
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.
He is a surgical practitioner, sculpt as a one of a scrub nurse,
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.
In July 2017, we established a formal complex our the committee, and in the first year we discussed a little 140 cases.
So it was a very, very successful first year of such MDT.
And the aim of this, and it is to have a multidisciplinary discussion that involves a cardiac surgeon,
cardiologists, vascular surgeon, vascular radiologist,
anaesthetic team and to provide the referral pathway for both patients and referral doctors to discuss indication and timing for surgery.
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.
And here you can see all of the, you know, doctors involved in this complex surgery and a reward that's offered our pay.
Tracy, as she does a fantastic job and overview of the patient with three things with this this
this in the in the tableau where you can see the results of our first year audit committee.
So fundamentally, we treat patients with active disease. Our taikonaut is an honourees.
My article, the section acute chronic by Cosby Aortic Valve Syndrome.
We call it the disease, including Marfan syndrome terminal syndrome.
We collaborated very close with Dr. Tamar from that endocrinology centre and realised this syndrome,
patient endocarditis, omnigraffle and prosthesis degeneration.
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.
Our third procedure, including total road replacement valve, Spedding growth replacement,
root remodelling and enlargement ascending and outcasts replacement,
including her MI after total heart and helfen trunk descend upon surgery for descending thoracic.
And we way we do a hybrid procedure. The branching and and the vascular treatment in collaboration with the vascular team.
And the complex review procedure. And we treat endocarditis to abscess and holmoe graft.
We looking at our outcome here, I will show you that three here.
So in cardiac surgery, every surgeon has to publish is a result.
Every three years they're published from our society and the raw mortality.
For Mr. Petrow, surgery for elective surgery was zero, so it was a very, very outstanding result.
And on the top graphic, you can see that most of a procedure.
There are other procedures, so they are not coronary artery surgeries, isolated, a vital mitral.
So that's going the category really of our tick surgery, most of them.
And from from from the research side of that, we look at retrospective review of at our valve preparation.
Our mortality for isolated reduced aortic valve replacement was zero percent and for review complexity valve surgery, it was 7.7 percent.
And we are talking of of a category of passion that they've got a risk predict risk of men of 11 12 percent.
And so we are you UK, this centre for elective valve repair and valve sparing route to replacement.
And Russ, procedure in introduced populism and personalised our of support to that is what we are going to talk to that in particular,
Oxford had the particularly the role in, you know, in study the role of peers for concomitant mitral valve surgery.
So what did this person Isaacson allow to support?
This is a novel surgical method that for the prevention of our secret dilatation in patients at risk of our sickness S.
So a replica of the patient thought, Dick wrote, and ascending our water is constructed,
combining city MRI and 3D printing technology and the suit and surgical implanted around the host of the patient.
This technique has been developed by a team of engineers and surgeons from Imperial College and Royal Brompton
Hospital in London is an evolution of the robust technique that was the rapid culture at the bar today.
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.
It becomes completely incorporated in the wall and I will show you the evidence of this.
And so that this concept was introduced for the first time at the forefront
of secession in 2000 and the engineer that is the design of this technique.
Mr Goldsworthy was also the first person to have the stent implanted in May 2004.
So really come out with this idea because he's a smartphone patient and he wants to treat himself.
And it didn't absolutely want the mechanical valve and Andy come out with this clever idea to reduce the risk of the operation.
So the manufacturing process in four involves four man steps.
So we got the imaging of the author, the computer. I decided to created a modelling of the aorta.
Then using a 3D technology, we created a format.
And on top of this format, the stent is is constructed.
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,
but the conventional graft is a low porosity graft.
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,
really, when you complete the replies as a vessel in this stunt is a neutered, marketable smash.
So it's easy to implant. It's is his core strength that anyway prevent any enlargement of the aorta bicycle micro-parties.
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.
The idea of using a mock riposte Mashaba was already described in the early 1890s and said
it was already have it done so that he got completely incorporated in the optic wall.
There are two ship models with the Alaska stand.
We know one model.
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,
and the mechanical evaluations show a five fold increase in maximal tensile strength of the heart out that was covered by
the stent and histological exam showed that the machine became completely embedded in the wall in the second animal study.
The graft was put around the outside of the sheep,
and on your left side you can see a conventional graft so you can see how the graft
created a shell around the water and the space between the nativo water and the stent.
