I have posted my approach to mini double valves in the past.  As I gain more experience, I continue to explore alternative approaches in order to further facilitate these operations.

I now believe that the best mini double valve approach is the following:

1. Mark out the entire sternum and delineate the mid portion of the sternum prior to prepping. Your incision will be lateral to the anterior axillary line starting at this point and extending it 6 cm superiorly and in a curvilinear fashion (semi-circular).

2. Place the right arm over the head on a brace. Have the axilla exposed as well in the event that the axillary artery, in the axilla, needs to be cannulated (see previous posts on my blog relevant to this technique).

3.  A retrograde cardioplegia cannula is placed in the right atrial appendage and exited through the incision.

4.  I place my pericardial sutures as I normally do in a mini MVR, although, I add one more over the left aspect of the pericardium near the PA in order to improve exposure of the aorta.

5.  After going on bypass, I will clamp the aorta through the incision (clamp exists the incision) and deliver a dose of antegrade CP. I have been using Del Nido CP lately.  Has anyone been using this routinely?  I am curious to know others experience.  I will share mine on a future blog.  I have used it for almost 2 months now.

6. I then open the LA and expose the MV with an atrial lift retractor and Visor.  There is no doubt in my mind that by placing the arm over the head the exposure to the MV is excellent.

7. On the other hand,  exposure of the AV is more challenging with this approach.  I have recently changed my aortotomy in these cases.  Previously, I extended the aortotomy deep into the non-coronary sinus since it was extremely difficult to see this portion of the annulus to resect the leaflet and place sutures. This usually required placing a suture  in the lateral aspect of the aortotomy (non-coronary sinus) prior to seating the valve in order facilitate closure of the aortomy. In some cases, I have even had to begin the closure with a pericardial patch.

8. I have recently began to perform a complete circumferential aortotomy. This significantly improves exposure of the AV and facilitates the AVR.

I have enclosed pictures.