 Right. Good. Can you see it? Yeah, it looks great, Elmari. Okay, fantastic. So I'm going to give you a very practical, a little bit of a shorter talk on some practical things that we've learned with anesthesia for minimally invasive cardiac surgery. My objectives for this talk are to describe specific pre-operative assessment considerations for minimally invasive cardiac surgery. I will be focusing on mixed cabbage. Is that something that we don't see as commonly around the world? And I think there's very specific considerations there. I'm also going to demonstrate a little bit about the integration of hemodynamics and DEE findings. So as you can imagine, with all of these different approaches that we have for minimally invasive cardiac surgery, there's also different approaches to the chest. So we do anterolateral thoracotomy for a martyl valve repair, which are chest valve repair, as well as for an ASD. For aortic valve repair and replacement, we do a right anterior thoracotomy, or we may do a minister notomy. If we do a mixed cabbage, depending on whether we're doing left-sided or right-sided, we either do a left anterior thoracotomy or a right-sided for a right coronary. And then you can even do external sparing procedure such as a mixed albat, where you do two incisions, one sparseternal and one over the apex. Taking this into consideration, it is very important that we choose our patients very carefully. You have to ask yourself whether you're going to require lung isolation. For us, we do most of our procedures with double lumen intubations, except for our mitral valves. As Piro stated, we do them with a single lumen tube. Double lumen tube is probably a better choice than a bronchial blocker, but in some patients it is often difficult to place the tube. If you absolutely need isolation, the risk with the bronchial blocker is that it may dislodge and dislodge the surgical feel, especially with a mixed cabbage. Then you have to think whether you're going to go on pump or off pump. And depending on that, how you're going to cannulate the patient, which brings me to the right internal jugular or SVC cannulation. So both Piro's very nicely showed us how to do the cannulation for the IVC. And Max also spoke about this in the potential complications. I'm going to take you through the practical approach on how to do the SVC cannulation. So we do this for every patient that we need access to the right atrium. So for tricuspid valve repairs and replacements, for ASDs as well as a patient that weighs more than 90 kilograms where you need more venous drainage. So the first thing we do is we assess the size of the internal jugular vein. If the vein is more than one centimeter, we put all of our lines on the right side. If it's a smaller vein, then we put our central line on the left and then the SVC cannula on the right. We always put the SVC cannula on the right as the risk of SVC perforation is very high if you go from the left hand side. So we do it with ultrasound guidance and then we place the three wires. So we move the wire in and out to identify the three different wires, guard wires that we placed. What we've also found useful is that if you place X-plane over this, you can actually identify the three different points. It's very important that you can see all of your wires. Once we've established this, we give the patient 5,000 units of hip ring. We put the guard wire for the SVC cannula, the most distally or closest to the clavicle, and that for the eye, the CVC closest to the head, so more cranially. Next, we then place the cordus and once the cordus is in place, we start placing this SVC cannula. We find it useful to have a second hand scrapped in to assist with this at the moment still. I think it's also because it's a bit of a learning curve. So you use multiple dilators to get to the adequate size. As you can see here, the guard, it's been dilated and while this is being performed, we have somebody watching the echo the entire time to make sure that we do not dislodge the guard wire and inadvertently cause vascular damage. Every time the dilator is placed, we ensure that the guard wire is still loose and not kinked. And as you can see, it's a rather big cannula that you need to place. So finally, now we'll place the SVC cannula and do this, we attach a three-way tap. So on the three-way tap, we have 100 cc's of saline with some hip ring, 1000 units of hip ring in it as well. So now we're going to remove the introducer and as we remove the introducer, the venous return from this line is very large. So we have a clamp ready. You see the blood already coming back. We now de-air the line and then prepare to flash towards the patient. At our institute, we place the SVC cannula as well as the bypass lines outside of the sterile surgical field. So next, we flash towards the patient. Here's the moment of celebration. And then you can see flashing towards the patient. And now what you want to see is just a little bit slow. You want to see these bubbles, sorry, want to see these bubbles entering into your bicable view. So what you're now left with are these lines as follows. So if you have more than one, how we decide on the size of the cannula is, if you've got a more than one centimeter IJ, we place an 18 French cannula less than one centimeter, we place a 16 French cannula. Unfortunately, vascular complications do occur in these cases. In this study, they showed 148 patients. 