And this is the whole technique with this innovative technique.
The stent that's completely embedded been down off the wall and became a single layer, so there's a massive difference.
So what are the indications for personalised electoral support?
So this procedure is indicated in patient with the rotation of the proximal or incompetent outtake valve.
The large cast of patients treated our muscle and patient in.
I mean, we all know that the medicine patient, our dissection is the most common cause of death in the natural history of medicine.
Patient and and surgical treatment is the most important prolonging treatment that we can offer.
These are by 2014, our thoracic guidelines confirmed also in the 2017 valvular heart.
Is this guidance that established should that replacement of assuming off for Marfan syndrome is
recommended by the when a diameter maximum of 50 or 45 if there are concomitant risk factor?
There are other conditions that kind the person that we also treat the world we can because they are very aggressive disease.
A lower threshold that has been set has been recommended to treat this patient
and is in below this syndrome tunnel syndrome and hairless Donalds syndrome.
The conventional treatment we go really the the the classical conventional treatment is the total root replacement or what we call mental operation,
and we just celebrate the fifth year of this procedure. And so we use a composite graph.
So there's a graft with the valve inside that could be a mechanical Volvo.
Or you can, you know, Taylor by a one with the with the tissue valve.
These is an effective, safe, reproducible and durable operation.
And it can be performed, respectively of the function of the valve, the size of the arrhythmia and is very the symbol.
So there's not much of a of surgeon variability.
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
patient with that required of just prophylactic surgery means that this person needs to be on anticoagulation for the rest of his life.
So to avoid this problem, you know,
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,
the proper bananas are considered the gold standard for these type of patients.
And we got excellent long term result with valves bearing the root procedure in a very big high specialised our centre.
But surgical registry meta analysis show worrying variability between centre and particularly within surgeon.
And this is probably because this procedure is very technically demanded and is based on our own surgeon
experience and the stress of judgement that technical skills are largely based on the surgeon's experience.
So here is where the peer scam really is.
So the piece is a just prophylactic surgery, so it can be done just before the 100sqm got too big or the valves leaks.
And so it's usually offered to young active, active symptomatic patients.
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.
Cholera with complex elective surgery like prolonged cardiopulmonary bypass
early recurrence of Arctic good need for the operation of thromboembolic events.
As for October 2017, 120% has been treated worldwide.
So with this technique and the large cohort of these patients who are Marfan syndrome oh one 124.
Question three were converted to conventional route surgery four and due to intraoperative funding and one patient died.
And this is the city's kind of a patient that died.
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.
There was a dominant of the last month's time.
The patient I was obviously put on bypass so Nachman and actually recovered well after three or four days.
But unfortunately he had the intracranial bleeding five day post-surgery and died and three female from patients had thought uneventful pregnancy.
This is very important because pregnancy is a big risk for my son patient because it's been noticed that during pregnancy,
the size of the aorta increase under the risk of dissection during pregnancy.
And one patient had the reoperation six year after. In this patient, he had the same M.O. dynamical instability.
In it, you lofted the first implant of appears so that the the stent was release on the proximal
around the sinus because they were worried about compression of coronary artery.
And actually, what's happened is that few thereafter come back because there was a dilatation specifically of that sinus,
though this this kind of a natural experiment to show that in that patient, they added, it wasn't covered by the stent.
Actually, the disease progressed. One patient presented with angina seven year after surgery.
This is his coronary, and there the region of the corner is completely free.
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.
This is probably the most important appearance we go so far that the president of the foreign and I fear from the implant died,
and the post-mortem examination showed no sign of our section, no complication correlated with the stent implantable.
The problem was probably a cardiomyopathy content academy party that is often associated with Marfan syndrome.
So this is the only relates to pathology funding. We're going to human,
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.
But the most important thing, too, is the the structure of the media.
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.
And and this is a sample of the art of the past that is not covered by this type in the figure.
Do you see the delta that is covered by the stent?
And there's there's a sign that the media within the implant recovers?
And we think that this is because the tensest stress has been removed that's been supported by the stand.
And so there's no pressure on the media and not not disintegration of the fibre to MRI study has been done.
And I'll just go quickly to this one to show you that that there has been proof that
the stent reduce the peak stress at the level of the sinus that is the green hot air.
So the first call Omni's that pre-op MRI. The second call on is Hadley.
MRI was the implant and the third colon is a light,
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.
