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.

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 have enclosed a You Tube link for a short video on a Minimally Invasive TVRepair.

This is a very simplified approach to either an isolated TVR or concomitant with a MVR.

I do not use a right IJ cannula for SVC drainage.  A long 25 Fr BioMedicus femoral venous cannula is inserted for venous drainage. Once the mini-thoracotomy incision is performed,  2 sump drains are placed through the chest tube incision.  Both cava’s are snared.  The assistant pulls on both snares and the femoral venous cannula is pulled into the IVC.  The right atrium is opened (remember there is a 6 minute safe period inflow occlusion), then the sump suction which was placed via the chest tube incision is placed through the atriotomy into the SVC. The SVC snare is temporarily released during this maneuver. Once the TVRepair is completed, the atriotomy is closed in a 2 layer fashion. Prior to complete closure, the sump drain is removed and the atriotomy completely closed. Both snares are released and the femoral venous cannula is advanced back into the SVC.

http://youtu.be/xBylyGGn3lI

I constantly hear that obese patients are not candidates for Minimally Invasive Surgery.  I truly believe that these are the ones that benefit the most. They ambulate sooner  due to improved chest wall stability. Physical therapy as well as pulmonary toilet is facilitated. In addition, the risk of sternal complications does not exist. I also have heard that the CT scan is essential in determining who is a candidate for a minimally invasive AVR. This is NOT true. I have enclosed a CT scan on a patient that I recently operated upon.( I do not order CT scans, but since she was being evaluated for a TAVR, it was performed).  As you can clearly see, her aorta on the the left side of the chest. Some would say that this is a contraindication. Some even draw a line from the mid portion of the sternum and trace it back to the spine. If the aorta is to the left, then this is an exclusion criteria for a mini AVR. This is absolutely WRONG!!!  In my experience, if the heart is further away from the chest wall, the visualization will be better. I have operated on many very obese patients, and the surgery has been easier than in some very slender patients. 

This is an 83 y/o very obese ,wheelchair bound, O2 dependent female with multiple hematologic problems (which excluded her from being Corevalve candidate) as well as pulmonary issues and an IVC filter which was crossed with the 25 Fr. Biomedicus venous cannula. (FYI, I have been able to cross all but one of 12 Vena cava filters!) who have critical AS.