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.

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.

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.

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.

http://www.medscape.org/viewarticle/760718?t=1

I came across this interview that Dr. Michael Moront and I participated in during an STS meeting 2 years ago in Ft. Lauderdale.

Despite being 2 years old, the concepts still hold true.

Check it out !!!