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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 minimally invasive aortic valve replacement

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.

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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)

 

 

During a minimally invasive AVR case, a single SVG to the RCA can be performed.  The PDA is more difficult to bypass, and unless the anatomy is very favorable, it will not be accessible.  Before considering a bypass to the RCA,  I prefer to stent the RCA, unless it is totally occluded.

Tips:

1.  It is best to perform the distal vein anastomosis before the AVR.

2.  The best retraction method is placing multiple silk sutures on either side of the RCA as well as one retracting the artery cephalad. I have used different suction devices but the space is very limited. Occasionally a sponge stick can help.

3.  The anastomosis needs to start at the toe of the vein.  If one begins at the heel, which is the usual way, the toe will be very difficult to see.

I have enclosed representative pictures.   Don’t let the pictures fool you.    It does take a little practice!

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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

 

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.