HYBRID PROCEDURE FOR CORONARY ARTERY DISEASE UNIVERSITY OF MARYLAND MEDICAL CENTER BALTIMORE, MARYLAND February 28, 2007

Transcription

1 HYBRID PROCEDURE FOR CORONARY ARTERY DISEASE UNIVERSITY OF MARYLAND MEDICAL CENTER BALTIMORE, MARYLAND February 28, :00:10 ANNOUNCER: Welcome to the University of Maryland Heart Center in Baltimore, where cardiac surgeons are working with interventional cardiologists to offer a unique operation for some patients with coronary artery disease. The webcast you are about to see shows a hybrid procedure that combines minimally invasive robotic coronary artery bypass surgery with stented angioplasty performed in just one operation. The University of Maryland Medical Center is among the first hospitals in the U.S. to offer this combined surgery. The use of robotic technology. 00:00:48 JAMES BORIN, MD: Good morning, and welcome to the University of Maryland. I m standing here in front of the revolutionary davinci robot, and we re getting set up currently for a unique case, a hybrid procedure doing a cardiac bypass using the robot as well as an endovascular approach to cardiac disease. University of Maryland is one of the few medical centers in the country doing this procedure. My name is James Borin, and I m the director of robotic surgery here at the University of Maryland. The davinci S surgical robot behind me represents the most advanced technique in surgical robotics in the country. There are a couple of unique features of the davinci robot. As you can see, it has a number of different arms which hold instruments. This arm right here is the camera arm. This represents the optic system of the davinci robot. The optic system is actually two cameras side by side which give the surgeon three-dimensional view as well as depth perception. The camera can be inserted into the abdominal cavity or the chest cavity as well. Each of the surgical arms holds holds one of various types of instruments specially designed for this robot. These instruments are what s called wristed instruments in that the tips of the instruments can bend in positions that are not able to be manipulated by the human hand. This gives a surgeon extreme dexterity to work in very small enclosed spaces. Here at the University of Maryland, we re currently using the davinci robot to do prostate surgery for prostate cancer as well as a variety of cardiac surgeries. I am now going to turn the presentation over to my colleague, Dr. Rob Poston, who will be performing today s surgery. 00:02:25 ROBERT S. POSTON, MD: Hi there. Welcome to the operating room here, room 26, where we have a hybrid approach to revascularization. This is a specially outfitted operating room with angiographic equipment that is also an operating room. And what that means is you can do a heart catheterization like you would do if you went to see your cardiologist, and then they can intervene with stents and other noninvasive or less-invasive approaches. And at the same time, we can use this operating room with our robot to do minimally invasive surgery. So it s a combines the best of both worlds, we like to say. That s a phrase that we have here because the one operation that we can do most reliably is this mammary LAD. The mammary artery taken off the chest wall with the robot, as I ll show you here in a little bit, to the artery on the front of the heart called the anterior descending. You ll see when we open up the heart that it s a very straightforward procedure because it s sitting right there on the front of the heart easy to get to. So I d like to introduce my colleague, Dr.

