**6. Right anterior mini-thoracotomy approach**

We shall now discuss our technique outlining key steps, safeguards and pitfalls.

## **6.1 Patient positioning and preparation**

It is very important to communicate clearly with all team members including anesthetists, perfusionists and theatre nursing staff, the minimally invasive approach planned.


**59**

*Minimally Invasive Right Anterior Mini-Thoracotomy Aortic Valve Replacement*

2. 5–6 cm transverse incision is made over right 2nd intercostal space.

3.Right internal mammary artery and vein are clipped and divided.

1.Chest is opened first as it helps in first hand inspection of pleural cavity and also helps in manual guidance of femoral venous cannula towards superior vena cava.

4.Inferior rib is transected at the costochondral junction which can be re-approximated with a vicryl suture at the end of the procedure. It increases the operative space and is a much better option than forceful mechanical retraction.

5.Soft tissue retractor and intercostal rib spreader further increase the exposure.

6. Pericardium is opened over right atrium and extended towards the inferior vena cava taking care of the phrenic nerve. Pericardial opening is extended towards the ascending aorta, carefully dissecting the thymic fat. Care is taken not to open the pericardium up to its attachment to aorta, as it can compromise pericardial stay suture placement. Carefully placed pericardial sutures provide exposure of the aorta.

About 3–4 cm transverse incision is made above the right inguinal crease. Femoral artery and vein along with branches are dissected and looped with vascular tape. Vascular clamp is placed proximally. Longitudinal incision is made over femoral artery and vein and cannulae are inserted into respective vessels after releasing the vascular clamp. Alternatively, a Seldinger technique may be used for peripheral

Cannula size is based on the size of the femoral vessels and body surface area. The femoral venous cannula is placed into the SVC under TOE guidance. After femoral decannulation, femoral vessels are repaired with prolene 6-0/7-0.

If peripheral vascular disease is suspected, axillary or central aortic cannulation

Vacuum assisted venous drainage of 30–70 mmHg as needed may be used to maintain bypass flows and to decompress the right heart. If venous drainage is

Under TOE guidance, a retrograde cardioplegia cannula is inserted through right atrium body/appendage. Its downward retraction facilitates the exposure of the aorta

A left ventricular vent is passed through right superior pulmonary vein. It is very helpful in unloading the heart and also in deairing the heart while coming off

The aorta is cross clamped using Chitwood clamp through separate incision in the chest wall near the anterior axillary line. Dissection between aorta and pulmonary artery is not required. If bleeding occurs in this area, it is difficult to control. Antegrade cardioplegia is delivered. If such is not possible due to moderate or severe aortic regurgitation, direct coronary ostial cardioplegia can be given along with retrograde cardioplegia. A CO2 catheter is placed in the operative field for de airing.

inadequate, additional central SVC cannulation is required.

*DOI: http://dx.doi.org/10.5772/intechopen.85242*

**6.3 Cannulation for cardio-pulmonary bypass**

vessel cannulation (**Figure 3**).

**6.4 Myocardial protection**

cardiopulmonary bypass.

(**Figures 4** and **5**).

is performed.

**6.2 Chest Approach**

*Minimally Invasive Right Anterior Mini-Thoracotomy Aortic Valve Replacement DOI: http://dx.doi.org/10.5772/intechopen.85242*

#### **6.2 Chest Approach**

*Cardiac Surgery Procedures*

atrial fibrillation (19.5 vs. 34.2%), shorter ventilation time (median 7 vs. 8 h = 0.003) and a shorter hospital stay (median 5 vs. 6 days) [29].

*Minimally invasive incisions: (A) mini sternotomy, (B) right anterior mini thoracotomy.*

We shall now discuss our technique outlining key steps, safeguards and pitfalls.

1.Patient is placed supine with a pressure bag inflated below the right shoulder to

4.Trans-oesophageal echocardiography (TOE) is a mandatory tool to help in place-

5.Defibrillation pads should be attached on the left side of the chest and on the back. Sterile pediatric internal paddles should be available on table, in case external

6. Sternal saw is kept on table, if required in emergency so that precious time is not

9. Left internal jugular vein central line is inserted if central SVC cannulation is planned.

7.Both groins are exposed. It is important to angulate the operation table to

8.Right radial catheter and Swan Ganz catheter is inserted.

It is very important to communicate clearly with all team members including anesthetists, perfusionists and theatre nursing staff, the minimally invasive

2.Midline sternotomy incision is marked in case emergency conversion is

3.Incision is marked in the right 2nd intercostal space for right anterior

ment of femoral venous cannula and retrograde cardioplegia cannula.

required intraoperatively. Wide preparation of the chest.

