I have performed many mini AVR/MVR’s using different incisions to enter the chest. I now feel that the right mini thoracotomy in the 4-5th interspace, with the patients arm positioned over the head is optimal. The exposure of the MV is similar to a mini MVR. Any complex MVRepair can be performed via this approach. On the other hand, visibility of the AV is facilitated if the ascending aorta is circumferentially transected. This will allow one to see the entire valve and annulus. I recommend a 2 layer closure of the aorta . This will limit the potential of bleeding from the suture line that may be difficult to access later. If the aorta is opened with a transverse aortotomy, visibility of the non-coronary annulus is limited. In these cases, I usually extend my aortotomy deeper into the non-coronary sinus. This will require either placing an aortotomy closing suture prior to implanting the valve, or even utilizing a pericardial patch to close the aorta.
I have enclosed pictures.
Joe, that’s fantastic. I must admit I’m a bit too chicken to completely transect the aorta. Can you comment on how you close the aorta? Do you place a few sutures then tie in order to maintain tension on the suture line? I have also found that placing the clamp through the mitral incision compresses the aorta in an A P plane which seems to make the aortic suture line more difficult to close as opposed to the clamp from the mini aortic incision compressing the aorta from side to side. Thanks again for taking the time to allow us all to learn from you.
Regards,
Neelan