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Miami Minimally Invasive Valves
Joseph Lamelas, MD
Dedicated to the Advancement of Minimally Invasive Cardiac Surgery
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Ascending Aorta

In some minimally invasive cases where the ascending aorta is replaced at the level of the STJ and the AV is sparred (not a David procedure, a supra-coronary replacement), I find it valuable to use 2 separate grafts. One segment of graft is initially anastomosed to the hemi -arch or the distal ascending aorta and the other segment of graft to the STJ.  These are then beveled and sewn together.  This 2 graft technique is especially helpful if the proximal anastomosis ( STJ) is far away.

 The technique that I have used to suture this proximal anastomosis entails inverting the proximal graft into the root and suturing it with a running suture. Once complete the small segment of graft is pulled from the root and there is a very hemostatic closure. The pictures below demonstrate the technique.

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When performing a minimally invasive AVR or MVR via a right mini-thoracotomy approach, assessing whether you are in the right interspace is sometimes questionable.  Even after performing thousands of cases, I question this at times. I have come to the conclusion that there is one landmark that I need to see in order to confirm that I have entered the correct interspace.  That structure is the Right Superior Pulmonary Vein.

During a mini AVR, after instituting CPB and opening the pericardium, if I see the RSPV directly in line with interspace that I entered, I know that I should be able to perform the operation, even if the aorta is displaced. It is key to then take your time and place as many pericardial stay sutures as needed to develop the exposure. This is crucial to optimizing the exposure. (TOP picture)

During a mini MVR, after instituting CPB and opeing the pericardium, if I see the RSPV directly in line with the interspace that I entered, or one interspace above the site that I entered, I know that I am in the correct interspace. I don’t what to be in line with the IVC. This will be very low and if this were the case, I would move to the next higher interspace. Again, use the pericardial stay sutures to optimize exposure. (BOTTOM picture)

Mini AVR

Mini AVR

Mini MVR

Mini MVR

 

Along my journey to constantly try to modify, simplify and improve all of my minimally invasive approaches, here is another one.

Since I very rarely use retrograde Cardioplegia and have gone to a one shot Modified Del Nido solution (4 parts Blood: 1 part Del Nido with 40 mEq of potassium, with a 2 liter induction dose, which allows me for 90-100 minutes of SAFE arrest time), I needed to have a device to retract the right atrial appendage in mini AVR procedures.  I have tried many different devices and maneuvers but placing a number 2 silk inside of an IV tubing and looping it out of one end provides the necessary retraction. The tubing and loop are passed through my chest tube incision or utility port.  My LV vent which is placed into the right superior pulmonary vein is also exited through the utility port. You will also see in the pictures a third tube, which is a long IV tubing (not to be confused with the loop tube) which is used as a guide to help pass all of the above through the utility port and avoid creating multiple false tracts in the chest wall as well as avoid damage to the intercostal vessels.DSCN9025DSCN9029DSCN9038DSCN9036

I have enclosed pictures to demonstrate this.

I have made several changes in my overall technique.
I have enclosed a picture demonstrating my new rib re-attachment technique.
I have decided to change this several months ago because I have had approximately 12 patients over the past several years that developed a chronic draining fistula from the stainless steel plate that I was using to re-attach the rib. This was a problem that did not occur often, but when it did, it was a nusiance. In fact, I have had several patients that required multiple interventions to debride the fistulous tract.
In the past, I used stainless steel 3 hole plate and a non-absorbable Fiberwire suture to fix the plate over the transected rib. This did provide stability but…..
Now I use only ABSORBABLE sutures for the rib attachment as well as the pericostal suture.
I start by placing a No. 2 pericostal suture, in a figure of 8 fashion, through the top and bottom ribs ,not around the ribs.
Before tying this, I will then use a 0 vicryl suture.
This is placed forehand through the anterior aspect of the sternum, entering the cortex and exiting the medulla. Then I enter the medulla of the detached rib segment and out through the cortex.(1)
Once this is done, I will tie the large pericostal suture which is initially place around the ribs.
Then I will use the 0 vicryl suture and pass it forehand into the detached rib. After exiting the rib, I will pass it forehand into the top rib (2).
Then I will backhand the same suture and pass it from undersurface of the sternum and out through its anterior table.
At this point I will tie this suture.
Occasionally I will pass it one more time around the bottom and top ribs to provide additional stability.
This really works and I have now done this on over 100 cases without problems!
rib.001

I have enclosed a link to the Annals of Cardiothoracic Surgery.
I have submitted 4 publications to this journal that I would like for all of you to review.
Two are relevant to Minimally Invasive AVR/MVR, one on Minimally Invasive AVR, and one on Building a Minimally Invasive Valve Program, of which I was a co-author with Dr. Tom Nguyen.
In addition, I think that all of the contributions to this journal are significant and will help advance the subspecialty of minimally invasive valve surgery.
I urge all to subscribe.
There are previous editions of this journal which are excellent and I believe serve as a reference for all Cardiothoracic Surgeons.
www.annalscts.com