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8 Valve Sparing Aortic Root Replacement
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Fig. 8.8 Once the internal suture line is completed, the coronary ostia
are positioned and attached to the Valsalva graft using 5/0 prolene running sutures
47
used to make a 7–8mm hole into the graft. A 5/0 prolene is
used to construct the circular anastomosis. The right coronary anastomosis is next constructed usually as anterior as
possible just below the sinotubular ridge of the graft. It is
constructed in the same manner as the left (Fig.8.8).
After completion of the distal aortic suture line, delivery
of cardioplegia into the aortic root can be used to test the
coronary buttons for haemostasis and the aortic root complex
can be assessed for function with the LV vent off. This is also
an excellent opportunity to test the haemostatic qualities of
the internal suture line. If there is any leak either from the
suture lines or the valve, we recommend attending this now.
This may require taking down the distal aortic suture line and
repairing the leak from within. It is also imperative to not
distort the distal end of the graft when performing the distal
aortic suture line, as this may inadvertently damage valve
geometry and integrity (Fig.8.9).
De-airing site is created with a DLP vent, and usual de-
airing manoeuvres are used prior to release of the crossclamp. Assessment of coronary perfusion is made along with
LV lling and dilation with the vent transiently switched off.
Next the vent is switched on, and the heart is reperfused for
10-min for every hour of cross-clamp. Standard removal of
vent, weaning from cardiopulmonary bypass, decannulation,
haemostasis, and repair are carried out. Transoesophageal
Fig. 8.9 Aortic root aneurysm pre- and post-repair following valve sparing aortic root replacement
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R. Q. Attia and R. J. de Silva
echocardiographic assessment of the valve is of paramount
importance. If there is any more than mild AR on weaning
off bypass, then the patient is placed back on bypass, heart is
arrested, and a conversion to a valve replacement within the
graft is performed. If there is problematic bleeding, then a
Bentall operation is carried out. Bleeding is less of a problem
with reimplantation compared to remodelling.
Post-Operative Care
Patients are enrolled in life long echocardiographic surveillance usually at 6-weeks post operatively and then annually.
Patients typically remain on lifelong beta blockers and aspirin. If on surveillance the patient is found to have increasing
valve degeneration, the patient might require valve replacement (although this is very rare in our series and other published outcomes from similar high-volume centres) [2–4].
Conclusions
VSARR has robust outcomes in selected patients who would
benet from preservation of the native root. It is best performed by surgeons within centres where there are high volume of aortovascular practice allowing the surgical team to
develop expertise in the operation and surgeons who are procient in already performing Bentall operations. The successful outcome depends on certain critical operative steps
such as graft sizing, assessment of valve leaet geometry,
apposition, and function. The aim being to provide a durable
result exceeding an articial prosthesis.
References
1. Cameron D, Vricella L. Valve-sparing aortic root replacement with the Valsalva graft, operative techniques. Thorac
Cardiovasc Surg. 2005;10:259–71. https://doi.org/10.1053/j.
optechstcvs.2005.11.001.
2. Price J, Magruder JT, Young A, Grimm JC, Patel ND, Alejo D,
Dietz HC, Vricella LA, Cameron DE.Long-term outcomes of aortic root operations for Marfan syndrome: a comparison of Bentall
versus aortic valve-sparing procedures. J Thorac Cardiovasc Surg.
2016;151:330–8. https://doi.org/10.1016/j.jtcvs.2015.10.068.
3. Cameron DE, Alejo DE, Patel ND, Nwakanma LU, Weiss ES, Vricella
LA, Dietz HC, Spevak PJ, Williams JA, Bethea BT, Fitton TP, Gott
VL.Aortic root replacement in 372 Marfan patients: evolution of
operative repair over 30 years. Ann Thorac Surg. 2009;87:1344–50.
https://doi.org/10.1016/j.athoracsur.2009.01.073.
4. Beckmann E, Martens A, Krüger H, Korte W, Kaufeld T, Stettinger
A, Haverich A, Shrestha ML.Aortic valve-sparing root replacement
with Tirone E. David’s reimplantation technique: single-Centre
25-year experience. Eur J Cardio-Thorac. 2021;60:642–8. https://
doi.org/10.1093/ejcts/ezab136.
