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Miami Minimally Invasive Valves
Joseph Lamelas, MD
Dedicated to the Advancement of Minimally Invasive Cardiac Surgery
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Posts tagged as double valve surgery

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.

 

DSCN9182DSCN9185DSCN9189DSCN9198DSCN9199DSCN9207

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.DSCN9025DSCN9029DSCN9038DSCN9036

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

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 have enclosed a link to a 14 minute video on an anterior leaflet augmentation performed via a minimally invasive approach.  I have used bovine pericardium in all but one case in which I used autologous, untreated pericardium.  I believe that this technique should be performed with bovine pericardium or glutaraldehyde treated pericardium.  There is a new product on the market called CardioCel which may also be promising. A recent paper presented at ISMICS in Boston by Dr. Guy demonstrated that there was a high incidence of patch complications utilizing Corematrix.

 

 

http://youtu.be/vrPhKUWAjz8