Atlas of Cardiac Surgical Techniques 2e 2019 - Elsevier

Atlas of
Cardiac Surgical
Techniques
Second Edition
Frank W. Sellke, MD
Karl Karlson & Gloria Karlson Professor of Surgery
Warren Alpert Medical School
Brown University;
Chief of Cardiothoracic Surgery
Director, Lifespan Cardiovascular Institute
Rhode Island Hospital
Providence, Rhode Island
Marc Ruel, MD, MPH

Professor
Michael Pitfield Chair
Head, Division of Cardiac Surgery
University of Ottawa Heart Institute
Ottawa, Ontario, Canada
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
ATLAS OF CARDIAC SURGICAL TECHNIQUES, SECOND EDITION ISBN: 978-0-323-46294-5
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Contributors
Arvind K. Agnihotri, MD Munir Boodhwani, MD, MMSc

Steward Center for Advanced Cardiac Surgery Assistant Professor
Division of Cardiac Surgery Director of Thoracic Aortic Program
St. Elizabeth’s Medical Center Division of Cardiac Surgery
Boston, Massachusetts University of Ottawa Heart Institute
Postinfarction Ventricular Septal Defect Repair Ottawa, Ontario, Canada
Aortic Valve Repair
Gorav Ailawadi, MD
Professor of Surgery Vincent Chan, MD, MPH
Chief, Division of Cardiovascular Surgery Division of Cardiac Surgery
Director, Minimally Invasive Cardiac Surgery University of Ottawa Health Institute;
Surgical Director, Advanced Cardiac Valve Center School of Epidemiology, Public Health, and Preventive
University of Virginia Medicine
Charlottesville, Virginia University of Ottawa
Percutaneous Mitral Valve Repair Techniques Ottawa, Ontario, Canada
Mitral Valve Replacement
Mani Arsalan, MD
Kerckhoff Heart Center Michael W.A. Chu, MD
Department of Cardiac Surgery Division of Cardiac Surgery
Bad Nauheim, Germany Department of Surgery
Transcatheter Aortic Valve Replacement Western University
London Health Sciences Centre
Gurjyot Bajwa, MD London, Ontario, Canada
Cleveland Clinic Abu Dhabi Hybrid Coronary Revascularization
Abu Dhabi, United Arab Emirates
Minimally Invasive Mitral Valve Surgery: Partial Sternotomy Joseph S. Coselli, MD
Approach Professor and Cullen Foundation Endowed Chair
Division of Cardiothoracic Surgery
Craig J. Baker, MD Michael E. DeBakey Department of Surgery
Division of Cardiac Surgery Baylor College of Medicine;
Department of Surgery Chief of the Section of Adult Cardiac Surgery
Keck School of Medicine The Texas Heart Institute
University of Southern California CHI St. Luke’s Health–Baylor St. Luke’s Medical Center
Los Angeles, California Houston, Texas
Ross Procedure Thoracoabdominal Aneurysms
Joseph E. Bavaria, MD Garrett Coyan, MD, MS

Department of Cardiovascular Surgery Department of Cardiothoracic Surgery
Hospital of the University of Pennsylvania UPMC Presbyterian
Philadelphia, Pennsylvania Pittsburgh, Pennsylvania
Thoracic Endovascular Aortic Repair for Descending Thoracic Ventricular Assistance and Support
Aortic and Aortic Arch Aneurysms
François Dagenais, MD
Johannes Bonatti, MD, FETCS Quebec Heart and Lung Institute
Chief, Heart and Vascular Institute Department of Cardiovascular Surgery
Cleveland Clinic Abu Dhabi Laval University
Abu Dhabi, United Arab Emirates Quebec City, Quebec, Canada
Robotic Coronary Artery Bypass Grafting Type A Aortic Dissections
iii
iv Contributors
Jolian Dahl, MD Jacqueline H. Fortier, MSc

Cardiothoracic Surgery Resident Division of Cardiac Surgery
University of Virginia University of Ottawa Heart Institute
Charlottesville, Virginia Ottawa, Ontario, Canada
Percutaneous Mitral Valve Repair Techniques Off-Pump Coronary Artery Bypass Grafting
Tirone E. David, MD Ravi K. Ghanta, MD

Professor of Surgery Associate Professor of Surgery
University of Toronto; Michael E. DeBakey Department of Surgery
Attending Surgeon Baylor College of Medicine
Peter Munk Cardiac Centre Houston, Texas
Toronto General Hospital Surgery for Left Ventricular Aneurysm and Remodeling
Toronto, Ontario, Canada
Aortic Valve-Sparing Operations Vincenzo Giambruno, MD
Division of Cardiac Surgery
Walter F. DeNino, MD Department of Surgery
Maine Medical Center Western University
Portland, Maine London Health Sciences Centre
Aortic Arch Aneurysms London, Ontario, Canada
Hybrid Coronary Revascularization
Sophie De Roock, MD
Medical Officer A. Marc Gillinov, MD
Quality and Outcomes Heart and Vascular Institute
University of Ottawa Heart Institute Department of Thoracic and Cardiovascular Surgery
Ottawa, Ontario, Canada Cleveland Clinic
Approaches and Techniques for Extracorporeal Membrane Cleveland, Ohio
Oxygenation Robotic Mitral Valve Surgery; Surgery for Atrial Fibrillation
John R. Doty, MD David Glineur, MD