Minimally Invasive Aortic Valve
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Replacement
RizwanQ.Attia andShakilFarid
9
Interest in minimally invasive aortic valve replacement
(MIAVR) has increased after the adoption of transcatheter
techniques to treat aortic stenosis and availability of sutureless valves [1]. Numerous minimally invasive surgical
approaches for aortic valve replacement have been proposed
including upper or lower hemisternotomy, right parasternal
minithoracotomy, and transverse sternotomy [2]. Many
reports including prospective randomised studies and metaanalyses have demonstrated advantages of these incisions,
which include reduced pain, reduced surgical trauma, less
bleeding, earlier functional recovery, reduced incidence of
chest and sternal wound infections, lower incidence of
arrhythmias, shorter hospital stay, improved cosmetics, and
reduced costs [3].
Surgical Technique: Mini Upper J Sternotomy
The patients were anaesthetised in the supine position and
intubated with a single-lumen endotracheal tube. Debrillator
pads were placed over the chest wall and back. A transvenous
pacing system was inserted at some centres via the internal
jugular vein, this is not our standard practice. Transoesophageal
echocardiography is used routinely to allow assessment of
aortic valve anatomy, annular sizing, de- airing, and assessment of post-operative valve and cardiac function.
Incision
After skin preparation and draping, a 4–6cm skin incision
usually an upper J hemisternotomy through the third or
fourth intercostal space is performed (Fig. 9.1). This is
guided by the planning aortic CT to allow cannulation of the
R. Q. Attia · S. Farid (*)
Department of Cardiothoracic Surgery and Transplantation, Royal
Papworth Hospital, Cambridge, UK
e-mail: shakil.farid@nhs.net
right atrial appendage for venous cannulation. A standard
hall saw is used from sternal notch down to the third or fourth
interspace. Then a small, bladed oscillating saw is used to J
into the right intercostal space. Standard haemostasis is
performed.
Dissection
It is important to have meticulous haemostasis from all soft
tissue sites, as the small operative eld is unforgiving even
for small amounts of blood from soft tissue sites. A small
Finochietto retractor is placed, and the sternum is opened.
The thymus is divided up to the brachiocephalic vein, and the
two lobes are dissected in the midline avascular plane. The
pericardium is opened, and the patient is heparinised at this
stage. A pericardial well is created with three 1/0 silk sutures
on either side through the skin. After the sutures are placed,
the sternal retractor is removed and then the sutures are tied.
This allows a deep well to be created. On placing the retractor and spreading, it again brings the ascending aorta into
view (Fig.9.2).
Cardiopulmonary Bypass
The aorta is cannulated with a standard aortic cannula
according to the patient’s body surface area ow requirements. A at 2-stage venous cannula is placed in the right
atrial appendage. Alternatively, a 29/37 FR Trim ex dual
stage venous cannula can be inserted through the superior
vena cava. A dual lumen DLP cannula is placed in the aortic
root for antegrade delivery of cardioplegia and venting the
aortic root (Fig. 9.3). Cardiopulmonary bypass (CPB) is
established with cooling to 32 °C. The ascending aorta is
cross-clamped and antegrade cold blood cardioplegia is
delivered into the aortic root to arrest the heart. Cardioplegia
is delivered every 20-min using direct coronary ostia
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
F. C. Wells (ed.), Atlas of Cardiac Surgery, Springer Surgery Atlas Series, https://doi.org/10.1007/978-3-031-43195-1_9
49
50
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R. Q. Attia and S. Farid
Fig. 9.1 (a) Full sternotomy; (b) mini T sternotomy; (c) mini J sternotomy; (d) right anterior thoracotomy
cannulae. CO2 is ooded into the operative eld via a small
delivery line to minimise the changes of air embolization.
Rapid deployment valves can facilitate the procedure and
are used as per manufacturers implantation criteria [4].
