J-Ministernotomy for Ascending Aorta and Rapid Deployment Aortic Valve Replacement

The authors present a case of ascending aorta and rapid deployment aortic valve replacement (Edwards Intuity Elite prosthesis) through a J-ministernotomy approach in an elderly patient.

Clinical Summary

• 86-year-old man
• Normal ejection fraction
• No coronary disease
• Chronic obstructive pulmonary disease (COPD)
• Severe aortic valve stenosis
• Ascending aorta diameter: 6 cm
• NYHA class III

1. You can see the preoperative angio CT scan. 
2. The authors have in canulated the left femoral artery and vein with the Seldinger technique. 
3. J-ministernotomy 
4. Separation of the ascending aorta and the pulmonary artery
5. Vent line is inserted
6. Aortic clamping and antegrade infusion of Custodiol cardioplegia
7. Transection of the aorta and exposition of the aortic valve
8. Resection of the aortic valve and completion of annular debridement
9. The annulus was sized using calibrated with Magna Ease sizers (EDWARDS, model 1133) (valve 25)
10. Three simple intertwined guide sutures without equidistant inserts were placed inside the native annulus in the nadir of each coronary cusp. These sutures should come out of the nadir, 2 to 3 mm above the ring. The positioning of the guide sutures, which guide the radial orientation and the appropriate seat of the valve frame in the native ring, should correspond to the markers on the valve cover, allowing the surgeon to confirm the correct valve seat by displaying the exit sutures.
11. Another two intertwined stitches were placed inside the native annulus of the noncoronary cusp.
12. The delivery system should be shaped to replicate the sizer angle, which allows perpendicular valve delivery to the annulus plane.
13. Guiding sutures should be passed through the valve cuff at the 3 suture markers. The surgeon should now fix the valve position within the annulus by securing the guiding sutures on the valve cuff with narrow-diameter snares.
14. The balloon was then inflated to 4.5 or 5.0 atmospheres for 30 seconds. 
15. Snare removal and sequential suture tying
16. Resection of the ascending aorta
17. The proximal anastomosis was performed using the polypropylene 4.0 between the vascular prosthesis and the aorta with interposition of a thin layer of Teflon felt. The proximal anastomosis was performed using the polypropylene 4.0 between the vascular prosthesis and the aorta with the interposition of a thin layer of Teflon felt.
18. A second suture was done, using polypropylene 4/0.
19. The distal anastomosis was performed using the polypropylene 4.0 between the vascular prosthesis and the aorta with the interposition of a thin layer of Teflon felt.
20. An epicardial pacing wire was placed.
21. The heart and the vascular prosthesis were de-aired and the cross-clamp was removed.
22. This is the final result. You can see the postoperative results on the echocardiographic: no evidence of paravalvular leaks. This is the patient 10 hours after the procedure.

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