**6. Right anterior mini-thoracotomy approach**

**6.1 Patient positioning and preparation**

slightly elevate the right chest.

defibrillator pads malfunction.

optimally expose the groin.

mini-thoracotomy.

approach planned.

**Figure 2.**

wasted.

**58**


#### **6.3 Cannulation for cardio-pulmonary bypass**

About 3–4 cm transverse incision is made above the right inguinal crease. Femoral artery and vein along with branches are dissected and looped with vascular tape. Vascular clamp is placed proximally. Longitudinal incision is made over femoral artery and vein and cannulae are inserted into respective vessels after releasing the vascular clamp. Alternatively, a Seldinger technique may be used for peripheral vessel cannulation (**Figure 3**).

Cannula size is based on the size of the femoral vessels and body surface area. The femoral venous cannula is placed into the SVC under TOE guidance. After femoral decannulation, femoral vessels are repaired with prolene 6-0/7-0.

If peripheral vascular disease is suspected, axillary or central aortic cannulation is performed.

Vacuum assisted venous drainage of 30–70 mmHg as needed may be used to maintain bypass flows and to decompress the right heart. If venous drainage is inadequate, additional central SVC cannulation is required.

#### **6.4 Myocardial protection**

Under TOE guidance, a retrograde cardioplegia cannula is inserted through right atrium body/appendage. Its downward retraction facilitates the exposure of the aorta (**Figures 4** and **5**).

A left ventricular vent is passed through right superior pulmonary vein. It is very helpful in unloading the heart and also in deairing the heart while coming off cardiopulmonary bypass.

The aorta is cross clamped using Chitwood clamp through separate incision in the chest wall near the anterior axillary line. Dissection between aorta and pulmonary artery is not required. If bleeding occurs in this area, it is difficult to control.

Antegrade cardioplegia is delivered. If such is not possible due to moderate or severe aortic regurgitation, direct coronary ostial cardioplegia can be given along with retrograde cardioplegia. A CO2 catheter is placed in the operative field for de airing.

**Figure 3.** *Peripheral femoral cannulation.*

**Figure 4.**

*Retrograde cardioplegia cannula in coronary sinus under TOE guidance.*

#### **6.5 Aortotomy**

The aortotomy is made at the level of fat pad on aorta. Stay sutures are placed on either edge of the aortotomy for retraction. Resection of valve leaflets, debridement of annulus and valve replacement is done as per standard techniques (**Figures 6** and **7**).

Resection and decalcification of a severely stenotic calcified valve is the most difficult step. Using commissural stay sutures and aortic wall retraction sutures significantly improve the exposure. Placing small wet gauze inside the left ventricle

**61**

**Figure 6.**

**Figure 5.**

*Retrograde cardioplegia with LV vent in situ.*

*Minimally Invasive Right Anterior Mini-Thoracotomy Aortic Valve Replacement*

while doing decalcification prevents small calcium fragments from getting lost. This wet gauze can be taken out after decalcification has been completed. Similar to the conventional sternotomy approach, decalcification should be followed by thorough

saline flushing of the left ventricle (**Figures 8** and **9**).

*Aorta cross-clamped with Chitwood clamp through separate skin stab.*

*DOI: http://dx.doi.org/10.5772/intechopen.85242*

*Minimally Invasive Right Anterior Mini-Thoracotomy Aortic Valve Replacement DOI: http://dx.doi.org/10.5772/intechopen.85242*

**Figure 5.** *Retrograde cardioplegia with LV vent in situ.*

*Cardiac Surgery Procedures*

**60**

**6.5 Aortotomy**

**Figure 4.**

**Figure 3.**

*Peripheral femoral cannulation.*

(**Figures 6** and **7**).

The aortotomy is made at the level of fat pad on aorta. Stay sutures are placed on either edge of the aortotomy for retraction. Resection of valve leaflets, debridement of annulus and valve replacement is done as per standard techniques

*Retrograde cardioplegia cannula in coronary sinus under TOE guidance.*

Resection and decalcification of a severely stenotic calcified valve is the most difficult step. Using commissural stay sutures and aortic wall retraction sutures significantly improve the exposure. Placing small wet gauze inside the left ventricle

#### **Figure 6.**

*Aorta cross-clamped with Chitwood clamp through separate skin stab.*

while doing decalcification prevents small calcium fragments from getting lost. This wet gauze can be taken out after decalcification has been completed. Similar to the conventional sternotomy approach, decalcification should be followed by thorough saline flushing of the left ventricle (**Figures 8** and **9**).