But there's a risk that this can be a little bit dislocated just after the nominator.
So that is exactly where the heart finish the idea that this stent coma.
These are the publications so far.
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.
And so initially, this technique was perceived very critical, particularly from the big American unit.
But the main issue was that they did not represent the difference between using
this kind of stent or using the whole vascular grafts to do the proper wrapping.
And the most frequent concern were migration of the stent thinning of the rock,
the vote out to the section within the support to the dilatation beyond the support.
So the publication of these long clinical results are changing the view of the surgical community on this technique
and this ongoing discussion about the need to reconsider the decision making process in Marfan patients,
and particularly in view also of the Montgomery case.
Now we are, we are obliged to our patient to discuss with them more on every, every option we got.
And and for a young man from patient, the priority is to have a low risk operation,
to have a healthy lifestyle, to be off of anticoagulation, to be allowed to get pregnant.
And so this is actually is a very is is a could be an ideal technique.
And the main Oxford contribution was in our study, the role of peers concomitant Mahto surgery.
So we come with our through our experience. So a total of seven patients receive an x of uske stent within our team.
Five procedures were performed at the Ratcliffe's hospital and two in the UK centre as part of our proctoring service.
Three patients underwent isolated the stent implant and four concomitant mitral valve repair.
All patient had done this to some Marfan syndrome. Two were five femur.
They were a very young patient population with the midnight of 33. So the procedure is done in mediastinal.
To me, they are still routine, dissected down to the level of the Honolulu's.
The left and right coronary artery are cut off full circumnavigated.
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.
We go to size one one on the percent and one ninety nine 95 percent reduction of the diameter of the narrative aorta.
And there are two marker that mark the site of a coronary artery and that the stent is placed around there,
sending out tiny root and proximal to the region of both coronary artery.
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?
The native author can help in supporting the healthy controls and reduce the risk of further Arctic regurgitation.
When you use this technique in combination with mitral valve repair,
the big the big one advantage is the most of a preparation for the routine plant is done before going on cardiopulmonary bypass,
and the actual implant is done have to release the cross clamp, so once the ischaemic time on the on heart is finished.
And so this technique is a very little impact on the ischaemic time,
and this means that allow the surgeon to dedicate a long time to the mitral valve technique.
So the first three patient, as we say, had isolated the stent implant.
The second patient had the previous tiver for abdominal thickness section, and she developed dilated our throat and showed the standard implant.
And the first patient is the first one that had concomitant mitral valve repair.
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.
And this patient had a mild central air that improved after the position of a stent and obviously a successful mitral valve repair.
This is the second patient who had combined procedure that you can see the monster,
a good titration and the posterior to intraoperative to the show, a nice, competent mitral valve and cut deeper.
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.
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.
But after the repair, he developed what we call some systolic continuous motion movement.
And there is a quite common complication,
particularly more from patients because of that mitral until you leave the mitral valve, that often is very large.
So this question required a second round of cardiopulmonary bypass and a bigger ring was implanted and the same mechanism was abolished.
So it was extremely long cardiopulmonary bypass and cross clump of 100 minutes.
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.
So in particular, in pressure like this, the stent is really, really an ideal technique.
And and the last question that we treat, we treat in Adeyemo and that he this patient had severe genre classification.
So again, that approach was uncomplicated but was quite challenging due to the Onalaska classification,
and they require quite a high number of TEACH- to plan their families.
So a review of all our little Sidious showed that to all the patient underwent successful stent implant,
all that required that had the person I was out to support.
The procedure was performed without requiring any cardiopulmonary bypass.
In the first case, the where we had combined mitral valve repair the the average quadruple,
my bypass was 145 minutes and the cross clamp around 90 minutes.
We had no significant residual Omar in all the patient in one patient.
The degree of our improved after the implant of a stent and no patient required blood transfusion clotting factor, I had major complication.
ICU length of stay was one an off day in hospital stay well, six days.
So very, very smooth. Postoperative day and just one patient that had a previous history of Biafra was discharged on warfarin.
Otherwise all these patients were free from any anticoagulation. We did.
The MRI scan follow up saw the men of nearly four years and the for the first five patient,
and all the scans showed that to the size of the aorta is stable and there's no significant progression.
And that puts you. This is delighted. As I said, you had the previous tiver.
So definitely high risk for the section and the proximal part of the auto stable after five years from the implant.
