Miami Minimally Invasive Valves
Joseph Lamelas, MD
Dedicated to the Advancement of Minimally Invasive Cardiac Surgery

Posts tagged as cannulation

There are many ways to repair a mitral valve and I have always liked the “tool box” concept.  In other words, I think that you have to be prepared to use different techniques, for similar pathologies, in different patients.  I think that you cannot resort to only one technique to repair all valves. Not all valves are created equally.

I have been using the loop technique now for all anterior leaflet repairs and occasionally for posterior leaflet repairs. I know that everyone has there own concepts and tricks on using loops. I think that for the anterior leaflet the loops should be in front of the papillary muscles and for the posterior leaflet the loops should be behind them.  The trick here is that the loops need to be positioned between the chords when they are being attached to the posterior leaflet. I think that this concept is more anatomical from a chordal standpoint. The mitral collar provides unimpeded visualization of the entire infra-valvular apparatus. Furthermore, a mini-thoracotomy approach provides direct in-line, truly anatomical visualization of the mitral valve.

I would be interested in what others think.

1. The first picture shows the loops to the anterior leaflet positioned to the anterior aspect of the papillary muscle. The posterior loops are behind the papillary muscle and are tied anterior to the papillary muscle. The tied knot to the posterior loops is visualized anteriorly.

2. The second picture shows the posterior loops behind the papillary muscle and positioned between the individual chords. In other words, all the loops are not brought around the entire set of chords.

In some minimally invasive cases where the ascending aorta is replaced at the level of the STJ and the AV is sparred (not a David procedure, a supra-coronary replacement), I find it valuable to use 2 separate grafts. One segment of graft is initially anastomosed to the hemi -arch or the distal ascending aorta and the other segment of graft to the STJ.  These are then beveled and sewn together.  This 2 graft technique is especially helpful if the proximal anastomosis ( STJ) is far away.

 The technique that I have used to suture this proximal anastomosis entails inverting the proximal graft into the root and suturing it with a running suture. Once complete the small segment of graft is pulled from the root and there is a very hemostatic closure. The pictures below demonstrate the technique.


In my quest to facilitate and simplify minimally invasive, right mini-thoracotomy aortic valve surgery over the past 11 years, I have tried many different techniques and devices.

I believe that the aortic cuff  (Miami Instruments, Miami, FL) significantly facilitates and improves the exposure necessary to perform an expeditious and safe operation.

I am constantly asked how is it that I insert the aortic cuff. Due to this, I have decided to make a short You tube video. This is the current and most effective way to insert the cuff.

Of note, patients that have a heavily calcified aortic root may not be good candidates for insertion of the cuff. The cuff needs a semi compliant aorta in order for it to expand inside the root.

There may also be difficulty with insertion of the cuff in patients with a bicuspid aortic valve.  In these patients, with fusion of the left and right cusps, I will place the cuff through the commissural stay suture between the left and right cusp. (Normally it will be placed through the suture between that left and non-coronary cusps). This is not always perfect but does help. If the cuff slips in these cases, I will remove it.

There are also a small group of patients who can have the procedure performed without a cuff because visibility is adequate.

Insertion of Aortic Cuff  (you can click this link or copy and paste the link below)



I have performed a total of 35 minimally invasive MVRepairs with an anterior leaflet augmentation for multiple different pathologies including rheumatic disease. severe MAC, radiation valvulopathy, and severe SAM with IHHS.

33 have been with bovine pericardium, 1 with untreated autologous pericardium and 1 with CardioCel.  I have not used CorMatrix because of the multiple reports claiming that on the left side of the heart, there can be a disruption of the patch.  I cannot personally attest to this since I have only used it once on a tricuspid valve reconstruction.

The last of the 35 cases that I performed an anterior leaflet augmentation was with CardioCel.  I found it very comfortable to work with.  It is very flexible and soft and it is easy to pass a 5-0 needle through it. A  saline test of the valve can be performed with this material as opposed to bovine pericardium which is very stiff and competency of the repair can only be assessed once the heart is beating.

I think this will be my go to patch for now and would like to eventually compare its results with the bovine pericardial cases. Of note, I have been told that all of the bovine pericardial patches will eventually calcify but I have not seen that yet since my follow up is not long enough.

I have enclosed pictures.  All of my cases have been performed via a right lateral mini thoracotomy. I truly believe that the visualization is superior to a sternotomy in addition to the fact that a more extensive and complete myectomy can be performed via the mitral valve.



When performing a minimally invasive AVR or MVR via a right mini-thoracotomy approach, assessing whether you are in the right interspace is sometimes questionable.  Even after performing thousands of cases, I question this at times. I have come to the conclusion that there is one landmark that I need to see in order to confirm that I have entered the correct interspace.  That structure is the Right Superior Pulmonary Vein.

During a mini AVR, after instituting CPB and opening the pericardium, if I see the RSPV directly in line with interspace that I entered, I know that I should be able to perform the operation, even if the aorta is displaced. It is key to then take your time and place as many pericardial stay sutures as needed to develop the exposure. This is crucial to optimizing the exposure. (TOP picture)

During a mini MVR, after instituting CPB and opeing the pericardium, if I see the RSPV directly in line with the interspace that I entered, or one interspace above the site that I entered, I know that I am in the correct interspace. I don’t what to be in line with the IVC. This will be very low and if this were the case, I would move to the next higher interspace. Again, use the pericardial stay sutures to optimize exposure. (BOTTOM picture)

Mini AVR

Mini AVR

Mini MVR

Mini MVR