Intermountain Heart Institute Division of Cardiac Surgery
Intermountain Medical Center University of Ottawa Heart Institute
Murray, Utah Ottawa, Ontario, Canada
Aortic Root Enlargement Techniques Off-Pump Coronary Artery Bypass Grafting; Approaches and
Techniques for Extracorporeal Membrane Oxygenation
Afshin Ehsan, MD
Associate Professor Andrew B. Goldstone, MD
Department of Surgery Postdoctoral Research Fellow
Warren Alpert Medical School Department of Cardiothoracic Surgery
Brown University; Stanford University
Director of Minimally Invasive Cardiac Surgery Palo Alto, California
Rhode Island Hospital Repairing Degenerative Mitral Valve Disease
Aortic Valve Replacement Juan B. Grau, MD
Gebrine El Khoury, MD University of Ottawa Heart Institute
Professor Ottawa, Ontario, Canada
Saint-Luc Hospital Off-Pump Coronary Artery Bypass Grafting
Bruxelles, Belgium
Aortic Valve Repair Dustin Hang, MD
Research Fellow
Elsayed Elmistekway, MD Department of Cardiovascular Surgery
Division of Cardiac Surgery Mayo Clinic
University of Ottawa Heart Institute Rochester, Minnesota
Ottawa, Ontario, Canada Surgery for Hypertrophic Cardiomyopathy
Tricuspid Valve Operations
Contributors v
Faisal Hasan, MD S. Ram Kumar, MD, PhD

Interventional Cardiologist Division of Cardiac Surgery
Heart and Vascular Institute Department of Surgery
Cleveland Clinic Abu Dhabi Keck School of Medicine
Abu Dhabi, United Arab Emirates; University of Southern California
Associate Clinical Professor of Medicine Los Angeles, California
Cleveland Clinic Lerner College of Medicine Ross Procedure
Case Western Reserve University
Cleveland, Ohio Joseph Lamelas, MD
Robotic Coronary Artery Bypass Grafting Professor and Associate Chief
Division of Cardiothoracic Surgery
Syed Tarique Hussain, MD Michael E. DeBakey Department of Surgery
Assistant Professor of Surgery, Associate Staff Baylor College of Medicine
Department of Thoracic & Cardiovascular Surgery CHI Baylor St. Luke’s Medical Center
Cleveland Clinic Texas Heart Institute
Cleveland, Ohio Houston, Texas
Surgery of the Left Heart Valve Infective Endocarditis Minimally Invasive, Mini-Thoracotomy Aortic Valve Replacement
John S. Ikonomidis, MD, PhD Scott A. LeMaire, MD

Professor and Chief Professor and Vice Chair for Research
Division of Cardiothoracic Surgery Division of Cardiothoracic Surgery
University of North Carolina at Chapel Hill Michael E. DeBakey Department of Surgery
Chapel Hill, North Carolina Baylor College of Medicine;
Aortic Arch Aneurysms Cardiovascular Surgery Staff
The Texas Heart Institute
Hoda Javadikasgari, MD CHI St. Luke’s Health–Baylor St. Luke’s Medical Center
Heart and Vascular Institute Houston, Texas
Department of Thoracic and Cardiovascular Surgery Thoracoabdominal Aneurysms
Cleveland Clinic
Cleveland, Ohio Jessica G.Y. Luc, MS
Robotic Mitral Valve Surgery; Surgery for Atrial Fibrillation Faculty of Medicine and Dentistry
University of Alberta
Bob Kiaii, MD Edmonton, Alberta, Canada
Division of Cardiac Surgery Thoracoabdominal Aneurysms
Department of Surgery
Western University Abeel A. Mangi, MD
London Health Sciences Centre Yale University School of Medicine
London, Ontario, Canada Department of Surgery
Hybrid Coronary Revascularization Section of Cardiac Surgery
New Haven, Connecticut
Won-Keun Kim, MD Postinfarction Ventricular Septal Defect Repair
Kerckhoff Heart Center
Department of Cardiac Surgery and Cardiology Thierry G. Mesana, MD, PhD
Bad Nauheim, Germany President and CEO
Transcatheter Aortic Valve Replacement University of Ottawa Heart Institute
Ottawa, Ontario, Canada
Irving L. Kron, MD Mitral Valve Replacement; Tricuspid Valve Operations
Professor and Chair
Department of Surgery Stephanie Mick, MD
University of Virginia Cardiac Surgeon
Charlottesville, Virginia Heart and Vascular Institute
Surgery for Left Ventricular Aneurysm and Remodeling Cleveland Clinic
Cleveland, Ohio
Robotic Coronary Artery Bypass Grafting; Robotic Mitral Valve
Surgery
vi Contributors
Tomislav Mihaljevic, MD Vivek Rao, MD, PhD

