I have performed 18 combined Mini AVR + Ascending Aorta/Hemi Arch Replacements.  I have utilized 2 approaches. One via the 2-3rd ICS with the incision starting at the sternum and extending laterally and the other through the 4th ICS with the incision starting lateral to the anterior axillary line and the patients arm positioned over the head. This later approach gives more visualization of the entire operative field.  Keep in mind that the compromise is that the aorta and AV are further away and one needs to feel comfortable with using the long shafted instruments and suturing at a distance. I have recently adopted the same technique for suturing a proximal or distal coronary anastomosis to suturing the hemashield graft to the hemiarch. I have my assistant hold the graft across from me and I begin suturing the graft to the  to the lesser curvature of the aortic arch, then run each arm of the suture towards me. It seems to be easier.  I also use a double row of sutures. The proximal suture line starts at posterior aspect of the sinotubular junction. I tie the suture down and then run each limb around. I will also use a second suture for reinforcement. This one is sutured on the inside and run along the suture line from the inside. I will stop at every 2cm along the way and tie the 2 limbs, which I believe will keep the sutures from becoming loose.

I have enclosed some pictures so that you can be the judge of the exposure. Each are in sequence from the incision to the proximal graft anastomosis. Notice on picture #2 the 24 Fr. venous cannula placed into the SVC (via the CT incision) which will be utilized for retrograde cerebral perfusion during the period of circulatory arrest.

All 18 patients have done well. Average LOS has been 5 days. Stay tuned for my publication with the results!