Typically, a transverse aortotomy has to be performed higher
(approximately 3 cm above the sinotubular junction) for a
Procedure
Perceval sutureless aortic valve as it has a higher height pro-
le. Otherwise, the conduct of the operation is the same. For
Once the heart is arrested, the ascending aorta is opened
using a hockey stick aortotomy and the aortic valve excised,
sized, and implanted as per standard aortic valve replace-
Edwards intuity valve, there is no need to perform a higher
aortotomy as the prole is similar to a Perimount Magna
Ease bioprosthesis.
ment technique. Cardioplegia is repeated at regular intervals
by delivering direct ostial cardioplegia. The conduct of the
operation is now the same as for conventional valve replace-
Venting
ment. In most cases, interrupted pledgeted (or non- pledgeted)
horizontal mattress 2/0 Ethilon sutures are used to implant
the valve in an intra-annular or supra-annular position.
A eld sucker is used through the aortic valve to vent the left
ventricle. Alternative venting strategies included inserting a
cardioplegia
9 Minimally Invasive Aortic Valve Replacement
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Fig. 9.2 Access to ascending aorta and right atrial appendage for surgical access for CPB cannulation and valve replacement
51
sump sucker through the main pulmonary artery or by
inserting a cannula through the right superior pulmonary
vein.
After the valve replacement, the aorta is closed with two 4/0
Teon pledgeted prolene sutures. A bipolar ventricular pacing
wire and a 24Fr chest drains (drains with perforations such as
Blake drain) are placed with the cross-clamp on as the right
ventricle is decompressed. In our practice, it is technically
much easier to place the drain and pacing wires at this stage.
Alternatively, a transvenous pacing wire can be placed during
placement of the anaesthetic lines prior to the procedure.
De-Airing
De-airing is extremely important as the heart cannot be
mechanically decompressed by the surgeon’s hand. We
placed the patient in deep Trendelenburg position, inate the
lungs to expel blood from the pulmonary veins into the left
atrium and ventricle so that all air is expelled via the aortic
root vent which is placed on high suction. De-airing is guided
Fig. 9.3 Upper
hemisternotomy with central
cannulation for
cardiopulmonary bypass
Aortic cross-clamp
Dual staged
right atrial cannula
Arterial cannula
Antegrade
cannula
Retractor
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R. Q. Attia and S. Farid
by TOE. Once through de-airing is complete, the crossclamp is released, and the patient is paced using ventricular
wires as required.
Discontinuation ofCardiopulmonary Bypass
The patient is weaned off CPB after a period of reperfusion
commensurate with the cross-clamp times (10-min for every
hour of cross-clamp) and ensuring the normal physiological
parameters are restored (TRAVEL: Temperature/Rate (pac-
ing check)/Arterial blood gas/Ventilation/Echocardiogram/
Levelling the table). Standard removal of vent, weaning from
cardiopulmonary bypass, decannulation, haemostasis, and
repair are carried out. Transoesophageal echocardiographic
assessment of the valve is of paramount importance.
Closure
The sternum is closed with four standard interrupted steel
wires. A single steel wire is placed obliquely from the lower
end of the sternotomy to the lower end of the intact sternum
to ‘lock-in’ the J sternotomy. Standard soft tissue closure
with 2/0 vicryl and 3/0 monocryl is undertaken in layers.
Post-Operative Care
To achieve the desired benets of MIAVR, the post-operative
philosophy has to be different to conventional surgery. By
better preserving integrity of the chest wall, MIAVR is often
associated with a faster recovery. To allow early extubation,
anaesthesiologists recognise the importance of moderating
the dosages of narcotics, sedatives, and muscle relaxants.
Either complete or near complete rewarming of the patient is
achieved while in the operating room. The limited incision
and chest spreading ameliorate the post-operative pain. The
use of parenteral narcotics is limited to the rst 48h. In the
event of signicant bleeding or tamponade, re-exploration
should be accomplished through the hemisternotomy. A sternal saw and wire cutters are always available in the event of
emergency re-sternotomy. In general, chest drains are
removed according to the local protocol. The patient is
mobilised prior to drain removal as this helps promote complete drainage from the pericardial cavity. Temporary pacing
wires are removed on day 3. Stable patients are aggressively
diuresed. The aim is to discharge the patient on day 4 postoperatively. This is achieved by anchoring patient expectations preoperatively. The patients are reviewed at 4–6weeks
post-operatively, and sternal precautions can be relaxed
early. The physical restrictions on upper limb range of
motion are eased, and heavy lifting is titrated to pain tolerance by week 4.