6% of them had venous complications and only 1% arterial. The venous complications were from the femoral mostly and they were the biggest one was retroperitoneal hematoma. You can also cause pseudoanalysms. The arterial complications though they are rare can be very devastating. We watch these patients very closely as cannulation is performed. Max just showed us a patient that that during cannulation from the femoral developed a dissection. We've also seen this with placing of the peach cannula. Unfortunately, we can also see a dissection and we had to convert to open procedure rapidly in this patient. So in anesthesia, I think that if you really want to have a tangle with your surgeon at the cardiac bed, it's by doing a mixed off pump cabbage. We do this procedure specifically for patients that want to get back to their life very quickly and need external stability. It's also very useful in older patients that require walkers or have crutches that they use and it's very useful in amputees. In patients that do heavy lifting that wants external stability, it also helps them. It however is extremely important that you choose these patients correctly as these procedures are performed the entire case off pump on one lung ventilation. If you could pick your ideal patient and especially if your unit is starting out with this, this is very important. You should pick a male that should have a lower BMI, a small cardiac thoracic ratio because it makes it easier for the surgeon to place the grafts and have good coronary targets. It's important that they have good peripheral vasculature because if you need to go on to pump emergently, you have to be able to cannulate the groin. From an anesthesia perspective, we do lung function tests on all of them. They must have an FEV1 of more than 60% and on ABG at room air at least a PAO2 of 70. All of them also get a period of test one lung ventilation in the OR before we commit to doing this on one lung ventilation via thoracotomy. We also want these patients to have a more than 40% ejection fraction. As with the manipulation of the heart, they can become huvydynamically very unstable. The smaller the diameter, the easier for the surgeon. Then we assess the mitral valve, the tricuspid valve, and the aortic valve for regurgitation. Anything more than mild excludes the patient from doing this procedure. As the heart is being manipulated, that degree of regurgitation will increase and you then have the risk of developing pulmonary edema or liver congestion. We completely exclude patients that have occluded left subtlavian artery. The reason for this is we do a lima analita graft and obviously if you don't have good flow, you cannot perform it. Patients in cardiogenic shock are not appropriate for this procedure as they would not tolerate it and also the lungs are often quite wet and makes the ventilation very difficult. Severe obesity becomes an issue not only for exposure but also because you are on a single lung ventilation. Then relative contraindications are for the surgeon if there's a intramascular vessel which makes it difficult for them to perform the surgery or whether vessels are small. If you have a patient that previously had rip fractures, we ask our very esteemed colleagues that do cardiac CTs to have a look if they can see any fibrosis. If there's a lot of fibrosis visible then these patients we prefer not to try and do them minimally invasive as the exposure is very difficult. We choose our patients based on their coronary anatomy. So a patient that has the ideal patients or patients that have one or two vessel disease with a normal RCA. As you can see in these pictures we've got left-sided disease but a normal RCA. You can also do three vessel disease where the patient have left main disease but have a non-dominant right coronary. And then if you have a patient that has left-sided and right-sided disease you can do a hybrid approach. So what we will do is we'll bring the patient to the operating room and do a med cap so a single vessel to the LAD and possibly to the circumflex and then three to five days after the procedure we booked him for a PCI of the right coronary. It is very important if we do this that these patients are kept in our unit post-operatively in order to ensure that they do not develop a sudden blockage of the or sudden ischemia of the right side. We also for these patients if it's a right dominant region place a pacemaker wire which we do not routinely do in our mixed cabbage cases. As the risk with the right is that they might develop a block and become very symptomatically radicotic. So specific considerations are we place W-lumen tubes in all of these cases. We confirm it with fiber optic. What we found useful is that we actually prefer the video above the fiber optic purely due to footprint size. I don't think the operating rooms were designed specifically to have to have all of these equipment that are associated with mixed cabbages. We also do lung protective ventilation for all of them with a tidal volume of four moles per kilogram. I optimize the PEEP by doing a gradual PEEP recruitment strategy and then for if the patient has saturation we try and keep the saturation above 92%. So if the patient becomes hypoxic we do CPAP we try and give them oxygen through a feeding catheter into the non-dependent lung. Very little though because we