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Minimally Invasive Aortic Valve Replacement via Anterolateral Thoracotomy

Monday, August 29, 2016

This video depicts a minimally invasive aortic valve replacement (AVR) via a right anterolateral mini-thoracotomy (RAT), using  the Edwards Intuity rapid deployment aortic valve system (Gen. 1), in a 75-year-old male patient with severe aortic stenosis. RAT access is performed in the second intercostal space over a 7 cm skin incision. A soft-tissue retractor and the ValveGate retractor are used for exposition. The authors use direct arterial cannulation of the ascending aorta with a 19 F uncoated ECMO cannula, as well as direct venous cannulation of the right atrial appendage with a 36 F angled cannula. Any groin cannulation is avoided. To overcome the limitations of this access, such as longer cross-clamp times and reduced exposure of the surgical field, the authors prefer to use the Edwards Intuity biological valve (in this case, 25 mm in size) in order to facilitate this procedure.

Comments

Ventricular pacemaker wires are placed before opening the cross clamp as it might be difficult to exposure right ventricular myocardium through this limited access after filling of the heart. (See 08:45)
Appreciate this interesting AVR. Why did you avoid groin cannulation? Any concerns with groin cannulation in general or was it done for this particular patient?
We used to perform the access with fem/fem cannulation. Over the time we shifted towards direct aortic cannulation and femoral venous cannulation and finally ended up in direct arterial and direct venous cannulation. The advantage of this approach is that you avoid any possible groin complication (no retrograde direction, no lymphatic fistula, no wound healing disturbance) and you make the approach even more less invasive. Apart from that cannulation of the right arterial appendage and pulling the cannulation downwards improves exposure of the aortic root and even facilitates access to the aortic valve.
We used to perform the access with fem/fem cannulation. Over the time we shifted towards direct aortic cannulation and femoral venous cannulation and finally ended up in direct arterial and direct venous cannulation. The advantage of this approach is that you avoid any possible groin complication (no retrograde dissection, no lymphatic fistula, no wound healing disturbance) and you make the approach even more less invasive. Apart from that cannulation of the right arterial appendage and pulling the cannulation downwards improves exposure of the aortic root and even facilitates access to the aortic valve.
I would like to congratulate the authors for their original contribution. They demonstrate that in an era of advanced instruments technologies, and exploding health costs, the could realize a minimally invasive, single access AVR with quite conventional instrumentations. We had a similar experience in the pioneer era of minimally invasive valve replacement. At that time we utilized a small right parasternal incision (1,2). A few years later, to improve cosmetic results in women, we commuted the incision in a small anterior transverse one, similarly to that one used by the authors (3). Again I would like to thank the author for their great work along with the originality of employing the Edwards Intuity rapid deployment aortic valve system (Gen. 1), which, by sure, facilitate the procedure. 1. Minale C., Reifschneider H.J., Schmitz E., Uckmann F.P.: Single access for minimally invasive aortic valve replacement. Ann Thorac Surg 64:120-3, 1997 2. Minale C., Reifschneider H.J., Schmitz E., Uckmann F.P.: Minimally invasive aortic valve replacement without sternotomy. Experience with the first 50 cases. Eur J Cardiothorac Surg;14 Suppl 1:126-9, 1998 3. Minale C., Tomasco B., Di Natale M.: A cosmetic access for minimally invasive aortic valve replacement without sternotomy in women. Ital Heart J ;3:473-5, 2002

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