Along my journey to constantly try to modify, simplify and improve all of my minimally invasive approaches, here is another one.

Since I very rarely use retrograde Cardioplegia and have gone to a one shot Modified Del Nido solution (4 parts Blood: 1 part Del Nido with 40 mEq of potassium, with a 2 liter induction dose, which allows me for 90-100 minutes of SAFE arrest time), I needed to have a device to retract the right atrial appendage in mini AVR procedures.  I have tried many different devices and maneuvers but placing a number 2 silk inside of an IV tubing and looping it out of one end provides the necessary retraction. The tubing and loop are passed through my chest tube incision or utility port.  My LV vent which is placed into the right superior pulmonary vein is also exited through the utility port. You will also see in the pictures a third tube, which is a long IV tubing (not to be confused with the loop tube) which is used as a guide to help pass all of the above through the utility port and avoid creating multiple false tracts in the chest wall as well as avoid damage to the intercostal vessels.

I have enclosed pictures to demonstrate this.

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

I have tried this technique several times. I was skeptical at first but I was made a believer by Dr. Torsten Doesnt.  He told me that all anterior loops should be 24 mm and all posterior loops should be 12 mm,  regardless of the case. I am still a true believer of reconstructing the posterior leaflet with the classical resectional techniques. I just don’t like to leave so much excess leaflet in the ventricle.  I feel like I am leaving too much diseased tissue behind. I have tried different techniques for the anterior leaflet and this last one has made things even easier.

I was using the one loop with multiple small loops originating from it,  but this has made it even easier.  With the 3 loop technique, I sequentially attached the loops further onto the anterior leaflet with a 5-0 gortex suture as one moves laterally.  You can only chose to use only one or two loops and leave the 3rd one behind.

I know it sounds crazy but leaving the loops at 24-25 mm on all cases really works !!!

Watch this You tube video that explains how to do it.

Please give me your thoughts.

www.youtube.com/watch?v=ihg0w_HnKuU

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 have enclosed a link for a comprehensive video on a Minimally Invasive approach to treat both ischemic and non-ischemic mitral regurgitation.These patients usually have poor EF’s. dilated LV with an inter papillary muscle distance greater than 2.5cm.

Femoral cannulation is preferred unless there is significant PVD and therefore axillary cannulation would be performed.  This technique is performed via a 5-6cm right mini-thoracotomy incision.  Aortic cross clamping is performed directly through the incision. I have been using Del Nido cardioplegia on a more frequent basis and delivering repeat doses every 45-55 minutes.

After the heart is arrested and an the atriotomy is performed, I place an atrial lift device and a Visor to provide additional visibility.  Once I have decided to place the papillary muscle SLING, I will use a mitral collar to provide further visibility of the the infra valvular structures. I then utilize a long curved clamp or a specialized curved instrument (developed by Raul Martinez, Nurse in charge of our Cardiac Team) to encircle the papillary muscles. (It is very rare not to be able to encircle the papillary muscles. I have recently encountered one case that had the papillary muscles completed fused to the ventricular wall.)  It is important to use a 4mm Gortex graft and to place the graft around the trabecula to avoid it from slipping and choking the chordae.  Once the graft is completely around the papillary muscles, I utilize a 4-0 proline to approximate the ends of the graft together. The graft needs to be relatively tight. A reference that I use is to place a yankour suction between the approximated papillary muscles.  You should not be able to softly push the suction between the papillary muscles.  If so, it needs to be tightened further.  Once the SLING is in place, I then place the annular sutures.  I never down size the annuloplasty ring in these cases.  I will size the ring to the exact size of the anterior leaflet.

I truly believe that this is a very good solution to a very difficult problem.  Our short and mid term results have been very good.

Stay blogged and I will soon post our data on over 35 cases.

http://youtu.be/wOfEz8d71jg