do not want to disturb the surgical field. We find that CPAP is often difficult to do to the non-dependent lung as it disrupts the surgical field and makes it very difficult for the surgeon to operate on. The next big issue is that normally for off pump surgery we like to keep the patient's full in order to keep him hemodynamically stable. So we have to unfortunately with these cases keep them very fluid restricted for two reasons. One is that the surgeon needs to operate on a very relaxed heart. So we restrict the volume to two moles per kilogram per hour we also use a cell saver and then we need the patients to have a very slow heart rate. Seeing as the exposure is so small if they are tachycardic it makes it extremely difficult for the surgeon to operate. You can imagine that if you have a patient that is hypovolemic and you require a heart rate this can become quite challenging. So different anaesthetists have different strategies short acting opiates are sometimes often your friend in this case. We also find that morphine works quite well. None of these patients are placed on inotropic support during the surgery until they're fully revascularized. We continuously use RTE as a monitoring device assessing the TR the MR and also for right ventricular artery tract obstruction. So you have to understand the steps of the surgery. So the RETA harvest gets performed then the first the RETA then the RETA and then the grafts are done. The most challenging steps for us as anaesthetists are when they perform the firstly the RETA harvest. As you can see here the surgeon is going from the left hand side to your on single lung ventilation on the right and then he uses a sponge to compress the right lung in order to have access to the RETA. This is quite difficult because you are on one lung ventilation with the ischemic heart and you're not basically ventilating the patient on a quarter of the lung. Most of the time this at the start of the surgery and it's actually reasonably well tolerated. So then the next part of the surgery that that becomes an issue is if we do the RETA to the PDA anastomersis. Because the surgeon needs to completely move the heart out of the surgical field, they bend the heart. So we use the T to monitor this. As you can see here the patient initially had only trace TR then with positioning developed this severe TR. We do not tolerate anything more than moderate as the risk for liver congestion as well as pulmonary edema is extremely high in these cases then. So we then reposition the heart and as you can see reduce this to a more acceptable degree that was moderate for the rest of the anastomersis. The next challenge with these cases are post-operative pain and this is for all minimally invasive cases. Regional techniques are very useful and it would depend which technique you use based on what type of surgery is being done. At our center our surgeon routinely places because routinely places an intercostal catheter that we thread towards the pervert triple space. We've also done ESP blocks that work quite well but you have to place a catheter. The issue is that the first six six hours they are okay but after that the pain is quite severe for the first three days. We've also used to rate this anterior blocks as rescue techniques. This is just to show you when we do the ESP block that you have access we normally try and perform this prior to the surgery as it's more easily to access the patient and then try and place the catheter in this specific space. So if you have to go through this you have to ask yourself if this is really worth the effort and so this study was performed at Leipzig by Dr. Tavir Vala and shows really good outcome. So they had 209 patients that they performed this on. Most of them were left under descending and circumflexed territory lesions. There are two vessel cabbages three vessel cabbages most of the time. As you can see none of these patients needed to go on pump which for for off we all know that off pump surgery is often quite risky to convert to an on pump procedure but in the 209 cases none of them required this and that's also been our experience with the cases we've done at Toronto General. You can see that in hospital mortality was zero the stroke risk which is phenomenal was also zero and this is most likely because it's a no-touch procedure today or then your risk for myocardial infarction was quite low and very nicely there was no chest wound infection. So in the patients that are at risk for developing chest wound infection and sternal wound infection this technique may be preferential. So in conclusion I think the most important thing with minimally invasive cardiac surgery is that it depends very heavily on teamwork. You have to understand the surgical steps. It's easier with a mitral valve where we can see what the surgeon is doing with the with the mixed cabbages you cannot see because there's no telescope. You have to have very clear communication with your surgeon at all times and very thorough attention to detail. Mixed cabbages are feasible and can be safely and effectively performed with durable long-term outcome in a very select patient population and patient selection as I've stated previously is crucial. Anaortic or no-touch mixed cabbages with bilateral internal thoracic arteries have the potential to eliminate the risk of period operative stroke and a low risk for wound infection.