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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 valve replacement surgery

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)

 

 

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

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.

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!
rib.001