And and this is question three, and this is the first patient who had concomitant mitral valve repair.
And obviously, we did also transfer Rosica account that confirmed a successful mitral regurgitation motor repair.
And you can see also that the.
Diameter of the ventricle are the ventricles getting smaller with the follow the repair of the mitral and this is the fifth patient.
This is a quite interesting case because it is coming out as a routine scan and we found
incidental funding of a torpedo section in a patient that was completely asymptomatic.
That the section originated just below the arch.
So we don't think it's correlated with the stunt because we say that maybe the aura can be can be high
risk after the stent is just one distant finish that it will be so after the nominal study and and edits.
And so extend this for six seven mm this dissection and reach a maximum diameter of 43.
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.
The main issue is also after so conventional surgical repair. They have the kind of other dissection, another part of the aorta.
And actually remember, this supports the idea that this person's shoes are quite high risk of the section,
and the proximal bit has been as been supported by the stand.
She's she's sorry this one hundred thirty three kilos.
So she's she's a very basic patient, so we are keeping an eye and try to be as conservative as we can.
And and and this is the Bristol patient.
Again, very good follow up at City Scan that the horror show the region of a coronary artery.
And and and again, the mature repair is very successful.
So just just to summarise, so much of dysfunction is the second most common cardiac manifestation in one patient.
So I think it's its role is quite underestimated. Six 80 percent of patients have a muscle with muscle pain syndrome,
mitral valve prolapse and one you need to develop a moderate to severe mitral regurgitation at the age of 30.
So much, so much. Fran syndrome is not just about the disease.
There's is a big component, also the other major disease and and these these matters four are very technically referred to,
usually because it's by leaflet prolapse.
The characteristic are elongated to rupture, cause thin leaflet and so very dilated and the classified the Honolua.
So we know that we can achieve from some study from the centre.
We cannot succeed with long term durability of the Repat, but the best management of the root in this patient is controversial,
and maybe the personalised electoral support may represent an ideal solution.
So why? Because we show doesn't have the significant complexity to the surgery.
It doesn't impact on the surgical ischaemic time.
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
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.
And obviously avoid anticoagulation and support thoughts of the analysts and prevent the Delta Valve regurgitation.
Obviously, a large number of patients are required the longer follow up.
These are just our early results, but they are very encouraging.
And I would like to thank Mr Petru for sharing these extensive experience with this technique and
with all and all his articles appearance and support my career and my research projects so far.
And I would like to invite all the students, a junior doctor and senior colleagues with an interest about surgery to contact them,
visit our team will come to you are welcome to come to our theatre.
As I say in many ways that we do this big our decays and these are the contacts.
If you want to contact us, many thanks. Thank you very much.
And, Mario. So I'm going to take a few years back and review my age, unfortunately.
1988, I was a registrar in cardiac surgery in Sheffield, and there was a symposium where Donald Hall was chairing Magdi Akume.
Was there Tom Pleasure, you know, to the guys and they were talking about the water surgery.
And I can tell you the mortality at the time was two figures.
Your results are spectacular when you quote a zero percent mortality.
Why is that? Are you a better surgeon?
Or is it the technology or is it the support and the the the the physiological conditions with bypass doing things without that?
What is it? What's made the difference over a period of 30 years?
Thanks for the question. And obviously, you mentioned some great grace our surgeons saw.
I do think the differences in the surgical skills.
The question is the now the system is different,
it will work in a big team and the MDT discussion is very important because we plan our surgery very carefully.
We do a lot of redo operation and the preoperative C.T. scanning is changed a lot.
That result because we are able to access the risk of free access to the chest and
use the other strategy to avoid the risk of major complication during the reopening.
That is a big part of our activity and the role of intraoperative toys, fundamentally because fundamental because we have a constant,
we have a good planning, intraoperative last minute planning for what we have to do.
We check our our quadriplegia distribution. That is very important because MyoKardia protection is very important and we we check the results of Iowa,
oh, our operating theatre and we are able to fine tune the repair.
So is is really is is a team effort and we found it's very important to have a team and the, you know,
expert scrub nurse and assistant and anaesthetists to optimise the blood management is the teamwork and the cardiologist before.
Very, very, very helpful to to to perform the surgery.
Thank you both very much. It's the first time I hear surgeons talk about physicians to say that they are health.
Okay, thank you.