Heart and Vascular Institute Chief, Cardiovascular Surgery
Department of Thoracic and Cardiovascular Surgery Peter Munk Cardiac Centre
Cleveland Clinic Toronto General Hospital;
Cleveland, Ohio Professor
Minimally Invasive Mitral Valve Surgery: Partial Sternotomy Department of Surgery
Approach; Robotic Mitral Valve Surgery University of Toronto
Toronto, Ontario, Canada
Hlal Moncef, MD Heart Transplantation
Quebec Heart and Lung Institute
Department of Cardiovascular Surgery Sajjad Raza, MD
Laval University Department of Surgery
Quebec City, Quebec, Canada University Hospitals Cleveland Medical Center
Type A Aortic Dissections Cleveland, Ohio
Aortic Root Enlargement Techniques
Zhaozhou Niu, MD
Division of Cardiac Surgery Igo B. Ribeiro, MD, MS(HPEd)
University of Ottawa Heart Institute Resident, Division of Cardiac Surgery
Ottawa, Ontario, Canada University of Ottawa Heart Institute
Mitral Valve Replacement Ottawa, Ontario, Canada
Off-Pump Coronary Artery Bypass Grafting
Michael J. Paulsen, MD
Cardiothoracic Surgery Resident Maria Lorena Rodriguez, MD
Postdoctoral Research Fellow Assistant Professor
Department of Cardiac Surgery Division of Cardiac Surgery
Stanford University University of Ottawa
Palo Alto, California Ottawa, Ontario, Canada
Repairing Degenerative Mitral Valve Disease Minimally Invasive Coronary Artery Bypass Grafting;
Aortic Valve Repair
Gӧsta B. Pettersson, MD, PhD
Professor of Surgery Fraser D. Rubens, MD, MSc, FACS, FRCS(C)
Vice Chairman Professor of Surgery
Department of Thoracic & Cardiovascular Surgery Division of Cardiac Surgery
Cleveland Clinic University of Ottawa Heart Institute
Cleveland, Ohio Ottawa, Ontario, Canada
Surgery of the Left Heart Valve Infective Endocarditis Cannulation Techniques for Cardiopulmonary Bypass
Ourania Preventza, MD, FACS, MBA Marc Ruel, MD, MPH

Associate Professor of Surgery Professor
Division of Cardiothoracic Surgery Michael Pitfield Chair
Michael E. DeBakey Department of Surgery Head, Division of Cardiac Surgery
Baylor College of Medicine; University of Ottawa Heart Institute
Cardiovascular Surgery Staff Ottawa, Ontario, Canada
The Texas Heart Institute Minimally Invasive Coronary Artery Bypass Grafting;
The Texas Heart Institute Mitral Valve Replacement
CHI St. Luke’s Health–Baylor St. Luke’s Medical Center
Houston, Texas Joseph F. Sabik III, MD
Thoracoabdominal Aneurysms Department of Surgery
University Hospitals Cleveland Medical Center
Dominique Prud’Homme, MD Cleveland, Ohio
Chief of Cardiovascular and Thoracic Anesthesia Aortic Root Enlargement Techniques
Department of Cardiothoracic Anesthesiology
Cleveland Clinic Abu Dhabi Hartzell V. Schaff, MD
Abu Dhabi, United Arab Emirates; Department of Cardiovascular Surgery
Cardiothoracic Anesthesia Mayo Clinic
Cleveland, Ohio Rochester, Minnesota
Robotic Coronary Artery Bypass Grafting Surgery for Hypertrophic Cardiomyopathy
Contributors vii
Christopher Sciortino, MD, PhD Vaughn A. Starnes, MD

