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.

After acquiring a significant amount of experience with redo sternotomy surgery and redo minimally invasive MV surgery, I decided to embark on redo minimally invasive Aortic Valve surgery. I have performed more than 50 of these cases.  Most have been in patients with a patent LIMA +/- patent SVG’s (one was a 3rd time redo with 2 previous CABG’s).  I was always hesitant to operate on patients who had bilateral IMA’s. Well the time came, and I did my first patient with a LIMA to the LAD and a RIMA to the RCA.  The RIMA was never clearly visible , although there was a fibrotic band which I assumed was the RIMA.  So therefore, these patients are candidates for a mini-thoracotomy AVR.

Then came the case which you can see in the enclosed pictures. This patient has a RIMA via the transverse sinus to the first OM.  My concern was whether I could clearly visualize the aorta and then clamp the aorta with the RIMA coursing behind it.   Since it is difficult to see the RIMA, I have enclosed duplicate pictures with one highlighting the RIMA in blue.  In general it is very common to encounter the least amount of adhesions over the greater curvature of the aorta in any redo operation, so therefore I believe that this allows this procedure to be performed via a mini-thoracotomy approach.

When performing a redo mini AVR with a patent LIMA (+/- RIMA), I usually cool the patients to 28C and give continuous cold blood cardioplegia.  I never attempt to identify nor clamp the IMA’s.  I truly believe that the redo mini AVR’s are the most challenging for the surgeon,  but are the subgroup that truly recover quicker.  These are cases that require experience.

I have performed 18 combined Mini AVR + Ascending Aorta/Hemi Arch Replacements.  I have utilized 2 approaches. One via the 2-3rd ICS with the incision starting at the sternum and extending laterally and the other through the 4th ICS with the incision starting lateral to the anterior axillary line and the patients arm positioned over the head. This later approach gives more visualization of the entire operative field.  Keep in mind that the compromise is that the aorta and AV are further away and one needs to feel comfortable with using the long shafted instruments and suturing at a distance. I have recently adopted the same technique for suturing a proximal or distal coronary anastomosis to suturing the hemashield graft to the hemiarch. I have my assistant hold the graft across from me and I begin suturing the graft to the  to the lesser curvature of the aortic arch, then run each arm of the suture towards me. It seems to be easier.  I also use a double row of sutures. The proximal suture line starts at posterior aspect of the sinotubular junction. I tie the suture down and then run each limb around. I will also use a second suture for reinforcement. This one is sutured on the inside and run along the suture line from the inside. I will stop at every 2cm along the way and tie the 2 limbs, which I believe will keep the sutures from becoming loose.

I have enclosed some pictures so that you can be the judge of the exposure. Each are in sequence from the incision to the proximal graft anastomosis. Notice on picture #2 the 24 Fr. venous cannula placed into the SVC (via the CT incision) which will be utilized for retrograde cerebral perfusion during the period of circulatory arrest.

All 18 patients have done well. Average LOS has been 5 days. Stay tuned for my publication with the results!

This is a very nice approach for a single bypass to the OM.  It is optimal if there is an old SVG placed to the vessel that needs to by grafted. The patient is placed in an almost lateral thoracotomy position with the left groin exposed. I usually place a line in the left femoral vein in the event that I need to insert a venous cannula. Arterial access can be obtained directly in the descending aorta if need be. The incision is made in the lateral aspect of the chest and usually at the level of the lower aspect of the scapula. I use a soft tissue retractor as well. The descending aorta is exposed after the inferior pulmonary ligament is completely dissected free.  The pericardium is opened below the phrenic nerve and retracted. The old SVG is followed until visualizing the OM. Of note, access to a high OM is not optimal via this approach. An off pump suction stabilizer is utilized to isolate the coronary. After this anastomosis is performed, a Satinsky clamp is placed on the descending aorta for the proximal anastomosis. The segment of vein is usually small and you need to let it loop down a little so that when the lung inflates, it does not place excessive tension on the graft. I also place a marker around the proximal in the event that the patient needs to be cathed, it can be easily identified. Usual LOS is 3 days in hospital.

pericardium opened and descending aorta dissected