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MINIMALLY INVASIVE AORTIC VALVE REPLACEMENTMICHAEL MORONT, MD

AcademiaMedical Education

What is a Minimally Invasive Aortic Valve Replacement

The procedure described here is a minimally invasive direct vision approach for aortic valve replacement. The procedure is performed through a 6 cm right anterior thoracotomy.

Michael G. Moront, MD Toledo, Ohio, USA

Potential Benefits of Minimally Invasive AVR• Reducedtraumaandpain

• Statisticallydecreasedbloodlossand transfusion requirements

Decreased wound infection• Statisticallyreducedrecoverytime

and more rapid return to work

• Bettercosmeticresultsandimprovedpatientsatisfaction

•Nodifferenceinmorbidityandmortality

• Facilitatesredosurgery

•Avoidssternalwoundcomplications

• Statisticallyreducedincidenceof wound infections

NOTE: The views and techniques expressed herein and in the training are the views of Dr. Moront. This information is provided as a general resource, but is not intended to constitute medical advice or in any way replace the independent medical judgment of a trained and licensed physician with respect to any individual patient needs or circumstances. Please see the ““Instructions for Use” for all product indications, contraindications, precautions and adverse events.

1. PATIENT SELECTIONExclusion criteria •Severelycalcified ascending aorta

•Priorsternotomy or cardiac surgical procedure

2. ANESTHESIA TECHNIQUE•Doublelumenendobronchialtube•Swan-Ganz®pulmonaryarterycatheter•Transesophagealechocardiography(TEE)•Radialandfemoralarteriallines•Defibrillationpatches

3. PATIENT POSITIONING•Rightinfrascapularroll•Prepanddrapeinusualfashion

4. CANNULATION•Performed prior to thoracotomy•Leftfemoralarteryandveincannulationare performedutilizingaSeldingertechnique (onlylimitedexposureisrequiredtoidentifytheanterioraspectofthevessels)•Performarterialcannulationfirst,thecannulashouldneverbeforcedandshouldadvanceeasily•Insertfemoralvenousguidewarefromthefemoralveinintothesuperiorvenacava(SVC)utilizingtransesophagealechocardiography(TEE)guidance•VerifywirelocationinSVCpriortopassingcannula(veryimportant)•Ultimately,the femoral venous cannula tip should be in the lower right atrium

5. INCISION AND EXPOSURE•6cmrightanteriorthoracotomy

•Thecostochondralribjunction,usuallyoftheinferiorribisdivided

•Excesspericardialfatisremovedfromthepericardium,beingcarefulnottoinjurethephrenicnerve

•Thepericardiumisopenedovertheascendingaortaandthepericardiumispulledupgreatlyimprovingaorticand rightatrialexposure

Rib TransectionIncision

Technique Overview

AcademiaMedical Education

6. CARDIOPLEGIA CANNULATION •Placeapledgetedsutureintherightatrialappendageforretrogradecardioplegiacannulation

•TheMedtronicMICSretrogradeauto-inflatecannula(MiRCSP®)isusedandpreparedbyplacingagentlebendontheMICSretrogradecannula,accentuatingthesteerabledeflectionofthecannula

•UtilizingTEEguidance,thecoronarysinusisvisualizedandtheMICSretrogradecannula(MiRCSP)isgentlyadvanced into the coronary sinus

Performingretrogradecardioplegiacannulationpriortovenouscannulationmakestheretrogradecannulationmuch easier.

LVventcanbeplacedpriortoinstitutionofcardiopulmonarybypassoronceonbypassthroughtherightsuperiorpulmonary vein in a standard fashion.

7. INSTITUTE CARDIOPULMONARY BYPASS• Identifytheleveloftheaortotomyrelativetotheoriginoftherightcoronaryartery (1.5cmaboveRCAorigin)

• Systemicallycoolthepatient’sbodytemperatureto36ºC(noncirculatoryarrestcases)

• Crossclamptheascendingaortadirectlythroughtherightanteriorthoracotomy

• Administerantegradeandretrogradecardioplegiainastandardfashion

• FloodtheoperativefieldwithCO2at2-3liters/minutetominimizeintra-cardiacair

8. AORTOTOMY• Opentheaortainastandardfashion

•Retractascendingaortasuperiorlyandthenplace3staysuturesatthetopofthevalvecommissurestooptimizeaorticrootexposure

AcademiaMedical Education

9. VALVE REPLACEMENT• Inspectthevalveandperformreplacementasneeded

• Administercardioplegiaintermittentlypernormalroutine

• Utilizestandardreplacementtechniques.Refertothe“Instructions for Use”whichaccompanyMedtronicheartvalverepairandreplacementproducts.Useonlythosesizers/obturatorsdesignedfortheproductbeingimplanted.Productimplant guides available upon request.

10. CLOSING• Closetheaortotomyinastandardfashion.StopLVventingastheaortotomyclosureisbeingcompleted.

• PlaceasingleRVpacingwireandtunnelitouttheanteriorchestwallviatheleftparasternalspace.Placeaskingrounding wire.

• Venttheaorticroot,filltheheartandventilatethelungstoaggressivelyde-airtheleftventricle and aorta

• Removethecrossclamp

• Defibrillatetheheartasneededutilizingthedefibrillationspatches

• Oncetheheartisbeatingbeginventilationandalsocardiacejection.TEEisusedtoassessthepresenceofintra-cardiacairandtodeterminewhenitiscompletelyevacuated.TEEisalsousedtoassesstheaorticvalvereplacement.

