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Safe Cerebral Protection: Double Patch Technique for Aortic and Mitral Valve Replacement

Friday, May 17, 2024

This patient required a double valve replacement, but she had grade V atheroma in the ascending aorta. This meant that the patient was at very high risk of stroke if routine techniques were used. 

Because of the patient’s high risk of stroke, the left carotid artery was cannulated and proximally clamped. The brain was perfused at one liter per minute through this cannula, which meant that no atheroma could pass up into the head vessels as blood passed back in a retrograde fashion down the opposite carotid artery. 

The aorta was then opened and the small aortic valve was visualized, showing that a root enlargement was clearly needed. The annulus was opened through the middle of the anterior leaflet of the mitral valve and opened into the left atrium. Next, the anterior and then posterior leaflets of the mitral valve were removed from the aorta. Mitral annular calcification was also discussed. 

The mitral sutures were then placed in a horizontal mattress technique and a mitral annulus enlargement patch was placed, which increased the size of both the mitral and aortic annuluses. A Dacron patch was then placed and, after the mitral valve, the aortic valve was sutured into place with the annular and aortic enlargement patch.


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Thank you for this great video Dr. Gaudiani. I really enjoy your videos and the tips you give. I have done similar operation twice on patients with radiation heart disease but took my cut from aorta to LVOT not as far down and then did the mitral portion through a standard left atrial approach, they were young and given the hx of radiation wanted to use mechanical valves. Do you have any tips or do you think the same way would work with mechanical valves given their need to be more intra-anular instead of supra-anular?
Radiated patients are a special case. The aim should always be to perform one definitive operation. Redo radiation cases are full of woe. So mechanical valves are the best choice in younger patients. Call my cell if you want to discuss further. 650-207-3951.
Thanks Dr Gaudiani for sharing your techniques. I really enjoy your videos. I have a question about your cerebral protection strategy. How can one be sure that the retrograde flow (from 1LPM antegrade R-carotid /innominate flow) via opposite carotid can overpower the forward flow from 3-3.5LPM aortic forward flow? Because if that did not happen the debris can go into Left carotid artery. Thank you.

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