Miami Minimally Invasive Valves
Joseph Lamelas, MD
Dedicated to the Advancement of Minimally Invasive Cardiac Surgery
May 31, 2015
Mini AVR or MVR – Assessing Access

When performing a minimally invasive AVR or MVR via a right mini-thoracotomy approach, assessing whether you are in the right interspace is sometimes questionable.  Even after performing thousands of cases, I question this at times. I have come to the conclusion that there is one landmark that I need to see in order to confirm that I have entered the correct interspace.  That structure is the Right Superior Pulmonary Vein.

During a mini AVR, after instituting CPB and opening the pericardium, if I see the RSPV directly in line with interspace that I entered, I know that I should be able to perform the operation, even if the aorta is displaced. It is key to then take your time and place as many pericardial stay sutures as needed to develop the exposure. This is crucial to optimizing the exposure. (TOP picture)

During a mini MVR, after instituting CPB and opeing the pericardium, if I see the RSPV directly in line with the interspace that I entered, or one interspace above the site that I entered, I know that I am in the correct interspace. I don’t what to be in line with the IVC. This will be very low and if this were the case, I would move to the next higher interspace. Again, use the pericardial stay sutures to optimize exposure. (BOTTOM picture)

Mini AVR

Mini AVR

Mini MVR

Mini MVR


2 thoughts on “Mini AVR or MVR – Assessing Access”

  1. Russell Stahl, M. D. says:

    Dr. Lamellas , thank you for the additional guidance, it is very helpful. I admire your skill and dedication.

    On my last mini AVR I struggled to get the cuff inside the aorta and had to work without it. Are there additional tips to get that seated (with the L/N suture through the guide holes ).?

    Thanks, Russ Stahl

    1. I would place all 3 commissural sutures first, then place the L/N suture through the holes in the cuff. Then lay the other commissure sutures inside the cuff, then you roll it a s tightly as possible and have your assistant clamp it. You then hold the 2 inside sutures with one hand and the clamped cuff with the other. You start delivering it into the aorta while your assistant is snarring down the L/N prolene. Once it is in place, you position the other to prolene sutures in the direction of there respective commissures and then release the cuff. It should now provide exposure of the annulus. Sometimes minor repositioning is required. It does not work well with true bicuspid valves.
      Keep trying and you will realize its benefit. Let m know if you need further clarification.

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