11. END OF PROCEDURE•AnOn-Q®painpumpsystemisinsertedintothesubpleuralspaceatthelateralaspectofthethoracotomy,anda

second catheter is inserted into the neurovascular bundle of the upper rib of the thoracotomy

•Transectedribreconstructedwithstainlesssteelfourholeplateand#2FiberWire™suture

•Placetwopericostalsuturesforribre-approximationusing#2Mersilene™suture

HOW DO I BEGIN?Medtronicofferspeer-to-peereducationforthoseinterestedinlearninghowtodoanAVRprocedure.PleasecontactyourCardioVascularsalesrepresentativeformoreinformation.

Over 35 years of scientific innovation, resulting in more options for minimally invasive heart valve repair and replacement.

Mosaic®Valve

1. ProstheticValve–MedtronicMosaic®Bioprosthesis2. ReusableInstruments a. MinimallyInvasiveRibRetractorSystem b. MinimallyInvasiveAtrialRetractorSet,LargeBlades c. MinimallyInvasiveFlexibleAorticClamp d. MinimallyInvasiveKnotPusher e. MinimallyInvasiveScissors,Curved f. MinimallyInvasiveScissors,30° g. MinimallyInvasiveNeedleDrivers,CurvedLocking(Qty.x2) h. MinimallyInvasiveForcepsStraight,DoubleAction(Qty.x2) i. ForcepsNarrowStraight,DoubleAction j. MinimallyInvasiveHook(Qty.x2) k. MinimallyInvasiveFlushPortAdapter l. MinimallyInvasiveInstrumentTray

3. DisposableSupplies a. Cannulation -MedtronicBio-Medicus®Multi-StageFemoral

VenousCannula,21Fr,25Fr -MedtronicBio-Medicus®FemoralArterialCannula

17Fr,19Fr,21Fr -MiRCSPTM MinimallyInvasiveRetrogradeCoronary

SinusPerfusionCannula b. On-Q®painpumpsystem

Instruments and Disposables* as typically used by Dr. Moront

Bio-Medicus®Multi-StageFemoralVenousCannula

Mosaic® Porcine Bioprosthesis Indications: Forthereplacementofmalfunctioningnativeorprostheticaorticand/ormitralheartvalves.Contraindications:Thisdeviceisnotintendedforuseexceptasindicated.Warnings/Precautions/Adverse Events: Accelerateddeteriorationduetocalcificdegenerationofbioprosthesismayoccurin:children,adolescents,youngadults,andpatientswithalteredcalciummetabolism(e.g.,chronicrenalfailure,hyperparathyroidism).Adverseeventscaninclude:angina,cardiacarrhythmia,cardiacdysrhythmias,death,endocarditis,heartfailure,hemolysis,hemolyticanemia,hemorrhage,transvalvularorparavalvularleak,myocardialinfarction,nonstructuraldysfunction,stroke,structuraldeterioration,thromboembolism,orvalvethrombosis.Foradditionalinformation,pleaserefertotheInstructionsForUseprovidedwiththeproduct.CAUTION: Federallaw(USA)restrictsthisdevicetosalebyorontheorderofaphysician.

Bio-Medicus® Multi-Stage Femoral Cannula and Introducer and Bio-Medicus® Femoral Arterial Cannula Indications for Use:Thesedevicesaretobeusedbyatrainedphysicianonly.Cannulaeareusedtocannulatevessels,perfusevesselsororgansand/orconnectwithaccessoryextracorporealequipment.TheCannulaObturatorisintendedtofacilitateproperinsertionandplacementoftheappropriatesizedcannulawithinthevesselforcardiopulmonarybypass. Contraindications: Alone,thecannulaandobturatorarenotmedicaltreatmentdevices.Therearenoknowncontraindications for the use of the cannula other than those generally contraindicated for cardiopulmonary bypass. ThecannulaobturatoristobeusedonlywiththeappropriatesizedBio-Medicus®Cannula.Thesedevicesarenotintendedforuseexceptasindicatedabove.

MīRCSP™ Minimally Invasive Retrograde Coronary Sinus Perfusion Cannula Product Description: The cannula consists of a wirewound silicone cannula body with a beveled tip. Two side holes are present near the tip. The back of the cannula body terminates in a locking female luer. A pressure monitoring line isanintegralpartofthecannulabody,beginningatthetipandterminatingina3-waystopcockwithalockingfemaleluerfitting.Aninflatableballoonislocatedatthedistalbeveledtip.Thereareradiopaquebandslocatedinsideeachendoftheinflatableballoon.Theinflationassemblyislocatedatthebackofthecannulabodyandcontainsafemaleslipluerandaone-wayvalveassembly.Theintroducerfeaturestipdeflectionandrotation.Sterile,nonpyrogenic,single use. Indications for Use: TheMiRCSPcannulaisintendedforuseduringcardiopulmonarybypassforthedeliveryofcardioplegiaretrogradethroughthecoronarysinusforuptosixhours.Itisindicatedforuseduringcardiacsurgeryformediansternotomyorminimallyinvasive(mini-sternotomyorrightthoracotomy)accessusingdirect,echocardiographicorfluoroscopicvisualizationtechniques. Contraindications: This device is not intended for use exceptasindicatedabove.

MosaicandBio-MedicusareregisteredtrademarksofMedtronic,Inc.On-QisaregisteredtrademarkofI-Flow.Swan-GanzisaregisteredtrademarkofEdwardsLifesciences.AlexisisaregisteredtrademarkofAppliedMedical.VicrylandMersileneareregisteredtrademarksofEthicon.FiberWireisaregisteredtrademarkofArthrex–Orthopedics.

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