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.

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

Over the years I have modified my technique for inserting the post for the atrial lift system.  Believe it or not,  patients were complaining about pain from this insertion site more than from the mini thoracotomy incision.

In the past I was making a small incision in the chest where I wanted to insert the post and thereafter passed a tonsil clamp from the incision and into the chest. I would then take a red rubber catheter , place it through the thoracotomy incision and pull it out through the small incision.  I would then use the red rubber catheter to guide the post back into the chest and later attach it to the blade.  I think that maybe the insertion of the clamp was just too traumatic.

Please view this short video to see the new technique that I strongly recommend.  I have provided the link below. (When you view it,  click on settings, which is the little pin wheel on the lower bar, third from the right.  This is the settings button. Click Quality and the select 720 HP. The resolution will be better)

If anyone has any suggestions or a better way, I would appreciate any comments.

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 now been able to successfully repair every ASD via a minimally invasive approach. I utilize the same cannulation strategy as I would for a mini TVR.  I will utilize a femoral platform for the arterial and venous cannulation. After entering the chest via a 5-6 cm incision (4-5th ICS, lateral to the anterior axillary line), I will institute CPB, drop the lungs, then encircle both the IVC and SVC with silastic vessel loops. Since there is an ASD, the aorta needs to be cross-clamped. The operation cannot be performed fibrillating. After arresting the heart, I pull the femoral venous cannula into the IVC and then snare both the SVC and IVC.  I then open the right atrium and insert a sump suction, which has been passed via my chest tube incision, through the atriotomy and into the SVC. I then snare the SVC.  With an Ostium Primum ASD, a pericardial patch needs to be placed over the defect as well as incorporating the  coronary sinus. This means that the CS will now be draining into the left atrium. This is done to avoid injury to the conduction system (AV Node). I place a running suture on the septal edge of the tricuspid valve leaflet which extends over and beyond the CS.  Of note, prior to this, the cleft in the anterior leaflet of the MV is repaired. I believe that it is important to approximate the natural coaptation zone of the cleft leaflet. A direct approximation of the free edges may lead to valvular insufficiency. Overzealous approximation may also lead to mitral stenosis.  Mild MR is better tolerated. Enclosed are pictures of the procedure.