2 Drummond. As I m working, he can explain more of what s going on. But at this point in the operation, we ve put in the robotic instruments. They re dime-sized incisions on the left chest. Hopefully you can get a chance to see those incisions. And then the robotic instruments are in, the camera s in, and I m getting ready to start the operation. 00:03:49 CHARLES DRUMMOND, MD: Dr. Poston is continuing to harvest the left internal mammary artery, dividing more the pleura that s on the inside of the chest there. He s using the spatula to separate the tissues. Just beneath that fatty tissue there is the left internal mammary artery. 00:04:10 ROBERT S. POSTON, MD: You may notice that I don t have shoes on. I don t know if that was something that was filmed or not, but that the purpose of that is to get a good feel of the of the instruments. And you know, I m out here in an unsterile area. Actually, this this console could be in a different state that I m working on right now because it communicates, you know, via radio waves to the robotic instrument. That was partly by design that surgeons can operate like in a battlefield without actually having to be at the patient s bedside. So we like to get a good feel of the pedals so that we re not pushing the wrong pedal. And take our shoes off. That s kind of the recommended technique. 00:05:10 CHARLES DRUMMOND, MD: The space that we re looking at is magnified. It s just a small area a couple of inches wide beneath the left side of the breast bone, or the sternum. And it a little bit of bleeding inside here. It looks like an awful lot, but it s really a tiny amount, maybe just a couple of cc s. And using these two instruments that he s controlling from the console way over there, he s dissecting the left internal mammary artery off the chest wall. Like we were saying before, you get a feel for where it is just beneath his grasper there. And he s literally just teasing it off of the inside of the chest wall, just pushing some of that fatty tissue out of the way and cauterizing the little small branches. He s grasping the fatty tissue with one hand and using the spatula or cautery with the other to push it out of the way. The cautery in the right hand he uses to burn the tissue, coagulate it so it doesn t the little small branches don t bleed. He has a bipolar cautery in the other hand that cauterizes just between the grasper tips. You can see there s a fairly large branch right there that he s approaching. He s going to divide the tissue around it on one side. Now, on the bottom side he s dissected almost completely around that large branch there, and then he ll reach in there and grab it with the bipolar cautery. Some of the larger branches sometimes you put clips on them. We re going to put a clip in the right hand. Right hand is out. Uh-huh. Clip s on the right hand. 00:08:06 ROBERT S. POSTON, MD: That s good. Perfect. Okay, nice. It just didn t let me use it. 00:08:14 CHARLES DRUMMOND, MD: Yeah, that was what it was. 00:08:15 ROBERT S. POSTON, MD: It went in. It just said, No, can t use this. 00:08:17 CHARLES DRUMMOND, MD: It was it didn t have any more uses left. So he s now put a clip on that large branch. We re going to come out with the clip applier on the right hand, going back in with the spatula in the right hand. Okay, going in with the spatula in the right hand. 00:08:41 ROBERT S. POSTON, MD: I think we ll just pick it up from the end where we 00:08:48 CHARLES DRUMMOND, MD: So now he s going to cauterize just above that clip that he placed. So now that large branch vessel to the mammary artery is taken care of. Pushing the mammary artery down. Sequentially dissects.

3 00:09:51 ROBERT S. POSTON, MD: Clip in the right. 00:09:54 CHARLES DRUMMOND, MD: Taking the right. 00:10:11 ROBERT S. POSTON, MD: What I m doing here is putting clips on the branches and then I just do something I call electrocautery on the other side. I like to clip the side that s on the mammary so that the electricity doesn t travel back onto the onto the mammary and hurt it, but I want the electricity to travel onto the chest wall and make sure that that thing is fully coagulated. So that s what we usually do even when we do I m essentially doing this case, this harvest, the same way I would do it open. I mean, I clip branches just like this and do the dissection quite similar; it s just amazing how quickly you can kind of pick it up. If you know how to do a mammary harvest open, then you can just kind of do it once you get comfortable with the concept that the robot is really just an extension of your hands. And that s a little bit difficult. When we first started, these cases were taking quite a long time because you just don t trust that the robot s going to do what you tell it to. And so you always take, you know, a little longer than you need to. But now I basically try to harvest things the same tempo that I would open. Being careful around a branch point like this, but where there s no branches, you don t have to be quite as slow and tedious. I ll take a branch on the right or a clip on the right. Another branch right here. I think you could probably make it out. I m pointing it with my instrument right now. A branch right there. So if I was just to cut right through that, it d bleed. So I want to put a clip on the mammary side and I ll coag coagulate this side. So a clip will go right here. Here s the clip that Charlie gave me. Oh, geez. Something happened. It didn t open up. Let me try one more clip. 00:12:15 CHARLES DRUMMOND, MD: Clip applier coming out. We need another clip. 00:12:17 ROBERT S. POSTON, MD: It s funny that clip applier didn t open up. It kind of slid off a little bit. Tack that back in there. 