References
1. Almeida AS, Ceron RO, Anschau F, de Oliveira JB, Neto TCL, Rode
J, Rey RAW, Lira KB, Delvaux RS, de Souza RORR.Conventional
versus minimally invasive aortic valve replacement surgery: a sys-
tematic review, meta-analysis, and meta-regression. Innovations.
2022;17(1):3–13. https://doi.org/10.1177/15569845211060039.
2. von Segesser LK, Westaby S, Pomar J, Loisance D, Groscurth
P, Turina M. Less invasive aortic valve surgery: rationale and
technique. Eur J Cardio-Thorac. 1999;15:781–5. https://doi.
org/10.1016/s1010- 7940(99)00119- 0.
3. Attia RQ, Hickey GL, Grant SW, Bridgewater B, Roxburgh JC,
Kumar P, Ridley P, Bhabra M, Millner RWJ, Athanasiou T, Casula
R, Chukwuemka A, Pillay T, Young CP.Minimally invasive versus
conventional aortic valve replacement: a propensity-matched study
from the UK National Data. IInnovations. 2016;11:15–23. https://
doi.org/10.1177/155698451601100104.
4. Chien S, Clark C, Maheshwari S, Koutsogiannidis CP, Zamvar V,
Giordano V, Lim K, Pessotto R.Benets of rapid deployment aor-
tic valve replacement with a mini upper sternotomy. J Cardiothorac
Surg. 2020;15(1):226. https://doi.org/10.1186/s13019- 020- 01268- y.
Part III
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Valve Surgery: Mitral Valve Surgery
Surgical Access totheMitral Valve
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FrancisC.Wells andNarainMoorjani
10
Reproducible and safe surgery requires both visibility and
vision. The rst comes through the correct positioning of the
patient on the operating table and the maximal utilisation of
the surgical incision. The second is harder won and comes
with increasing experience and an ever open and questioning
mind. Both require a close involvement by the surgeon
responsible for the case at all times.
There is much contemporary debate about the pros and
cons of minimal access or open surgery to reach the mitral
valve. This chapter does not set out to explore this conundrum but to give clear guidelines on how to reliably expose
the valve through either route.
Positioning ofthePatient ontheOperating
Table
This is the responsibility of the surgeon in charge of the case.
The patient is positioned on the operating table in the supine
position. The head should be a comfortable distance from the
upper end of the operating table to give good clearance
between the anaesthetist’s territory and that of the surgeon.
Clashing hands and elbows through the surgical drapes are
unnecessary but it is surprising how often it is encountered.
If the patient is tall, then it is important to make sure that the
feet are properly supported, so as not to allow for the potential of foot drop through over extension of the common peroneal nerve, as it passes around the lateral head of the bula.
Properly designed silicone gel rests should be placed under
the dorsal aspect of each lower leg to prevent stasis in the
deep soleal plexus of veins.
F. C. Wells (*)
Royal Papworth Hospital, Cambridge University Group of
Hospitals, Cambridge, UK
e-mail: francis.wells@nhs.net
N. Moorjani
Department of Cardiothoracic Surgery, Royal Papworth Hospital,
Cambridge, UK
A similar silicone gel roll is also placed horizontally
beneath the patient’s shoulders to push the upper chest forwards. This brings the thorax into a horizontal plane to the
operating table. In some patients, especially deep chested
men, the diameter of the thorax at the level of the tenth thoracic vertebra is much larger than that at the thoracic inlet.
Without this support, the sternum slopes downwards, sometimes at a steep angle and once inside the thorax, the heart
tends to fall towards the superior mediastinum. If the intercaval distance is short, this will worsen the access to the left
atrium. This simple manoeuvre improves this access.
The patient’s arms are comfortably secured to the patient’s
side. The essential nal check of patient identity and procedure, along with the presence of cross-matched blood and
sterile instruments, as laid out in the WHO guidelines, is
completed. The patient is then ready for full and careful skin
preparation with the chosen antiseptic solution and surgical
draping. The surgical team should be present for all of this
process.
