Mini-Bentall Procedure With Mitroflow Valsalva Conduit

Minimally invasive cardiac surgery has been associated with faster recovery and less post-operative pain, bleeding, and respiratory compromise. Despite these factors, a minimally invasive approach is not routinely adopted during aortic root surgery (1, 2). This video demonstrates a mini-Bentall technique through a J-shaped ministernotomy at the 4th intercostal space.

A 74-year-old female patient had severe aortic regurgitation, normal left ventricular function (left ventricular ejection fraction = 60%), and ascending aorta aneurysm (aortic root 52 mm, ascending aorta 55 mm). She was classified as NYHA II. Coronary angiography ruled out any significant coronary artery disease. The aorta was approached using a J-ministernotomy at the 4th intercostal space through a 5 cm skin incision. The aortic arch and the right femoral vein were cannulated for cardiopulmonary bypass (CPB) institution. The modified "button technique" Bentall procedure was performed using a 23 mm Crown aortic valve prosthesis and a 28 mm Mitroflow Valsalva Conduit (LivaNova, United Kingdom). Cross-clamp and CPB time were 105 and 125 minutes, respectively. The patient was extubated six hours after surgery and required no red blood cell transfusion. The postoperative course was uneventful.

The classic approach for root replacement interventions involves a longitudinal median sternotomy to expose the heart and the aorta, and cannulation of the distal ascending aorta (or aortic arch) and right atrium to establish CPB. Recently, several surgeons have begun to perform aortic root interventions through reduced chest incisions, aiming to reduce surgical trauma and improve the clinical and cosmetic outcomes (3-6).

The minimally invasive approach shown in this video provides excellent visualization of fundamental anatomical structures (aortic root, ascending aorta, aortic arch, main pulmonary artery, superior vena cava, right superior pulmonary vein, and the right atrial appendage) and allows the operating surgeons to keep their techniques straightforward and uncomplicated throughout the surgical procedure. Moreover, it does not significantly extend CPB and myocardial ischemia time. Considering the safety, efficacy, and patients’ appreciation of these minimally invasive procedures, the authors believe mini-Bentall operations could be offered more frequently, especially when performed by surgeons experienced in aortic root and minimally invasive interventions.

References

1. Murtuza B, Pepper JR, Stanbridge RD, Jones C, Rao C, Darzi A, Athanasiou T. Minimal access aortic valve replacement: is it worth it? Ann Thorac Surg. 2008;85:1121-31.
2. Brown ML, McKellar SH, Sundt TM, Schaff HV. Ministernotomy versus conventional sternotomy for aortic valve replacement: a systematic review and meta-analysis. J Thorac Cardiovasc Surg. 2009;137:670-679.e5.
3. Perrotta S, Lentini S, Rinaldi M, D'armini AM, Tancredi F, Raffa G, Gaeta R, Viganó M. Treatment of ascending aorta disease with Bentall-De Bono operation using a mini-invasive approach. J Cardiovasc Med (Hagerstown). 2008;9:1016-22.
4. Sun L, Zheng J, Chang Q, Tang Y, Feng J, Sun X, Zhu X. Aortic root replacement by ministernotomy: technique and potential benefit. Ann Thorac Surg. 2000;70:1958-61.
5. Roselli EE. Interventions on the aortic valve and proximal thoracic aorta through a minimally invasive approach. Ann Cardiothorac Surg. 2015;4:81-4.
6. Shrestha M, Krueger H, Umminger J, Koigeldiyev N, Beckmann E, Haverich A, Martens A. Minimally invasive valve sparing aortic root replacement (David procedure) is safe. Ann Cardiothorac Surg. 2015;4:148-53.