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.

Enclosed is a link to a 3 minute and 20 second You tube video that demonstrates a mini thoracotomy replacement of the aortic valve , ascending aorta, and hemi arch with re-implantation of the coronaries with a composite Freestyle stentless mini root and hemashield graft under circulatory arrest with retrograde cerebral perfusion. (BTW, this patient is 85 years old and had an uneventful post operative course).

An extended version of this video was accepted to the ISMICS meeting in Boston.  After being accepted as a video presentation, I was informed that all the slots were taken and it would have to be a poster presentation.  It is difficult to convey the message with a poster, but I inserted representative pictures in the poster and provided a link to my blog (and video) so that anyone interested could view it.

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.

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)

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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.