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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 ostium primum atrial septal defect

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.

 

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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.

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 gone away from using a diaphragm suture to facilitate exposure on my mini MVR’s.  I not only think that it has the potential to add complexity to the procedure, but can also be dangerous.  This suture can cause liver injury, sub-capsular hematoma of the liver, as well as bleeding from the abundant vascular network on the tendinous portion of the diaphragm.

I utilize 3 pericardial sutures on the inferior aspect of the pericardium.  I initiate my pericardiotomy approximately 2-3 cm above the phrenic nerve (BTW, I think that all of those surgeons out there that are skeptics or antagonists, overplay the incidence of phrenic nerve injury causing diaphragmatic palsy – I REALLY DON’T SEE IT, IN MORE THAN 250 MINI- MITRAL VALVE OPERATIONS THAT I PERFORM YEARLY!). I extend the pericardiotomy inferiorly towards the diaphragm. Once I am 4-5 cm from the diaphragm, I now continue the pericardiotomy towards the left of the patient. I will place one retraction suture at this angle, and one on either side of this as well.  If I need additional retraction, I will place more pericardial sutures on the pericardium over the diaphragm. These sutures are then pulled through my utility port (chest tube incision) and retracted with the aid of a hemostat.

I have enclosed pictures of my new approach to make this clear.

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