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 made several changes in my overall technique.
I have enclosed a picture demonstrating my new rib re-attachment technique.
I have decided to change this several months ago because I have had approximately 12 patients over the past several years that developed a chronic draining fistula from the stainless steel plate that I was using to re-attach the rib. This was a problem that did not occur often, but when it did, it was a nusiance. In fact, I have had several patients that required multiple interventions to debride the fistulous tract.
In the past, I used stainless steel 3 hole plate and a non-absorbable Fiberwire suture to fix the plate over the transected rib. This did provide stability but…..
Now I use only ABSORBABLE sutures for the rib attachment as well as the pericostal suture.
I start by placing a No. 2 pericostal suture, in a figure of 8 fashion, through the top and bottom ribs ,not around the ribs.
Before tying this, I will then use a 0 vicryl suture.
This is placed forehand through the anterior aspect of the sternum, entering the cortex and exiting the medulla. Then I enter the medulla of the detached rib segment and out through the cortex.(1)
Once this is done, I will tie the large pericostal suture which is initially place around the ribs.
Then I will use the 0 vicryl suture and pass it forehand into the detached rib. After exiting the rib, I will pass it forehand into the top rib (2).
Then I will backhand the same suture and pass it from undersurface of the sternum and out through its anterior table.
At this point I will tie this suture.
Occasionally I will pass it one more time around the bottom and top ribs to provide additional stability.
This really works and I have now done this on over 100 cases without problems!

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.

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.