00:12:31 CHARLES DRUMMOND, MD: Okay. Coming in with the clip applier. 00:12:39 ROBERT S. POSTON, MD: Let s see if I can get that clip on. Okay. That s a better clip. Okay, spatula. 00:12:43 CHARLES DRUMMOND, MD: Coming out with the clip applier. 00:12:47 ROBERT S. POSTON, MD: Yep. Thanks for the communication because there s another branch down there. It s fairly big size. If we can get that. Right now. I say you ve got to get branches before they get you. Because as we re tugging, you can see it kind of put some tension on that. Okay, I ll take a clip applier and clip in the right. So it s got a nice pull, so you can see it right in here. Nice, big mammary. I m going to enjoy sewing this to his LAD because I think it s going to give him a lot of flow. That that clip. Do you see that clip, Charlie? I think it s a little bit -- Let me try it. I think I might be able to get it on. 00:13:54 CHARLES DRUMMOND, MD: Looks like it worked. 00:13:56 ROBERT S. POSTON, MD: I think it did. Okay, spatula. One way to find out. The clips for some reason are very tricky to put on. I don t know why. 00:14:13 CHARLES DRUMMOND, MD: Is it working? 00:14:15

4 ROBERT S. POSTON, MD: All right. Once I get this branch, then we ll have a lot of this mammary down because this is a pretty major branch here. And it s tacking it up. It s tacking the mammary up pretty big there. See how that thing now just kind of drops way down. What s that? 00:14:57 ASSISTANT: [inaudible]. 00:15:02 ROBERT S. POSTON, MD: Okay. And let me just give you a view. So here s where I m headed. Here s where I m headed, here s where I ve been. Come a long way here, all the way from the this is the this kind of prominent area is the first rib. And so this is we re even upstream of the first rib, which is that s pretty standard. Here s the aorta beating down here. Phrenic nerve is right here. That s the nerve that goes to the diaphragm. When we do this thing without the robot, oftentimes we would inadvertently kind of cut down and damage that nerve right there. But with the robot, obviously, you know, I can be very precise and I m not going to come close to that nerve. They re pretty close, though. This is about 2 cm where I am right now, but I don t need to go any further than that because it s not going to provide me any length or any advantage. Here s the heart right here. We re going to be sewing to it about right here. That s about where my LAD is. So I need to get it down to about right here. I had started showing it right there. And then we ll be done. So I got, oh, about two-thirds done right now. 00:16:05 CHARLES DRUMMOND, MD: Dr. Poston is finished harvesting, or taking down the left internal mammary artery from the chest wall. He s opened up the pericardium, he s enlarging that incision right now. This incision is it looks large because this is a magnified view. Really it s just a few centimeters in length. 00:16:26 ROBERT S. POSTON, MD: Can I have a clip in the right? 00:16:29 CHARLES DRUMMOND, MD: Okay, we re going to put a clip in the right hand here. 00:16:33 ROBERT S. POSTON, MD: Just to give you a summary of what s being going on, last time we were about we saw we were showing you scenes. We re about three-quarters done now. We ve got it all the way down. You can see the mammary taken down pretty close. You wouldn t want to go any further because you might hit that phrenic nerve right there. So that s about as far up as we can go upstream. And then downstream we are right here where it starts to get small divide into various branches. You ve got a bunch of clips here on a lot of branches. And just getting the final branch taken care of, and I m going to swing it over onto my heart. You can see here I ve opened up the heart sac, called the pericardium. And that left anterior descending is this vessel right here. It s fairly decentsized. So that s where we re going to suture this artery to that artery right there is into that into the side of that. So we ll just go ahead and proceed here. 00:17:36 CHARLES DRUMMOND, MD: I m going to push on the shoulder. 00:18:!2 ROBERT S. POSTON, MD: Just getting rid of the last few attachments, swinging it over here. See, it seems one thing we do right now is just check and make sure it s long enough for my my site. We re going to sew at the so-called target site. And it certainly seems like the answer to that is yes. Clip in the right. 00:18:34 CHARLES DRUMMOND, MD: Okay. Spatula s coming out. 00:18:39 ROBERT S. POSTON, MD: Little bit of oozing there on the mammary, but that s right where we re going to have access to it, so we re not too concerned about that. We ll find out where