Surgical Director of the Advanced Heart Failure Division of Cardiac Surgery
Center Department of Surgery
Department of Cardiothoracic Surgery Keck School of Medicine
UPMC Heart and Vascular Center University of Southern California
University of Pittsburgh School of Medicine Los Angeles, California
Pittsburgh, Pennsylvania Ross Procedure
Ventricular Assistance and Support
Ibrahim Sultan, MD
Hiroshi Seki, MD Assistant Professor of Surgery
Division of Cardiac Surgery Department of Cardiothoracic Surgery
Yamato Seiwa Hospital University of Pittsburgh
Yamato, Kanagawa, Japan Pittsburgh, Pennsylvania
Surgical Incisions Thoracic Endovascular Aortic Repair for Descending Thoracic
Aortic and Aortic Arch Aneurysms
Frank W. Sellke, MD
Karl Karlson & Gloria Karlson Professor of Surgery Rakesh M. Suri, MD, DPhil
Warren Alpert Medical School Heart and Vascular Institute
Brown University; Department of Thoracic and Cardiovascular Surgery
Chief of Cardiothoracic Surgery Cleveland Clinic
Director, Lifespan Cardiovascular Institute Cleveland, Ohio
Rhode Island Hospital Robotic Mitral Valve Surgery
On-Pump Coronary Artery Bypass Grafting; Wilson Y. Szeto, MD
Aortic Valve Replacement Division of Cardiovascular Surgery
Department of Surgery
Richard Jay Shemin, MD University of Pennsylvania
Robert & Kelly Day Professor University of Pennsylvania School of Medicine
Professor and Chairman Peen Presbyterian Medical Center
Division of Cardiac Surgery Philadelphia, Pennsylvania
University of California, Los Angeles Thoracic Endovascular Aortic Repair for Descending Thoracic
Los Angeles, California Aortic and Aortic Arch Aneurysms
Bentall Procedure
Sharven Taghavi, MD, MPH, MS
Neel R. Sodha, MD Clinical Fellow
Assistant Professor of Surgery Department of Surgery
Division of Cardiothoracic Surgery Brigham and Women’s Hospital
Warren Alpert Medical School Boston, Massachusetts
Brown University Postinfarction Ventricular Septal Defect Repair
On-Pump Coronary Artery Bypass Grafting Patrick Teefy, MD
Division of Cardiology
Edward G. Soltesz, MD Department of Medicine
Department of Thoracic and Cardiovascular Surgery Western University
Heart and Vascular Institute London Health Sciences Centre
Cleveland Clinic London, Ontario, Canada
Cleveland, Ohio Hybrid Coronary Revascularization
Surgery for Atrial Fibrillation
Hadi Toeg, MD, MSc, MPH, FRCS(C)
Kumar Sridhar, MD Division of Cardiac Surgery
Division of Cardiology University of Ottawa Heart Institute
Department of Medicine Ottawa, Ontario, Canada
Western University Cannulation Techniques for Cardiopulmonary Bypass; Approaches
and Techniques for Extracorporeal Membrane Oxygenation
London Health Sciences Centre
London, Ontario, Canada
Hybrid Coronary Revascularization
viii Contributors
Dai Une, MD Y. Joseph Woo, MD

Chief, Division of Cardiovascular Surgery Norman E. Shumway Professor and Chair of
Yamato Seiwa Hospital Cardiothoracic Surgery
Yamato, Kanagawa, Japan Department of Cardiothoracic Surgery
Surgical Incisions Stanford University
Palo Alto, California
Gus J. Vlahakes, MD Repairing Degenerative Mitral Valve Disease
Massachusetts General Hospital Cameron D. Wright, MD
Boston, Massachusetts Professor of Surgery
Chronic Thromboembolic Pulmonary Hypertension Division of Thoracic Surgery
Massachusetts General Hospital
Thomas Walther, MD Boston, Massachusetts
Kerckhoff Heart Center Chronic Thromboembolic Pulmonary Hypertension
Department of Cardiac Surgery
Bad Nauheim, Germany
Transcatheter Aortic Valve Replacement
Preface
The first edition of Atlas of Cardiac Surgical Techniques was very well received, giving trainees
and veteran surgeons a quick reference on how some established technical masters perform
selected cardiac operations. The Pearls and Pitfalls Section at the end of each chapter gives
clinically important details that may be missed in other textbooks, and allows all cardiac surgeons
to benefit from the years of experience of established experts, many of whom developed the
operations they are describing. Thus, we were especially pleased when we were asked to revise
the first edition. Several new techniques have developed since the publication of the first Atlas,
such as percutaneous mitral valve repair and transcatheter aortic valve replacement. Other
methods, such as aortic valve repair, have become a more standard method to treat aortic valve
insufficiency. Chapters on these techniques and others are included in this new edition of the
Atlas. Although many chapters are similar to those found in the previous edition, all were
rewritten. Several chapters were completely rewritten by new authors, not because the authors
of the previous chapters did not do an excellent job, but to give a novel perspective of the surgical
treatment of the cardiovascular conditions. Because some operations, such as pulmonary end-
arterectomy and surgery for hypertrophic cardiomyopathy, are only performed routinely in
several centers, we decided to include chapters on these operations. Minimally invasive techniques
of coronary artery surgery and aortic and mitral valve surgery are emphasized in the new edition.
As in the previous edition, the treatment of aortic disease is covered extensively. To make room
for new chapters, some old chapters unfortunately had to be deleted. Although the purpose of
the Atlas is not to give an exhaustive description of all cardiac operations, the vast majority of
adult cardiac operations currently performed are described in sufficient detail to allow young
surgeons to learn the techniques and help established surgeons to refine their methods according
to experts in the field.
The editors of this edition of Atlas of Cardiac Surgical Techniques are indebted to their teachers
and surgical colleagues. We hope the second edition will honor the legacy of our teachers and
be as well received as was the first edition.
Frank W. Sellke, MD
Marc Ruel, MD, MPH
ix
CONTENTS
Section I Bc.lsic Techniques

CHAPTER I SURGICAL 11 CISIONS
I liroshi Seki and Dai Unc
CHAPTER :2 CAN ULATIO TECHi'\IQUES FOR CARDIOPULJ\ \01 ARY BYPASS 1.�
I ladi ·1ocg and Fraser D. Rubens
Section 11 Operations for Corondry Artery Dis 'dSC

CHAPTER-� 0 '-PUMP CORO ARY ARTERY BYPASS GRAl·-rlNG 55
Frank W. Scllkc and Neel R. Sodha
CHAPTER 4 OFF-PUMP CORONARY ARTl:RY BYPASS GRAl·-r!NG -w

