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Miami Minimally Invasive Valves
Joseph Lamelas, MD
Dedicated to the Advancement of Minimally Invasive Cardiac Surgery
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Posts tagged as ASD

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

As I have mentioned in a previous blog, I have been getting more comfortable with using Del Nido Cardioplegia.

I have enclosed the components that we utilize.

We use a 4:1, blood: cardioplegia ratio

I believe that it has been described using a 1:4 ratio.

I usually deliver a 2 liter induction dose and then I give an additional 500cc , 45-55 minutes later.

I would recommend not giving an additional dose within 20 minutes of unclamping because I have noticed that the heart is a bit more stunned and takes longer to resume electrical activity.

1 liter of Plasmalyte or Isolyte or Normasol

Mannitol 20% 16 mL
Magnesium 2 g 4 mL
KCL 35 mEq
Sodium Bicarbonate 13 mL
Lidocaine 2% 6.5 mL

I usually end up using approximately 2 liters of this cardioplegia because I also utilize this solution to irrigate the aortic root and LV after debriding the calcium or for testing my mitral valve repair.

I know that we are all busy in our daily work and family lives , but please take the time to answer a few questions.
Everyone who has subscribed to the blog has an interest in minimally invasive surgery.
To those that don’t accept it, it is disruptive. To those that embrace it, realize that the future is minimally invasive surgery.

1. How can we disseminate the word to the public?
2. How can we better train surgeons?
3. Why is adoption slow?
4. How can we facilitate the operation? (Different techniques or instruments)
5.  Should these techniques be offered to all surgeons? (Recently graduated or experienced surgeons)

Our patients have benefited and there is a real benefit. Don’t let the skeptics and antagonists cloud our vision of the future. Remember, nothing comes easily, but those who change the current philosophies in cardiac surgery are those who contribute to its advancement.

Please respond directly through the blog or my personal email (jlamelasmd@aol.com)

I value EVERYONE’S response. They will be kept anonymous unless you chose otherwise.

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.

DSCN9755 DSCN9758 DSCN9761 DSCN9764 DSCN9773 DSCN9779 DSCN9808

http://www.medscape.org/viewarticle/760718?t=1

I came across this interview that Dr. Michael Moront and I participated in during an STS meeting 2 years ago in Ft. Lauderdale.

Despite being 2 years old, the concepts still hold true.

Check it out !!!