5 that s coming. I m going to tack it to the pericardium, this heart sac, because when I take out the robotic instruments, then I want to make sure that this things stays in the correct position that it s in right now. Ah, clip came out, Charlie. 00:19:11 CHARLES DRUMMOND, MD: Okay. Coming out. Another clip applier. Coming in. 00:19:43 ROBERT S. POSTON, MD: Okay. So that tacks that there. And see it coming down there. And tacked right to the heart sac. 00:20:00 CHARLES DRUMMOND, MD: Okay, taking the clip applier out of your right hand. 00:20:01 ROBERT S. POSTON, MD: Yeah, taking all the instruments out. 00:20:03 CHARLES DRUMMOND, MD: Are you happy with the mammary bed? 00:20:06 ROBERT S. POSTON, MD: Yes. 00:20:08 CHARLES DRUMMOND, MD: You want we re going to undock now? 00:20:10 ROBERT S. POSTON, MD: Yep. So now I I get my loops on and we ll do that last suturing job by hand. So this is just like we do it in the traditional route is to make an incision and hand-sew it. So I m not compromising the quality anastomosis using a robot to do the suturing job. Harvesting the mammary can be done easily with either the robot or by hand, and so the technical difficulty part is done the old-fashioned way, the way we know by 20 years works well. 00:20:48 CHARLES DRUMMOND, MD: All right. Right there is the left anterior descending artery right there peeking in. And what we ve got these sutures on is my mammary artery right there. Okay? So I think that s a better view of it right there. 00:21:15 ROBERT S. POSTON, MD: And this is the extent of our incision here. Can you look in the light in there? That s the extent of our incision. All right. Well, let s see if we can t get that exposed 00:21:28 CHARLES DRUMMOND, MD: Yeah, I was going to do that. 00:21:30 ROBERT S. POSTON, MD: See if we can t get that exposed just a little better. That s good. And I ll take a stabilizer. 00:21:40 CHARLES DRUMMOND, MD: We ll be able to pull it down towards us a little bit. 00:21:48 ASSISTANT: Suction s on. 00:22:28 CHARLES DRUMMOND, MD: Suction on already. 00:22:30 ROBERT S. POSTON, MD: Yeah, it s on. I like it on. I only turn it off if I m struggling, but in general. Like now. Now might be a good one to turn it off. 00:22:47 CHARLES DRUMMOND, MD: Yep. I m going to shut it off. Go ahead. Ready? Okay. 00:23:37 ROBERT S. POSTON, MD: All right, do you want to get the high-definition scope again? 00:23:39 ASSISTANT: HD light on, please.

6 00:23:43 ROBERT S. POSTON, MD: See if you can t show that, Charlie. 00:23:44 CHARLES DRUMMOND, MD: Okay. Just going to show you this is the stabilizer that s going into the wound right where Dr. Poston is working is the left anterior descending artery. He s getting ready to dissect it out. 00:24:20 ROBERT S. POSTON, MD: Can I get new double D s? 00:24:33 CHARLES DRUMMOND, MD: That stabilizer s sitting right on top of the left anterior descending coronary artery. It has two feet. On the feet are some suction cups. Suction tubing comes into the side and applies suction to those little feet areas which stick to the surface of the heart and stabilize it. 00:24:55 ROBERT S. POSTON, MD: Silastic loop. 00:25:01 CHARLES DRUMMOND, MD: So there is the artery right inside of there, right between the two feet. I m going to have to put this down to help Dr. Poston. He s getting ready to put a small rubber suture around the proximal portion of the left anterior descending coronary artery. And he ll pull tension on that rubber suture as it goes around the artery to occlude the artery while he s doing the anastomosis. And it s at this point that we really like to, you know, pick up the pace and move rather quickly because once the flow on that coronary artery is shut off, the heart doesn t like that. And we need to get the good blood flow coming in with the mammary artery. So he s pulling up the mammary artery into the field right now. 00:26:12 ROBERT S. POSTON, MD: All right. Let s tack that up needle driver. 00:26:31 ANNOUNCER: Because this surgery is anastomosis, the surgical connection between two structures such as blood vessels is difficult to see. Here is an example from a previous surgery. 00:28:02 CHARLES DRUMMOND, MD:...the coronary artery from bleeding. If there s any residual blood in the field, I m going to try to blow it away with this small blower. 00:28:48 ROBERT S. POSTON, MD: Okay. Forwards? 