Igo 13. Ribeiro Juan B. Grau, Jacqueline H. Fort ie r and David Glineur
. .
CHAPTER ·1 1\1li':l1\'1ALLY INVASIVE CORO 'ARY ARTERY BYPASS GRAFT! 'G 70

Maria Lorena Rodriguez and Marc Ruel
CHAPTER 6 I IYBRID COR01 ,.\RY REVASCULARIZATION Bs

Bob Kiaii. Vincenzo Giambruno. Patrick Teefy. Michael \V.A. Chu. and Kumar Sridhar
CHAPTER; ROBOTTC CORONARY ARTERY BYPASS GR1\FTTNG 105

Johannes Bonatti, Faisal Hasan, Dominique Prud"l lommc, and Stephanie Mick
CHAPTER H POSTTNFARCTION VE TTRICLTLAR SEPTAL OF.FF.CT REPAIR 1q

Sharvcn Taghavi, Abecl A. Mangi, and Arvind K. Agnihotri
Section 111 Opcrntions for Va lvul a r Hec1rt Disc;1sc

CHAPTER 9 AORTIC VALVE REPLACEMENT 129
Afshin Ehsan and Frank W Scllkc
CHAPTER 10 1\\li'\llv�ALLY INVASIVE, 1'v\1Nl-Tl lORACOT01\\Y AORTIC VALVE

RF.PLACF.1\ \E1'1T qo
Joseph Lamelas
CHAPTER 11 AORTIC ROOT ENLARGE,\ \.E1 T TECI INJQUES 1'>6

john R. Doty, Saijad Raza. and Joseph F. Sabik Ill
CHAPTER u AORTIC VALVE REPAIR IT/

Maria Lorena Rodriguez, Gebrinc El Khoury. and \lunir Boodhwani
CHAPTER 1-s AORTIC VALVE-SPARlNG OPERATIO S 199

Tirone F.. David
CHAPTER q HE TALL PROCEDURE .215

Richard Jay Shem in
CHAPTER 115 SURGERY OF THE LEFT HEART VALVE INFECTIVE: ENDOCARDITIS D:i
Gosta 13. Peuersson and Syed Tarique Hussain
CHAPTER 16 TRA 'SCATHETER AORTIC VALVE RIPLACEi\\E T :i.µ

Mani Arsalan, Won-Kcun Kim. and Thomas Walther
xi
xu Contents
CHAPTER 17 ROSS PROCEDURE 260

Craig]. Baker, S. Ram Kumar, and Vau ghn A. Starnes
CHAPTER 18 REPA JR J JG DEGE fRA TlVE .t'vUTRAL VALVE DISEASE

! 269
Woo
Michael J. Paulsen, Andrew B. Goldst0ne, and Y. Joseph
CHAPTER 19 MTTRAL VALVE REPLACE1\l\ENT 306

Zhaozhuo Niu, Thieny G. Mesana, Marc Ruel. and Vincent Chan
CHAPTER 20 MJNIMJ\Ll Y INVASIVE MITRAl VALVE SURGERY:

PARTIAL STERNOTOMY APPROACH 33:.i
Gu rjyo1 Bajwa and Tomislav Mihaljevic
CHAPTER 2·1 ROBOTIC MTTRAL VALVE SURGERY 34/

Hoda J ava clika sgar i A. Marc Gillinov, Stephanie Mick, Tomislav Mihaljevic, and Rakesh M. Su r i
,
CHAPTER :u PERCUTANEOUS MITRAl VALVE REPAIR TECHNIQUES 364

jolian Dahl and Gorav Ailawadi
CHAPTER 1·5 TRTCUSPID VALVE OPERATIONS 384

Elsayed Elmistekawy and Thierry G. Mesana
section lV Operations for Aortic Disease_

CHAPTER 24 TYPE A AORTTC DISSECTlON 409
I-Ila! Monce! and Fran<;ois Dagenai s
CHAPTER 25 AORT I C ARCI J At'-IEURYSMS 424

Walter E DeN ino and john S. l kon om id is
CHAPTER 26 TT JORACOABD01\l\JNAL ANEURYSi\t\S 438
Ourania Preventza, Jessica G.Y. Luc, Scott A. LeMaire, and Joseph S. Coselli
CHAPTER 27 THORACIC ENDOVASCULAR AORTIC REPAIR FOR DESCENDING TIIORACIC

AORTIC AND AORTIC ARCJ I ANEURYSi \S 455
Ibrahim Sultan, Joseph E. Bavaria, and Wilson Y. Szeto
Section V 1\!\iscella.neous Operations
CHAPTER 28 SURGERY FOR ATRIAL FIBRILLATION 479

Hoda javaclikasgari, Edward G. Soltesz, and A. Marc Gillinov
CHAPTER 29 SURGERY FOR TTYPERTROPTTTC CARDJ01\l\YOPATITY 489

