Miami Minimally Invasive Valves
Joseph Lamelas, MD
Dedicated to the Advancement of Minimally Invasive Cardiac Surgery
March 17, 2013
Redo Mini AVR

Most Redo AVR are still being performed via a sternotomy. The next most common approach is a mini-upper sternotomy. This approach is probably better than a full sternotomy because I believe that the sternum is the major source of post operative bleeding.  Few have ventured into performing this operation through a mini- thoracotomy approach.  One reason is lack of familiarity of the operative field and anatomy from a more lateral access site.  Once experience is gained performing a mini-thoracotomy AVR , one should attempt a redo mini- AVR with this technique.  Despite being a technically more challenging operation because of adhesions, the post operative benefits are enormous. I consistently see that this subset of patients (redo AVR’s) have the best post operative course.  I am constantly amazed to see this. I have performed 4 redo mini- AVR’s this week with the average age being 85 years old, average EF was 40 % , one was 87 years old and was a 3rd time redo, and one had a 20 % EF and severe MR and required a trans-aortic Alfieri stitch.  BTW, all are doing well. The 3rd time redo was discharged on post op day 4.

I have enclosed a few pictures of the 3rd time redo.  I initially begin by entering the chest and dissecting adhesions of the lung to the heart. Once I identify the region of the right atrial appendage, I will place a purse string suture and insert a retrograde CP cannula. Most of the time I do this prior to going on CPB. Once on bypass, I will identify the RSPV and place an LV vent. Usually the greater curvature of the aorta has few or no adhesions. On the other had, the anterior aspect of the aorta requires careful dissection. I will usually drop the flow of the pump and pull down the aorta while my assistant uses a retractor to elevate the sternum. Dropping the flows really facilitates the dissection. Care is taken to identifying all of the grafts. I do NOT dissect between the aorta and PA, although I will dissect the tissue on the undersurface of the aorta and develop a plane between the aorta and right branch of the PA. This is where my cross-clamp is placed. If there is a patent graft to the Right coronary system, it is crucial to dissect as much of the graft to allow it to be mobilized laterally. This will allow an aortotomy to be performed under this graft. The rest of the operation proceeds in the usual fashion. If the patient has a patent LIMA and native LAD, there will be constant blood return into the aorta from the left main. I will connect a red rubber catheter to a sump suction and drop this into the sinus or the LM. One other point is to have your anesthesiologist insert a temporary transvenous pacer pre-operatively so you don’t need to worry about placing a pacing wire.

Overall, this is a more technically challenging operation, but the bleeding is minimal and the recovery is surprisingly spectacular!!!!DSCN8095

3 thoughts on “Redo Mini AVR”

  1. Excellent work and write up as usual. Everytime I have done this I find it hard to pull the aorta towards my incision with the aid of the pericardial sutures because the prior adhesions. Any tricks for exposure? Also placing the inside ring of the soft tissue retractor is often limited by the adhesions. I usually use a medium, but wonder if a small is better. I see by your pictures you have no trouble. I’ve tried a small fogarty catheter to plug up the left main in the setting of a patent IMA, but it always seems to pop out and the catheter is stiff and gets in the way. I will try the red rubber to the sump as mentioned. Again, thank you for allowing us all to learn and benefit from your efforts!

    1. I try not to pul the aorta towards me. Most of the pericardium anteriorly is very thin and at times non-existent. I drop the flow of the pump multiple, have my assistant use a retractor to lift the sternum and I carefully dissect the aorta and grafts. I will also concentrate on dissecting the the aorta from the right branch of the PA. My cross clamp will be placed here. I usually use a medium soft tissue retractor. Sometimes it does push the mediastinal tissues and makes it more difficult to see. I would recommend placing the rib spreader first, without the soft tissue retractor, dissecting some of this tissue away first, then inset the soft tissue retractor. I have used multiple suction catheters, but the red rubber seems to work best. It may not stay in the osmium, but as long as it stays in the sinus, this will keep things relatively dry. Good luck, you have been helping lead the way!

      1. Thank you Joe! I will give it a try and report back! Patients really love this approach. Dreading the sternotomy again is often the reason patients persist with medical management, despite strong indications for an operation.

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