00:29:03 ROBERT S. POSTON, MD: All right. So right now you re seeing the left anterior descending. And you might see a little piece of string coming out of that. I don t know if you can really see it. So don t turn on it. That is the that is a shunt that s in there. You know, we don t have great access to the heart right now, right? I mean, that s the whole point of this. And so, if the heart was to get into trouble while I m occluding that vessel, then sorry no talking there. If the heart was to get into trouble, then we could have a difficult time addressing that, so we like to prevent that by putting a shunt in. And that s what that is. So, okay, now the other thing we re doing here is suturing the you can see the mammaries up here and the LAD is down here. Just like we showed you before. The heart s beating. And what allows me to suture it even though it s beating is this medical device made by Medtronic called octopus. There s other devices, other companies that are pretty similar, but it really did, you know, make this all possible. Any EKG changes at all? Sorry, Gary. Yes. There was a what we call triple vessel disease, and that is always a surgical almost always somebody that comes to surgery. Now, stenting has become more aggressive for the treatment of those patients because of the improved results with the coded stents. But the gold standard in terms of what the literature research literature supports is the use of

7 surgery. This is a combination of the two using stenting for the lesser important vessels, the anything other than this vessel I m sewing right here is not quite as important in terms of the patient s survival. But you know, my view is that the LAD, this vessel right here, should always be treated with a mammary, if ever possible. That stenting should only be done for people that you cannot put an LAD graft on a lima graft onto that. And so that s what we do as part of this procedure is we kind of acknowledge the superiority of LAD. Okay, we re going to have to cut this. 00:32:16 CHARLES DRUMMOND, MD: Okay. Scissors to me, please. 00:32:18 ROBERT S. POSTON, MD: Let me actually, here s the way I do it. Let me have a forwards. All right. Let s see. Where does this thing stop here? 00:32:35 CHARLES DRUMMOND, MD: It s kind of tight on that metal. 00:33:16 ROBERT S. POSTON, MD: Could you pull that one tight? You re wrapped around something? 00:33:42 CHARLES DRUMMOND, MD: Something, yeah. 00:33:46 ROBERT S. POSTON, MD: Yeah, the next thing is to is to do the is to take this yellow clamp off of the mammary and that will allow blood to flow back into the coronary artery. And then take this shunt out this thing I m grabbing right now. And then we ll have taken care of that distribution of the heart. And then once that s done, you know, essentially the patient has 60% of the heart taken care of. Like I was saying before, that s how important the mammary, or the LAD, is. Even though it s only one of three vessels on the heart, it supplies 60% of the heart muscle. And so, so that then allows the stenting to be done with much more protection, particularly when you re stenting the left main coronary artery. That is something that can be high-risk unless it s done under the protection of an LAD graft like we re doing here. So then, you know, we ll proceed with the stenting and normally we would be grafting all these other vessels, but if we did that it would require us to really get a complete job with this guy, who has multiple blockages, would probably have done a sternal incision. And so, the question is, is it worth it to do a sternal incision or to have a vein or a radial artery graft placed onto your heart? Or would you rather just have stents, which, you know, there s plenty of people that feel that stent might be better than a radial artery or a vein graft. So it means this can be done without a sternal incision, and it s worth it s worth giving it a shot. So we re about 10 minutes out. Have we called the cardiologist, you guys? Tell him to come on. It d be nice to have him setting up right now. The thing about doing these as a hybrid is that you get to know right away, you know, if this is a good suture job. Normally you just kind of suture it on here and that s it. You learn if the patient does okay if you did a good job suturing, but here we get to know right away, which is, I think, an important part of doing things in an unconventional fashion, at least for your first couple of hundred, it s nice to know that everything s working out okay, which so far knock on wood it has been. 00:37:19 DAVID ZIMRIN, MD: Okay, I m Dr. David Zimrin. And Dr. Poston has completed the surgical portion of this procedure, and what we re planning now to do is to put a stent into the midright coronary artery where that 80% stenosis is present. There s some disease extending proximal to it, which we will probably cover with the stent. Working with me is Dr. Habtab Faseha, who is one of our fourth year interventional fellows. And that s the team. So what I m doing now is I have a.025-inch guidewire which I ve put through the lumen of the stent balloon. The stent is loaded over the balloon, and the wire Dr. Faseha s going to Dr. Faseha s going to pull the wire back into the catheter. And then what we re going to do is through this device, called a twoey borse connector [sp?], we re going to load this balloon

