**5. Surgical approaches**

### **5.1 Median (Re-do) sternotomy**

Primary or repeat sternotomy has been the most commonly used approach. Technical aspects of repeat sternotomy with or without peripheral cannulation have been discussed previously [12].

### **5.2 Left posterolateral thoracotomy**

Left posterolateral thoracotomy has been used as an alternate to sternotomy/ repeat sternotomy for PVR [13]. With the patient in the modified right lateral decubitus position, the chest is usually entered through the left fourth/fifth intercostal space. Normothermic cardiopulmonary bypass is established *via* the femoral vessels. It is important to rule out the presence of any intracardiac shunts before proceeding with this approach. The right ventricular outflow tract and main pulmonary artery are identified, and once the pulmonary artery is incised, the PVR is proceeded as described below.

## **5.3 Minimally invasive left anterior thoracotomy incision**

We have utilized left anterior minithoracotomy as an alternative approach to sternotomy for PVR in selected patients who required isolated PVR and in the absence of intracardiac shunts. This approach carries the advantage of being less invasive with rapid recovery, but careful patient selection is required. It is not advisable in the presence of previous pulmonary conduits, but it can be useful in cases where hostile mediastinum is encountered after multiple previous surgeries or in the presence of a large aorta in close proximity to the sternum, which increases the risk of repeat sternotomy.

We have previously published our technique that can be used in both primary and reoperative settings [14] (**Figures 6A–F** and **7A** and **B**). In summary, the patient is positioned supine, prepped, and draped as for standard median sternotomy. A 6-cm horizontal incision is performed through the left third or fourth intercostal space. In primary operative settings, the left lung is gently retracted to expose the pericardium, which is then incised anterior to the left phrenic nerve to expose the RVOT and the main pulmonary artery. In re-operative settings, the left lung is usually adherent to the RVOT and/or the previously placed transannular patch if the pericardium was not closed after the first procedure and will need to be dissected off the main pulmonary artery and RVOT.

Cardiopulmonary bypass is established *via* the femoral vessels (open/percutaneously cannulated) at normothermia. It is important to achieve adequate right

### **Figure 6.**

*Intraoperative photos demonstrating the technical steps for pulmonary valve replacement via a minimally invasive left anterior thoracotomy. (A) The patient is positioned supine and a 6-cm horizontal skin incision is created along the left parasternal border along the left third/fourth ribs, (B) the left chest is entered through the left third/fourth intercostal space, and the left lung is retracted medially to expose the pericardium or the previously placed transannular patch, (C) in reoperative settings, pleural adhesions (asterisk) need to be taken down to free the lung from the right ventricular outflow tract, (D) cardiopulmonary bypass is established via the femoral vessels and once the heart is decompressed, the main pulmonary artery/transannular patch is incised longitudinally to expose the pulmonary valve, (E) remnants of the pulmonary valve leaflets are excised, annulus is sized and a new bioprosthesis is seated along the posterior annulus using running polypropylene suture, and (F) the majority of the prosthesis is seated along the native pulmonary annulus, while the anterior portion will be secured to the pericardial patch that will be used to augment the right ventricular outflow tract. P: pericardium, L: left lung, PA: main pulmonary artery.*

*Surgical Options for Pulmonary Valve Pathology in the Current Era DOI: http://dx.doi.org/10.5772/intechopen.100297*

### **Figure 7.**

*Intraoperative photos showing the remaining steps in pulmonary valve replacement via a left anterior thoracotomy. (A) A pericardial patch is commonly used to complete the augmentation of the main pulmonary artery and right ventricular outflow tract and the prosthesis is sewn to the undersurface of this patch with a running polypropylene suture, and (B) once the reconstruction is completed, the patient is weaned off cardiopulmonary bypass, and a single chest tube (asterisk) is placed, and the incision is closed in layers in the standard fashion. P: pericardial patch.*

heart decompression during this procedure owing to the limited exposure. Along with routine use of vacuum-assisted venous drainage, we prefer to use a multistage venous cannula that is inserted *via* the common femoral vein and advanced all the way up to the superior vena cava. A vertical incision is made along the previous transannular patch/main pulmonary artery and remnants of pulmonary valve leaflets are excised if present. The PVR is then continued as described below. The right side of the heart is then deaired, and the patient is weaned off cardiopulmonary bypass. Once TEE is satisfactory, the groin is decannulated and femoral vessels are repaired. A single chest drain is placed and both groin and chest incisions are then closed in layers. The patient is typically extubated in the operating room at the end of the procedure.

Our experience with this technique is in its early phase, but we have performed the procedure in 6 patients (the youngest at age 13 years; 4 with previous tetralogy of Fallot repair). The procedure was feasible, with no conversion to open sternotomy in any. There was no early or late mortality. One patient developed a femoral artery pseudoaneurysm during follow-up due to percutaneous cannulation and required late repair. The length of stay averaged 2 days [15]. We believe that weight more than 30 kg is necessary for satisfactory groin vessel cannulation.
