Mini-Bentall Procedure and Hemiarch Replacement: Graft Anastomosis and Mini-Sternotomy Closure

In this video, the final episode in a seven-part series, Tristan Yan demonstrates how to anastomose the Ante-Flo graft to the Valsalva graft, wean the patient off bypass, and close the mini-sternotomy incision.

1. Once the root procedure is completed, the proximal valve conduit is trimmed just above the Valsalva portion of the graft.
2. The distal Ante-Flo graft is put under a stretch and cut to an appropriate length.
3. A graft-to-graft anastomosis is performed using a continuous 3-0 running prolene suture. The spacing between the adjacent stitches needs to be narrow and precise when doing a graft-to-graft anastomosis, usually only a couple of millimeters apart.
4. The aortic root vent is inserted, the aortic cross clamp is slowly released, and a 21-gauge needle is used to de-air the graft. In order to ensure an absolute hemostasis, pledgeted 4-0 prolene sutures are applied to reinforce the proximal anastomosis.
5. A bi-polar temporary pacing wire is inserted in the epicardium over the right ventricle.
6. Two 28 Fr soft drains are inserted and brought out below the xiphoid cartilage.
7. Hemostasis is carefully checked and the patient is weaned from cardiopulmonary bypass.
8. Protamine is given to reverse the Heparin effect. Topical Floseal Hemostatatic Matrix (Baxter Healthcare, Zurich, Switzerland) is applied around the anastomotic sites.
9. Once the hemostasis is deemed satisfactory, two stainless steel double wires are used to approximate the sternum.

This completes the Mini-Bentall procedure and hemiarch replacement. As shown in this video series, the fundamental principles of a traditional aortic root replacement must be respected. It also cannot be emphasized enough that a meticulous surgical technique to ensure absolute hemostasis is of utmost importantance in minimally invasive surgery. This results in a complete aortic repair via a minimal access incision, and successful treatment in selected patients with aortic root and/or ascending aortic aneurysm.

View all videos in this series here.