**Figure 7.** *Aortic valve sutures in place—interrupted pledgeted.*

**Figure 8.** *Aortic valve replaced.*

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*Minimally Invasive Right Anterior Mini-Thoracotomy Aortic Valve Replacement*

After aortotomy closure, but before removing the cross clamp, ventricular pacing wire (s) is/are placed on the anterior aspect of the right ventricle. It's extremely difficult to place pacing wires on a beating right ventricle and sometimes, bleeding

Defibrillation is performed using external pads or pediatric paddles if required.

After aortotomy closure and before the cross clamp is removed, ventilate the lungs and fill the heart and remove the air through the aortic root vent. Insufflating the operative field with carbon dioxide gas helps in deairing. It's important to ventilate the lungs and let the heart eject blood during the reperfusion period. TOE plays a very important role in assessing the effectiveness of

The heart is not manipulated directly for air removal maneuvers. Left-right positioning of patient and external compression of chest wall and forceful shaking

After appropriate ABG results and optimum rewarming, CPB is gradually discontinued. Femoral venous and arterial cannulas are removed and femoral vessels

For pain relief, epidural anesthetic catheter is placed into pleural space and

Ribs are approximated with vicryl or prolene suture and muscle layers closed in

Conversion to full sternotomy is a psychological stress for the team and an additional scar on the patient. It occurs in 0.8–8.0% with 3–4% average in most of the series [20]. Possible reasons include inadequate exposure, bleeding from the right

of rib retractor may be performed to agitate and disperse air bubbles.

**6.8 Weaning from cardio-pulmonary bypass and closure**

from the right ventricle can force conversion to sternotomy.

*DOI: http://dx.doi.org/10.5772/intechopen.85242*

**6.6 Pacemaker wire placement**

**6.7 Deairing**

**Figure 10.** *Post-operative scar.*

deairing maneuvers.

repaired with Prolene 6-0/7-0.

standard fashion (**Figure 10**).

0.25% bupivacaine is given for 72 h.

**7. Conversion to full sternotomy**

**Figure 9.** *Aortotomy closure.*

*Minimally Invasive Right Anterior Mini-Thoracotomy Aortic Valve Replacement DOI: http://dx.doi.org/10.5772/intechopen.85242*

**Figure 10.** *Post-operative scar.*

*Cardiac Surgery Procedures*

**Figure 7.**

*Aortic valve sutures in place—interrupted pledgeted.*

**62**

**Figure 9.** *Aortotomy closure.*

**Figure 8.**

*Aortic valve replaced.*

#### **6.6 Pacemaker wire placement**

After aortotomy closure, but before removing the cross clamp, ventricular pacing wire (s) is/are placed on the anterior aspect of the right ventricle. It's extremely difficult to place pacing wires on a beating right ventricle and sometimes, bleeding from the right ventricle can force conversion to sternotomy.

Defibrillation is performed using external pads or pediatric paddles if required.

#### **6.7 Deairing**

After aortotomy closure and before the cross clamp is removed, ventilate the lungs and fill the heart and remove the air through the aortic root vent. Insufflating the operative field with carbon dioxide gas helps in deairing. It's important to ventilate the lungs and let the heart eject blood during the reperfusion period. TOE plays a very important role in assessing the effectiveness of deairing maneuvers.

The heart is not manipulated directly for air removal maneuvers. Left-right positioning of patient and external compression of chest wall and forceful shaking of rib retractor may be performed to agitate and disperse air bubbles.

#### **6.8 Weaning from cardio-pulmonary bypass and closure**

After appropriate ABG results and optimum rewarming, CPB is gradually discontinued. Femoral venous and arterial cannulas are removed and femoral vessels repaired with Prolene 6-0/7-0.

For pain relief, epidural anesthetic catheter is placed into pleural space and 0.25% bupivacaine is given for 72 h.

Ribs are approximated with vicryl or prolene suture and muscle layers closed in standard fashion (**Figure 10**).

#### **7. Conversion to full sternotomy**

Conversion to full sternotomy is a psychological stress for the team and an additional scar on the patient. It occurs in 0.8–8.0% with 3–4% average in most of the series [20]. Possible reasons include inadequate exposure, bleeding from the right

ventricle, aortotomy site or right internal mammary, or an inability to defibrillate. A ministernotomy incision can be extended to full sternotomy. With right mini-thoracotomy, incision can be extended to a transverse sternotomy or, alternatively, full sternotomy can be created. It leads to longer bypass times, adding to the morbidity of the procedure [30].
