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Vinnie Bapat of Guy’s and St. Thomas’ NHS Foundation Trust, London, UK, discusses the development of a minimally invasive aortic valve replacement program at his institution. Mr. Bapat points out that although aortic valve replacement via a right anterior thoracotomy is a technically challenging procedure with a steep learning curve, it can have a large psychological and cosmetic benefit for patients. Mr. Bapat shares the challenges he and his team faced when starting the minimally invasive program, and the successful strategies they adopted.
This presentation was originally given during the SCTS Ionescu University program at the 2016 Annual Meeting of the Society for Cardiothoracic Surgery in Great Britain and Ireland. This content is published with the permission of SCTS. Please click here for more information on SCTS educational programs.
2 Comments
Thanks for sharing this.
I have started MiniAVR program 2 years ago at our center and went through the same challenges. What made a difference and simplified the procedure is the use of minimally invasive insturments, the use of Gluber clamp in selected cases and the use of single shot antegrade modified Del Nido plegia.
I am still hesitant to use LV vent through RSPV which explain my long pump and cross clamp times due to challenges with exposure but I felt it is safe not to deal with deep seated cannulation which could become hard to fix if I ran into trouble and this could mean conversion.
I also found taking the antegrade cannula out after giving 2 liter of plegia help improving the exposure.
One important concept with the use of Del Nido plegia is to cool the patient to at least 32 to maintain arrest and I have cases where I did not give plegia for 80 minutes.
I use CO2 and I notice the rate of defibrillation is markedly reduced and the amount of air inside the heart is much less.
I use silk loop placed at the tip of the right atrial appendage and pull it toward the diaphragm through the chest tube site and this had made tremendous improvement in the aortic root exposure and very helpful especially during aortotomy closure.
I did not use knot pusher in all 26 cases that I have done so far and I do believe it is important skill to acquire if I will start more challenging case and placing LV vent.
interesting observation is the shorter hospital stay . most of my patient went home day 3 or 4 with one patient went home day 2. the other interesting observation are less blood transfusion and the risk of postoperative Atrial fibrillation.
I did attend Dr. Lemelas’ course, started the program 9 years ago and then 5 years later went back to see him again. I also use del Nido CP in the root if no AI and directly into coronary ostia in case of AI and would repeat it after 60 minutes if I have to do root enlargement , concomitant aneurysm resection or mitral/tricuspid procedures via RAT. I would strongly encourage use of LV vent especially in case of AI and use teflon pledgets for proline vent suture and bring the vent through CT site. I also spend some time to set up exposure and use lots of silk stay sutures. You may want to try Cor-knot device, it will cut down cross clamp time by at least 15-20 minutes.