I have gone away from using a diaphragm suture to facilitate exposure on my mini MVR’s.  I not only think that it has the potential to add complexity to the procedure, but can also be dangerous.  This suture can cause liver injury, sub-capsular hematoma of the liver, as well as bleeding from the abundant vascular network on the tendinous portion of the diaphragm.

I utilize 3 pericardial sutures on the inferior aspect of the pericardium.  I initiate my pericardiotomy approximately 2-3 cm above the phrenic nerve (BTW, I think that all of those surgeons out there that are skeptics or antagonists, overplay the incidence of phrenic nerve injury causing diaphragmatic palsy – I REALLY DON’T SEE IT, IN MORE THAN 250 MINI- MITRAL VALVE OPERATIONS THAT I PERFORM YEARLY!). I extend the pericardiotomy inferiorly towards the diaphragm. Once I am 4-5 cm from the diaphragm, I now continue the pericardiotomy towards the left of the patient. I will place one retraction suture at this angle, and one on either side of this as well.  If I need additional retraction, I will place more pericardial sutures on the pericardium over the diaphragm. These sutures are then pulled through my utility port (chest tube incision) and retracted with the aid of a hemostat.

I have enclosed pictures of my new approach to make this clear.