Surgical Incision
For median sternotomy, the skin incision must be central
allowing access to the sternal notch superiorly and the xiphisternum inferiorly. The length can vary from the middle twothirds to the full length of the sternum depending upon the
experience of the surgeon. Before the sternum is divided, the
suprasternal space is developed and a nger is used to free
the upper mediastinal space. Similarly, the sub-xiphisternal
space is developed with a nger and the xiphisternum divided
with heavy scissors. Separation of the sub-sternal tissues for
as far as possible, along with interrupting ventilation and disconnecting the endotracheal tube for a moment, will allow
the lungs to fall away from the anterior mediastinum, thereby
reducing the chance of opening either of the pleural spaces
when using the sternal saw.
The sternal saw should be allowed to pass through the
bone without excessive pressure and following the anterior
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
F. C. Wells (ed.), Atlas of Cardiac Surgery, Springer Surgery Atlas Series, https://doi.org/10.1007/978-3-031-43195-1_10
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F. C. Wells and N. Moorjani
convexity of the sternum. Once divided, the edges of the sternum are sealed with softened bone wax and the periosteal
vessels sealed with diathermy. The sternal retractor can then
be inserted over drapes to ease the pressure on the edge of the
bone.
The fat in the anterior mediastinal space is then separated
in the midline. The thymic remnant, which is mainly fat in
the adult, is separated and any vessels cauterised. Often,
however, there are signicant vessels within it crossing the
midline. These vessels can be clamped on each side, divided
and then the tissue within the clamps can be ligated. This will
ensure haemostasis. The innominate vein is identied and
the thymic vein, which drains into it, identied and clipped,
as it is often of signicant size. It is important to ensure that
the there is no bleeding prior to the institution of cardiopulmonary bypass. During this process, the appropriate dose of
heparin is given in preparation for cannulation of the heart
for the establishment of cardiopulmonary bypass. The pericardium is then opened along a vertical line two-thirds of the
way towards the left side of the visible pericardium. This
allows for the pericardium on the right side to be more easily
slung under the retractor blades, thus elevating the heart in
the pericardial cavity and rotating the left atrium towards the
surgeon, thereby improving access. The visceral pericardial
reection between the pulmonary artery and the aorta is then
divided, separating these vessels to allow easy application of
the aortic cross-clamp.
Two aortic purse-string sutures are then placed concentrically, just at the beginning of the arch of the aorta, using a
braided polyester suture. The cardiopulmonary bypass tubing is then clamped and divided at an appropriate place so as
to allow the tubing to lie comfortably on either side of the
sternotomy. The aortic cannula is inserted into the aorta in
the centre of the purse-string sutures, which are snugged
down to secure the cannula in place. The snugger tubing is
then secured to the cannula with a heavy gauge tie to prevent
any outward migration of the aortic cannula during the procedure. It is then further secured with a heavy-duty suture to
the wound edge, so as to secure the aortic pipe in a gentle
curve.
Next the venae cavae are cannulated. One purse-string
suture is placed around the right atrial appendage and a second just above the inferior cavo-atrial junction. Venous cannulae are chosen depending upon the surface area of the
patient. For superior caval cannulation, a gently curved vascular clamp is applied across the base of the atrial appendage. The rst assistant then steadies this, and the tip of the
atrial appendage is amputated. As the clamp is removed, the
venous pipe is slid into the atrium. The retaining suture is
gently pulled downwards towards the feet of the patient. This
allows easy passage of the venous pipe up into the superior
vena cava. Its tip should rest close to the conuence of the
innominate vein and the superior vena cava. The snugger is
then secured and tied to the pipe with a heavy gauge tie. For
inferior caval cannulation, the atrial wall is incised in the
centre of the purse-string suture with a pointed blade and
then gently dilated with the tip of a Robert’s clamp to allow
easy passage of the cannula into the atrium. A nger is placed
over the hole until the pipe is ready to be inserted. Once the
cannula is within the atrium, the rst assistant gently retracts
the purse-string suture towards the head of the patient and
the tube will then pass easily into the inferior cava, as the
cranial tension causes the caval valve to atten against the
atrial wall. It is essential that if resistance is encountered, as
a result of the venous valve, that undue force is not used, as
that can result in a tear to the posterolateral wall of the inferior cavoatrial junction. Once again, the venous pipe is
secured to the snugger with a heavy tie (Fig.10.1).
