I have continued my quest to advance the field of minimally invasive valve surgery by performing more complex procedures through mini-thoracotomy incisions. As you have probably seen in a previous blog, I have been performing AVR with supracoronary replacement of the ascending aorta and hemi-arch via a mini-thoracotomy incision. My first 12 cases were performed via a 6cm 3-3rd ICS incision which starts 1cm lateral to the sternum. My last 4 cases have been through a 6cm, 4th ICS incision which starts lateral to the anterior axillary line.The right arm needs to be positioned over the head.

soft tissue retractor and rib retractor

distal anastomsis and AVR completed

de-airing of graft

 It is similar to my double valve incision. If you have read my blog posts in the past, I was originally performing my double valves through a 3-4th ICS incision above the right nipple.

This approach allows visualization of the entire aorta. The only slight pitfall is that it is further away and one needs to feel comfortable with the long shafted instruments and use of a knot setter.  The aortic valve is easy to see since the aorta is completely transected. I will place a double row of sutures in the graft, both proximally and distally. You do want to make sure that there is no bleeding. To tackle a bleeder is not easy! Most of the distal suture lines (14/16) have been done on circulatory arrest. I use a 24 Fr. venous cannula which gets placed into the SVC via the chest tube incision (utility port).

I will keep exploring this option with this pathology and keep you posted.

incision, AVR/Asc Ao/arch