Dustin Hang and Hartzell V. Schaff
CHAPTER 30 SURG E R Y FOR LEFT VENTRICULAR ANEURYSM AND REM O DE LIN G �>os
Ravi K. Gh ant a a nd l rvi ng L Kron
CHAPTER 31 APP ROACHES AND TECHNIQUES FOR EXTRACORPOREAL 1\1\EMBRANE

OXYGENATTO 510
l-Iacli Toeg, David Glineur, and Sophie De Roock
CHAPTER 32 VEN TRJC ULAR ASSISTANCE AND SU PPORT 531

Garrett Co)'an and C hris t o p her Sciortino
CHAPTER 33 HEART TRA1 SPLN TATl01 546

Vivek Rao
CHAPTER 34 CHRONIC THROJ\11BOEMJ30LIC PULMONARY HYPERTENSION "66

.)
Gus J. Vlahakes and Cameron D. Wr ight
Video Contents
CHAPTER 4 Off-Pump Coronary Artery Bypass Grafting

LAD Exposure
Sling Technique for Lateral Wall Exposure
Shunt Insertion
CHAPTER 5 Minimally Invasive Coronary Artery Bypass Grafting

Opening
Identifying and Avoiding the Phrenic Nerve
Pericardial Traction of Aortic Aneurysm
Aortic Presentation
Proximal Anastomoses
Apical Positioner
Distals
Distals B
Closure
Distal Anastomoses
CHAPTER 12 Aortic Valve Repair

Assessment of Valve Prolapse
Cusp Prolapse Repair
Subcommissural Annuloplasty
CHAPTER 22 Percutaneous Mitral Valve Repair Techniques

Echocardiographic Clip of Degenerative Mitral Regurgitation (DMR) Caused by a Flail Leaflet
MitraClip System IAS Perforation
MitraClip Leaflet Capture
MitraClip Creation of the Double Orifice
CHAPTER 26 Thoracoabdominal Aneurysms

Use of a Prefabricated Branch Graft to Reattach Visceral Arteries
CHAPTER 32 Ventricular Assistance and Support
Implementation of Left Ventricular Assist Device
xiii
'
SECTION i·
Basic
Techniques
CHAPTER
1
Surgical Incisions
Hiroshi Seki and Dai Une
◆ The median sternotomy was reintroduced by Julian in 1957, which was already described
by Milton in 1897.1 The median sternotomy has become a gold standard approach for cardiac
procedures, with subsequent developments in cardiac surgery. The skin incision could be
shortened caudally or cranially up to half the length of the sternum. This approach allows
excellent access to every cardiac chamber and to vessels entering and leaving the medial
mediastinum. It could also be extended laterally through the ribs into the intercostal space,
which allows extension of the procedure to the distal arch and descending aorta, if required.
◆ Another approach is the thoracotomy. Ludwig Rehn, in Frankfurt, Germany, is noted as the
first surgeon who successfully placed a suture through a left-sided thoracotomy. This was
done in 1896 on the heart of a 22-year-old gardener’s assistant, who was injured after a
stabbing.2
◆ A thoracotomy can be divided into anterior and posterior thoracotomies, depending on the
surgical procedure required. The anterior approach allows good access to the internal mammary
artery and to the coronary vessels and heart valves. The posterior thoracotomy requires a
lateral decubitus position and enables access to the descending aorta and distal aortic arch.
During thoracoabdominal aortic surgery, this incision could be extended and combined with
a pararectal incision and entry into the retroperitoneum.
◆ The choice of incision is influenced by certain factors, such as urgency of the procedure,
nature and extent of the procedure, and possibility or necessity of extension of the procedure.
A history of previous cardiac or thoracic procedures, comorbidities of the patient, patient’s
preference, and cosmetic aspects are other factors.
◆ Diabetes, obesity, chronic obstructive pulmonary disease, and the use of bilateral mammary
arteries are known risk factors of a sternal wound infection. These factors may influence the
decision of which incision to use and the method of closure.
3
Chapter 1 • Surgical Incisions 3.e1
Keywords
sternotomy
partial sternotomy
lateral anterolateral thoracotomy
posterolateral thoracotomy
4 Section I • Basic Techniques
Sternotomy
Step 1. Operative Steps
Full Sternotomy
◆ The most essential consideration in performing a sternotomy is that it is done through the
midline. The suprasternal notch and xyphoid process are used as landmarks. The latter
sometimes has an asymmetric configuration and therefore it is helpful to control the edge of
the ribs on both sides to find the middle. A paramedian sternotomy may be harmful to the
sternum and is a significant risk factor for sternum instability, which could lead to disturbances
in wound healing.
◆ The patient is placed supine on the operating table. A linear incision is made from just above
the sternal angle to the level of the xiphoid process. Subcutaneous fat and presternal fascia
are divided, and the linea alba is divided inferiorly about 2 to 3 cm to obtain adequate
exposure of the pericardium (Fig. 1.1). It is essential to divide the interclavicular ligament at
the top of the suprasternal notch using electrocautery. Special attention should be taken to
identify the veins crossing this area—the jugular venous arch. Injury of the veins in this area
could injure other important structures, such as the trachea or brachiocephalic artery, if the
bleeding is not controlled, especially if the view is limited due to small incisions. There are
also veins crossing the upper part of the xyphoid cartilage, which should be identified and
cauterized. The midline of the sternum is marked by electrocautery. Scissors could be used
to divide the xyphoid process separately. The sternum is divided with a saw in a caudocranial
fashion, with close attention paid to staying on the midline. The sternum could be also be
divided in a craniocaudal fashion, changing the direction of the saw blade.
◆ It is prudent to ask the anesthesiologist to stop the mechanical ventilation to avoid unnecessary
opening of the pleura with the saw. The saw should be lifted slightly against the posterior
plate of the sternum, and care should be taken to avoid injury to the pericardium, thymus,
and innominate vein. If the peritoneum is opened accidentally, it is important to close the
peritoneum expeditiously to avoid fluid incorporation and subsequent adhesion in the peri-
toneum. Extension of the incision cranially facilitates exposure of the arch and supraaortic
vessels. On the other hand, the gastroepiploic artery could be harvested, extending the incision
into the peritoneal space.
◆ In patients with previous cardiac procedures, extra attention must be paid not to injure the
cardiac structures, which could lead to hemorrhagic shock or an air embolism, with lethal
consequences. Careful blunt dissection may be performed below the xyphoid process to free
the pericardial and pleural adhesions. Gentle elevation of the sternum with sharp hooks or
unloading and establishing a cardiopulmonary bypass (CPB) over the femoral vessels may be
advisable in select cases as a safeguard. In case of redo, computed tomography (CT) and
magnetic resonance imaging (MRI) are helpful imaging modalities to evaluate the risk of
reentry.
◆ After sternum division, hemostasis is obtained by cauterizing the periosteal surface of the
sternum. Bone wax may be used to seal the bone marrow and control bleeding, although
some surgeons prefer to simply apply a towel.
◆ In redo cases, it is crucial to dissect the attachment to the edge of the sternum before retracting
because the retraction could injure structures, such as the lung or innominate vein through
tension.
Chapter 1 • Surgical Incisions 5
Jugular venous arch