Cardiopulmonary bypass can then be commenced once
the pipes are connected to the circuit. A left ventricular vent
can then be inserted, via the right superior pulmonary vein or
left ventricular apex. The apical approach keeps the operative eld free of blood on the ventricular side. A purse-string
is then placed in the ascending aorta for the insertion of the
cardioplegia line, which again is secured in place using a
strong tie. Retrograde cardioplegia is sometimes also used
by placement of a purse-string suture on the lateral wall of
the right atrium above the inferior vena caval suture. Systemic
cooling is then commenced, usually at a systemic temperature of 32°C.
The aortic cross-clamp is then applied with reduced pump
ow to minimise the potential for trauma to the aorta. One
litre of antegrade cold blood cardioplegia is then administered.
Fig. 10.1 Operative image illustrating the setup for cardiopulmonary
bypass prior to performing mitral valve surgery
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The heart is bathed in cold saline at 4°C.Using this technique, the heart will arrest rapidly and the ventricle cannot
distend, as there is a left ventricular vent in place. Once the
heart has been arrested, the superior and inferior vena cavae
are mobilised and tapes are passed around each of the cavae.
It is done at this stage, as it is very easily done in the arrested
heart with no risk of damage to the pulmonary artery superiorly or the back of the inferior vena cava inferiorly.
Exposure oftheMitral Valve
Standard Left Atriotomy
The standard left atriotomy approach requires mobilisation
of Sondergaard’s interatrial groove to reach the intra-atrial
septum (Fig.10.2).
Following snaring of the cavae, the caval snares are ele-
vated under some tension bringing the heart a little further
RA
SVC
4-6 cm
RSPV
IVC
Incision
anteriorly in the pericardial space. This also places a little
tension on Sondergaard’s interatrial groove at the superior
margin of the right superior pulmonary vein. This makes it
easier to nd the correct place to begin the separation of the
right and left atria. All of these small manoeuvres give
improved access to the interior of the left atrium (Fig.10.3).
Sondergaard’s interatrial groove is then mobilised to
reach the level of the fossa ovalis and an incision is made in
the left atrium. The incision is extended cranially beneath the
superior vena cava just onto the roof of the left atrium and
caudally beneath the right atrium, taking care not to circumcise the inferior pulmonary vein (Fig.10.4). Care should also
be taken not to open the right atrium, which can overhang the
left atrium as it approaches the inferior vena caval origin.
A further pump sucker is then placed into the left atrium
and secured in place with two polypropylene sutures passed
through the opened free edge of the left atrium and the parietal pericardium, taking great care not to injure the phrenic
nerve by placing them quite high on the pericardium. Selfretaining retractor blades can then be inserted into the left
atrium to give a very good view of the mitral valve (Fig.10.5).
In addition, placement of annuloplasty sutures prior to
any mitral valve repair brings the leaets closer to the operating surgeon. Through these simple manoeuvres, a satisfactory operative view of almost all mitral valves will be
obtained (Fig.10.6).
The left atriotomy is usually closed with a single layer
continuous 3/0 polypropylene suture, started at either end of
the incision and tied in the middle.
In some patients, access to the mitral valve through a standard left atriotomy may be limited, such as in a patient with
dense adhesions following previous mitral valve surgery or
in patients with a small left atrium. In these patients, alternative approaches need to be considered to access the mitral
valve, including a vertical trans-septal bi-atrial incision,
superior left atrial roof incision, or horizontal trans-septal biatrial incision. For some surgeons, these approaches may be
the preferred access to the mitral valve.
SVC
Fig. 10.2 Standard left atriotomy approach to the mitral valve with an
incision made via Sondergaard’s interatrial groove to reach the intraatrial septum (top); the incision is then extended cranially beneath the
superior vena cava just onto the roof of the left atrium and caudally
beneath the right atrium (bottom)
LA
RSPV
RA
IVC
Vertical Trans-Septal Bi-Atrial Approach
An oblique incision is made from the right atrial free wall
through the right atrial appendage and down to the left atrial
roof (Fig. 10.7a). This is joined by a second incision through
the fossa ovalis, medial to the crista terminalis, from the
Eustachian valve to the edge of the superior limbus
(Fig.10.7b). Although this incision affords excellent exposure to the mitral and tricuspid valves (Fig.10.7c), it may
require considerable time to close the incision. In addition,
the sino-atrial nodal artery is at risk during this incision.
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