Operative Steps

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The patient is anesthetized in the supine position and intubated with a single lumen endotracheal tube. Defibrillator patches are placed on the patient's back and anterior left chest wall. A transesophageal echo Doppler probe is placed to assess the pathology of the mitral valve disease and assist in removing air from the heart at the completion of the procedure. An 8-10 centimeter incision is made beginning half-way between the sternal notch and the Angle of Louie. The incision is carried down to the sternum using cautery. The sternum is opened from the sternal notch to the fourth interspace and extended into that interspace on the right.

For mitral valve procedures the superior vena cava is cannulated with a 20 Fr cannula and the inferior vena cava cannulated with a similar venous cannula. The ascending aorta is cannulated at the pericardial reflection. The small sizes of these cannulae prevent them from being an obstacle to the surgical procedure. The mitral valve, tricupsid valve and intraatrial septum are approached through the right atrium. The incision in the right atrium is indicated by the dotted line.

After the aorta is clamped and cardiac arrest achieved with cardioplegia, the right atrium is opened. The fossa ovales is incised and the left heart decompressed. A purse string suture is placed around the coronary sinus and a retrograde cardioplegia catheter placed. The incision in the right atrium is extended through the fossa ovales and onto the dome of the left atrium between the superior vena cava and the aorta.

Three pledgetted mattress sutures are placed in the intraatrial septum and placed on the traction. This retracts the intraatrial spetum and enhances visualization of the mitral valve.

Hand-held retractors placed on the septum improve exposure but cannot be pulled anteriorly because of the intact sternum.

To facilitate exposure of the mitral valve, a Harrington retractor is placed in the left atrium and traction placed laterally towards the surgeon. This helps deliver the mitral valve into the direct view of the surgeon.

With hand-held retractors placed in the superior and inferior portion of the left atrium and the Harrington retractor exerting lateral traction, exposure of the valve is excellent in all but those patients with marked increased anterior posterior dimension of their chest.

After completion of the repair of the valve mechanism, an annuloplasty is performed. Horizontal mattress sutures of multifilament 2-0 are placed beginning at the fibrous trigone and proceeding around the posterior annulus of the opposite fibrous trigone. Sutures are then passed through the Cosgrove-Edwards Annuloplasy band at regular intervals.

The handle is released and the annuloplasty band slid into position.

Sutures are tied and the stent is removed, leaving the annuloplasty band in place.

The incision in the left atrium is closed using continuous 4-0 Prolene. Prior to closure of the incision of the interatrial septum, air is removed from the left atrium by inflating the lungs and the sutures tied. De-airing of the left ventricle is facilitated by gentle suction through the cardioplegia cannula in the ascending aorta prior to and after removal of the aortic clamp.

The incision in the right atrium is closed. After normal cardiac function has returned, the cannulae are removed. Four pacemaker wires are placed and two chest tubes are placed in the right chest.

A right angle tube is positioned over the top of the diaphragm and a straight tube placed into the pericardial sac. The wound is closed in layers with monofilament stainless steel sutures for the sternum and continuous layers of absorbable sutures for the subcutaneous tissue and skin.

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Preference Card

Cosgrove Flex Clamp
(V. Mueller, Allegiance Healthcare Corporation, 1435 Lake Cook Road Dearfield, IL 60015)

This clamp is flexible and can be easily moved out of the way.

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Tips and Pitfalls

• This approach represents a progression thoughts based on different incisions used. Having used a parasternal and transverse sternotomy incision, this seems to be the most useful with the best healing.

• Small flexible cannulae should be used to minimize obstruction of the operative field.

• If the venous cannulae are attached to the cardiotomy suction set at (-80mmHg) smaller cannulae can be used with better venous drainage and prevention of an airlock in case of air aspiration.

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References

1. Chitwood Jr WR, Elbery JR, Chapman WHH et al, Video-assisted minimally invasive mitral valve surgery: The "Micro-Mitral" operation. J Thorac Cardiovasc Surg 1997;113:413-4.
   
2. Benetti FJ, Rizzard JL, Pire L and Polanco A, Mitral Replacement under video assistance through a minithoracotomy. Ann Thorac Surg 1997;63:1150-2.
   
3. Carpentier A, Loulmet D, Carpentier A et al, First open heart operation (Mitral valvuloplasy) under videosurgery through a minithoracotomy. C.R. Academie of Sciences, Paris 1996;319-219-23.
   
4. Chitwood Jr WR, Elberry JR, Chapman WHH et al. Video-assisted Minimally invasive mitral valve surgery. The "Micro-Mitral" operation J. Thorac Cardiovasc Surg 1997;113:413-4.
   
5. Cosgrove DM and Sabik JF, Minimally invasive approach for aortic valve operations. Ann Thorac Surg 1996;62:596-7.
   
6. Cosgrove DM, Sabik JF and Navia J. Minimally invasive valve surgery. Ann Thorac Surg 1997 [in press].
   
7. Gundry SR, Shattuck OH, Rassouk AJ, del Rio MJ, et al. Cardiac operations in adults and children via ministernotomy facile minimally invasive aortic, valve replacement. Ann Thorac 1997 [in press].
   
8. Lin PJ, Chang CH, Chu JJ, Liu HP, et al, Video-assisted mitral valve operations. Ann Thorac Surg 1996;61:1781-7.
   
9. Minale C, Reifschneider HJ, Schmitz E and Uckmann FP, Single access for minimally aortic valve replacement. Ann Thorac Surg 1997;64:120-3.
   
10. Navia JL and Cosgrove DM, Minimally invasive mitral valve operations. Ann Thorac Surg 1996;62:1542-4.
    
11. Schwartz DS, Ribakove GH, Grossi EA, Stevens JH, et al, Minimally invasive cardiopulmonary bypass with cardioplegic arrest: A closed chest technique with equivalent myocardial protection. J Thorac Cardiovasc Surg 1996;111:556-66.

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