8 with a stent on it to the end of our guiding catheter, which before you guys got here I put into the right coronary ostium via the right femoral artery, where I have a 7-French sheath inserted. So using what we have up there as a guiding catheter if you can put that up as a guide for me we have a guide picture that ll show up on our screen, which we could probably do without but we will use it. And what you re going to see on our live screen is our guiding catheter sitting in the right coronary ostium. And Dr. Faseha s going to give me a little bit of dye in there. We ve already given the patient Heparin. And we have adequate anticoagulation documented with an activated clotting time. And our wire thus far we ll dye there was going into a branch and now is going down the main channel of the artery, so what we ll do is very gently try and get that all the way down to the distal vessel. 00:40:20 Sometimes the wire doesn t want to go where you want it to go, so what we ll do is look at another view and find out why. In fact, where the wire is is probably adequate, but we d rather do better. We ll dye again. Good puff of dye. All right. So now we got the wire where we want it to go. And we ll go back to our other view. So once we ve got the wire little puff of dye there, let s make sure. Yeah, but I think we re fine. We have a choice of which vessel we want to be in there. I think at this point it doesn t matter. Both of them come out far beyond the lesion. And what I m going to do is hold the wire in place and now I m advancing our stent balloon over the wire into the coronary and down to about where we want it to be. Let me get a good puff of dye, a nice hard one. And we ll get a nice injection of dye. Looks like we can come back a little bit, you think? And then we ll take a picture of this just to make sure we want we re where we want to be. 00:41:42 All right, so there s our live picture. And we ve got the do you see the two dark dots? One is just past our target lesion and the other extends back to the beginning of the disease segment. And I think we can probably pull back just a little bit more. We ll probably cover this just the way we want to. Little puff of dye there. Nice hard one. One more time. All right. I think we got it. So, what we do next is we have this little inflation device. And the first thing we re going to do is, just in case, we re going to suck whatever air we can out of the balloon so that just in case the balloon happens to rupture, which it probably won t, dye rather than air goes down the patient s coronary. It s a very unlikely event. In addition, if we have dye mixed with saline in the balloon, like we do now, we can then see the balloon when it inflates and know that we re in the right place which I think we are. I got it. So what we re going to do is this little device here tells us the pressure. And we re going to inflate the balloon, which you can see there inflating on the screen. And I ve got this on this pressure device up to 14 atmospheres, which is a reasonable pressure. Sometimes go higher, sometimes don t go this high. It s usually around this level. We ll film that just so we have a record of it. And you can see on that picture as it replays itself that the balloon with the stent on top of it is pretty well fully inflated and looks about the same size as the target vessel. So we could do this for anywhere from 15 seconds to 20 minutes if we want to, but generally we go 30 seconds or a minute or something along those lines with the stents. And then we ll put negative pressure on it. That s down at So that s 14 atmospheres on that inflation. 00:44:21 Well, I m going to make it one-to-one. And then we have some nitroglycerin in this little blue syringe that we can I got it I got it. Okay. And we re ready to get some nitro and we re ready to get some nitro. So I m going to take off this device here because it s in our way. And we re going to get this wire straightened out so it s not in our way. And what we ll do next is we re going to pull the stent balloon back into the guiding catheter. You see those two little dots: there s a balloon between them. And our wire is still in place across the lesion. The stent is now deployed across the stenosis. And we ll give a little puff of nitroglycerin. That s 200 nitro. And we see we have good flow in the vessel. And then we ll give the vessel a couple of seconds to do its thing and respond the way it wants to, and