Suprasternal notch
Incision
Xiphoid
process
Linea alba
Figure 1.1
Figure 1.1 Standard median sternotomy. Identification and division at the middle of the sternum is the A and O. The skin incision could
be reduced to ca. 10 cm and still divide the sternum completely.
Step 2. Partial Sternotomy
◆ An upper or lower partial sternotomy may be used for certain procedures, such as isolated
aortic or mitral valve repair or replacement or bypass surgery with certain target vessels. The
sternum could be divided into different patterns through the third or fourth intercostal
space—J shape, L shape, or inverted T shape (Fig. 1.2). The fourth intercostal space usually
enables a good exposure of the aorta and root to be obtained. Access to the right atrium
could be limited, which makes direct insertion of the venous cannula into the appendage of
the right atrium laborious. It is important to have the option to cannulate the femoral vein
if exposure of the right atrium is not sufficient, especially in the case of a smaller incision
through the third intercostal space. Venting through the pulmonary artery may be useful in
select cases with limited access to the upper right pulmonary vein.
◆ A small incision has the advantage of reducing the wound area and preventing wound infections
due to sternum instability, reducing the requirement for a blood transfusion, and shortening
the stay in the intensive care unit. Small incisions are also preferred by the patients for
cosmetic reasons.
Step 3. Sternotomy Closure
◆ At the end of the procedure, chest drains are placed through separate stab incisions at the
epigastrium. Care must be taken so that the drain passes through the fascia of the rectus
muscle, avoiding the epigastric pedicle. If necessary, chest drains for the pleura should be
placed through the fifth or sixth intercostal space or through a subcostal tunnel from a stab
incision below the costal arch.
◆ After thorough hemostasis and placement of chest drains, the sternum is closed using six to
eight stainless steel wires. Consideration for ensuring the stability of the manubrium is essential.
The risk of cutting by wires could be reduced through placement of the wires through the
intercostal space. Care should be taken to stay close to the edge to minimize the risk of injury
to the internal thoracic artery. Bands or plates could be used as an alternative to the wires to
stabilize a fragile sternum with osteoporosis, or a paramedian sternotomy could be carried
out in select cases.
◆ The insertion sites of the wires are controlled for bleeding. The wires are tied individually or
by putting two together in a figure-of-eight fashion. Reinforcement of the sternum edge is

