Mini-Sternotomy for Hemiarch and Bicuspid Aortic Valve (BAV) Repair

The patient was a 27-year-old male with a 5 cm ascending aneurysm, BAV and 3+ aortic insufficiency (AI). He underwent a mini-sternotomy using an 8 cm skin incision. He was centrally cannulated and cooled to 20 degrees Celsius while the aortic valve was repaired. Deep hypothermic circulatory arrest (DHCA) was initiated and the ascending and hemiarch were replaced with a 24 mm graft. The total cross-clamp time was 72 minutes and DHCA was 14 minutes. The patient required no red blood cell transfusions. He was transferred to stepdown on postoperative day (POD) one with oral pain medicines and discharged home on POD eight after drainage of a moderate pleural effusion. Follow-up echo showed trivial AI with peak/mean gradients of 14/7 mmHg. Postoperative CT showed an intact aortic repair without dissection or aneurysm. He had no wound complications.

DHCA, aortic valve, and hemiarch repair can be safely performed through a mini-sternotomy with acceptable circulatory arrest and ischemic times. This approach requires minor modifications in standard techniques that can be readily learned by most surgeons comfortable with conventional ascending aortic and valvular surgery.

Minimally Invasive Toolbox

• CTA imaging to plan the incision – refer to Loor and Roselli - JACC Cardiovasc Imaging. 2013 Feb;6(2):269-71.
• Pericardial traction sutures
• Mid ascending aortic cannulation - alternative is axillary or femoral
• Right angle 24 F superior vena cava cannula (retrobrain perfusion)
• 2 stage venous cannula (26-28F) – alternative would be femoral venous cannulation
• Cardioprotection via direct coronary givers – alternative would be retrograde but difficult to insert, echo guidance may help
• Estech universal arm retractor to lift the inominate vein superiorly
• Novartis right angle cross clamp
• Epicardial and proximal aortic stay sutures for valve work
• Flexible basket sucker in the outflow tract for venting and drainage
• Ascending graft with a side arm
• Flexible SVC clamp for circulatory arrest and retro brain perfusion
• Basket sucker in the distal aorta to facilitate sewing the back wall
• Flexile alligator clamp on the completed graft to allow flexibility in assessing the back wall of the distal anastamosis
• Oversew the side graft once complete
• Pacing wires and chest tubes should be inserted in the decompressed heart while on bypass. The chest tube enters the subxiphoid space just under the sternum
• Consider opening the right pleura to decrease incidence of tamponade