Step-by-Step Implantation of Edwards Intuity Aortic Valve in Mini-Sternotomy with Neck Lines

This video demonstrates a minimally invasive aortic valve replacement, using neck lines and an Edwards Intuity bioprosethesis. The patient was a 77-year-old female in sinus rhythm. She was classified as functional class III and was limited in ordinary physical activity.

Intraoperative echocardiographic analysis confirmed the presence of a severe aortic stenosis, associated with moderate to severe aortic regurgitation with normal LVEF. The surgical approach used was an upper J-sternotomy with a complete percutaneous vein cannulation. Postoperative echocardiographic control confirmed the normal function of the Intuity with no PVL and a mean gradient of 8 mm Hg.

Steps

1. The anesthesiologist introduced a ProPledge for retrograde warm blood cardioplegia infusion and an EndoVent in the pulmonary artery under echocardiographic vision. At the same time, the surgeon cannulated the femoral vein percutaneously and 5,000 units of Heparin were administered.

2. A small incision (6-8 cm) was made in the mid-portion of the sternum, and a J-shaped ministernotomy in the 4th intercostal space was performed. The patient was then placed on the heart-lung machine.

3. Direct aortic cross-clamping was performed. Aortotomy was done in the hockey stick way. At the same time, the retrograde cardioplegia was infused via the ProPlege catheter. Myocardial protection was completed in an anterograde way. Normal debridement of the annulus was performed.

4. The annulus was carefully sized. It is advisable to use different sizes to confirm the choice of the correct valve.

5. Three stiches were positioned at the nadir of the three resected cusps. The operating surgeons checked the correct distance of the stiches with a sizer.

6. Retrograde cardioplegia was repeated during the preparation of the valve, and the 19 mm Intuity valve was parachuted. The operating surgeons checked the correct position of the valve before inflating the balloon. A quick inspection of the inflow frame was done in order to confirm that it was completely under the native annulus. Before removing the clamp, it is advisable to place the wire in the right ventricle and the drainage tube.