Mini-Bentall Procedure and Hemiarch Replacement: Coronary Button Reimplantation

In this video, the sixth in a seven-part series, Tristan Yan completes the “French Cuff” annular anastomosis, and demonstrates the coronary button reimplantation technique via a mini-sternotomy incision.

1. The second “French Cuff” layer is performed using a 4-0 running polypropylene suture, starting from the commissure between the left and right annulus and going clockwise, circumferentially. It is important to ensure that this layer of running suture incorporates the remnant of aortic wall and the everted “French Cuff” edge. This double layer annular anastomosis technique greatly improves the hemostasis.
2. The left coronary artery button is rested in its anatomical position. The appropriate site on the Valsalva graft (Vascutek Ltd, Renfrewshire, Scotland) for left coronary button reimplantation is determined with the heart fully loaded, so that there is no tension or rotation of the left coronary button anastomosis. Once the position of the anastomosis is marked, the heart is off-loaded.
3. A Bovie electrocautery (Bovie Medical Corporation, Clearwater, FL, USA) is used to create a circular hole for receiving the left coronary button.
4. The coronary button is trimmed, left with a 3 mm circumferential cuff, and re-implanted using a 5-0 running polypropylene suture.
5. The cuff of the coronary button needs to be attached snuggly to the outside of the Valsalva graft.
6. In a similar fashion, the right coronary button is prepared and reimplanted. It is imperative to ensure that a full thickness bite is achieved with each stitch.
7. The aortic root is pressurized and the anastomoses are tested by delivering a full dose of antegrade cold-blood cardioplegia.

View all videos in this series here.