9 what we ll decide next is whether we need to post-dilate the stent. Sometimes the stents, as in this patient, it appears, fully inflate and become well-opposed to the vessel and open up the stenosis as well. Sometimes they don t. And if they don t, we then have to use a high-pressure balloon within the stent to open it up to its full size. We may get lucky here, and if we do, we ll be done. If we don t, we ll do some more work. All right, want to take a picture? All right, well, that stenosis is gone. And the question is, is the stent big enough? Clearly, it s big enough on the distal end of it. Question is, do we need to open up the stent a little more to match it up proximally? And it might be a good idea, what do you think? Go with a 275 balloon? Or even a 3-0 up there. We don t have a 3-0 balloon, do we? We have a 2 a 3-0 balloon? How about a 3-0 less than 24, 16 or something? 00:47:03 All right. What we re going to do next is the proximal end of that vessel is significantly bigger than the distal end. Let s straighten this out and see if you can get that out of the way. And then what we re going to do is we could be done now, but I think we ll get a better result long-term if I can get the twoey we can get a better result long-term if we optimize our stent deployment. So what I m doing now is leaving the wire right where it was let s fluoro for a second. Okay, good. You can come on. And we re going to try and keep the wire right where it is. Taking this stent deployment balloon out. Got it? And then we re going to do the same series of maneuvers with our post-dilation balloon. As you can see, that vessel itself tapers. It s a little larger where it starts and then get a little smaller down distally within the vessel. And what we re going to do is try and open up the proximal end to match it better to the size or match the stent better to the size of the vessel itself. So what we have here is a 3-mm noncompliant balloon that we re going to try and put in over the wire. Yeah. I ll show it to you when we re going to load it on the ballon. Let s switch it. I want to get this. Let s not drop anything on the floor. Want to pull the wire through? Want to pull the wire through? It was already out. There. Okay. Okay, well there s you the balloon is between these two dots, very small, very hard to see because it s almost the same size as the shaft while it s deflated. So what Dr. Faseha s going to do is hold the wire. And what I m going to do is fluoro for a second, make sure it s where we thought, which it is, and I m going to advance the balloon over the wire and he s going to hold the wire right where it belongs, and if we re lucky, the wire won t move. And this will slide right inside the stent. Put that on there. 00:49:56 What I ll do on this particular balloon is to suck all the air out of it in advance. We often don t do that with our stents because we re afraid that it s possible that the stent can be dislodged from the balloon if you do too much aggressive de-airing of the balloon, so we generally don t do that much of it. But this doesn t have a stent on it. And the smaller this balloon is, the easier it should be to cross, which it sort of didn t want to for a second, but now it did. Okay. Let you get the puffer there. And what you see now, if you look on the live picture, is those two dots have a balloon between them. Let me get my guide in a little bit. All right. More puff of dye there. More puff of dye. I want to see where it is. Because we re just yeah, that s probably perfect. Okay. So we ve got that postdilation balloon. Now with it s proximal end forward at about the proximal end of the stent and its distal end so one more puff of dye its distal end within the stent. And there you go one more puff of dye. And that way the stent hopefully will reverse taper, or taper as it goes distally just as the vessel appears to taper as it goes distally. We re up. And I ll record that for posterity there. You can see that balloon looks a little bigger than the last one because it is a little bigger. The distal dot, the distal marker, is actually within the stent. That s 14 for 30, we re down. Fourteen. And then I often give a little nitroglycerin at the end, just for good luck. I got it. And I ll see about taking this balloon back into the guiding catheter and leaving the wire in place. And then we ll give a little bit of nitro. It s 200 of nitro. 00:52:41

10 And we re going to get ready and take our picture. Hopefully this will be the last one. Ready? All right. Now it looks like the vessel tapers down the stent tapers down as the vessel tapers down. Appears to be well-opposed based on the presumed size of the vessel. And we ll take another view of this. Yep. I think that looks like we ve got it. Looks like the vessel and the stent both taper. The stent s a little bigger than the vessel, which is sort of what you d want. Just slightly larger. And I think we got it. So what we ll do now is disconnect, or disengage. We will disconnect and we ll take a picture of Dr. Poston s work just to make sure that his graft looks good. Okay. How s that? Little puff of dye there, please? All right. Nice. Little puff of dye there, please? Ready? Okay. Beautiful result on the internal mammary to the LAD. And in general, that should do it. 00:55:30 ANNOUNCER: This has been a robot-assisted heart bypass combined with cardiac catheterization from the University of Maryland Heart Center in Baltimore, Maryland. To obtain more information, to make an appointment, or make a referral, please click the appropriate buttons on your screen. 00:55:52 [end of program]