advisable in case of asymmetric division of the sternum by placing an extralongitudinal wire
at both sides of the sternum to avoid cutting through the wire, as proposed by Robicsek
et al.3 (Fig. 1.3). Wire tips are then buried in the presternal fascia. The linea alba is closed
using running or interrupted fascia closure sutures, and the subcutaneous tissue is closed
using absorbable sutures. Skin closure is performed using subcuticular sutures or skin staples.
Figure 1.2
View from the side
Figure 1.3
Figure 1.2 A partial sternotomy gives good exposure of the aortic root and could be selected to reduce the incidence of sternum instability
and wound infection.
Figure 1.3 Closure of the sternum with additional bilateral longitudinal wires for reinforcement introduced from Robiscek.
Thoracotomy
Step 1. Approaches in Thoracotomy
◆ A right anterolateral thoracotomy incision may be used for mitral and tricuspid valve repair
or replacement, aortic valve replacement, atrial septum defect repairs, and right-sided pulmonary
vein isolation procedures for atrial fibrillation. The right anterior thoracotomy may be further
divided into a supramammary, usually through the second intercostal space, and a submammary,
usually through the fourth or fifth intercostal space.
◆ The right-sided supramammary anterior thoracotomy allows good access to the aortic valve.
In most cases, the second or third rib needs to be detached from the sternum, and the right
internal thoracic artery would need to be sacrificed. Using a thoracoscope and aortic clamp,
with a Chitwood clamp through another site, can provide better exposure of the operative
field. In such cases, the detachment of the rib and sacrifice of the internal thoracic artery
may not be necessary. This approach is reported to be useful in all aortic valve cases,4 especially
in patients with an elongated aorta, in which the ascending aorta is shifted to the right; this
would exacerbate an approach through a partial sternotomy.
◆ A right submammary thoracotomy allows an approach to the lower part of the heart, including
the mitral and tricuspid valves. A right submammary anterolateral thoracotomy can be an
alternative approach for mitral valve procedures; it may be the desirable approach in the
setting of a high-risk sternal reentry. A small right thoracotomy can be used for other procedures
on the tricuspid valve, for closure of an atrial septal defect, or for tumor resection using a
minimally invasive technique. Technologic advancements and new developments in instruments,
video-assisted vision, and additional femoral access for the CPB have facilitated minimal
incisions, with preserved quality of the surgical repair, similar to that achieved by a traditional
sternotomy.5 Minimization of the incision is cosmetically attractive and prevents wound
complications of the sternum in high-risk patients. On the other hand, complications such
as lung hernia and lymph fistula, as may be found particularly with this method, have been
reported.
◆ A left-sided submammary anterolateral thoracotomy through the fourth or fifth intercostal
space can be used for coronary artery bypass surgery or pericardial window. A lower incision
and approach through the fifth intercostal space enables excellent access to the apex of the
heart and can be used for transapical aortic valve implantation. It can also be used for
implantation of the inflow part of a left ventricular assist device within the pericardial space.
A small left anterior thoracotomy incision can be used for single-vessel coronary artery bypass
to the anterior coronary circulation, as well as for multivessel coronary revascularization in
select cases (see Chapter 5). Compared with off-pump coronary artery bypass grafting (CABG),
CABG through a small left thoracotomy has resulted in less wound infection, less transfusion,
and earlier recovery.6
◆ A posterior left-sided lateral thoracotomy is used for descending aortic procedures, and this
incision can be extended, dividing the rib cage to get exposure of the supra- and infradiaphragm
part of the aorta. It provides good access to the left heart bypass. Occasionally, this approach
may be used for grafting to isolated lesions of the circumflex coronary artery territory from
the descending aorta in situations in which sternal entry carries high risk.
Supramammary Anterolateral Thoracotomy
◆ The patient is placed supine on the operating table and the ipsilateral side is elevated 30 to
45 degrees with the arm placed at the side. An incision is made above the upper edge of the
third rib, and the pectoralis major and minor muscles are divided using electrocautery (Fig.
1.4). The desired intercostal space (mostly second, occasionally third) is entered after dividing
the intercostal muscles on top of the rib and the rib is disattached from the sternum using
an oscillating saw and then pushed into the thoracic space to facilitate exposure. The right
internal thoracic artery should be detected and sacrificed with metal clips at this step. With
assistance of a video scope and an extra site for the aortic clamp, the supramammary incision
could be shifted lateral and the procedure could be performed through the intercostal space
without resection and dislocation of the rib.
Submammary Anterolateral Thoracotomy
◆ The patient is placed supine on the operating table, and the ipsilateral side is elevated 30 to
45 degrees, with the patient’s arm placed at the side. A submammary incision is made, and
the pectoralis major muscle is divided using electrocautery (Fig. 1.5). The serratus anterior
muscle is divided using electrocautery. The dorsal latissimus muscle could be divided or
retracted and preserved as well. The desired intercostal space (fourth or fifth) is entered after
dividing the intercostal muscles on top of the rib to avoid injury of the intercostal neurovascular
bundle. A partial rib resection may be performed to facilitate exposure.
Posterolateral Thoracotomy
◆ The patient is placed in the lateral decubitus position, with a roll placed underneath the
dependent axilla. After the patient is secured to the operating table and adequate cushioning
is provided to dependent areas, the upper arm is extended anteriorly and cephalad.
◆ A curvilinear incision is started in the submammary region and extended posterolaterally,
traversing 1 to 2 cm below the tip of the scapula and extending craniad midway between the
spine and scapula (Fig. 1.6).
◆ The subcutaneous tissue and trapezius muscles are divided using electrocautery. The serratus
anterior muscle is divided but may be preserved and retracted. The latissimus dorsi muscle
is similarly retracted away from the surgical field. The incision may be continued posteriorly
up to the level of the paraspinous muscle.
◆ The thoracic cavity may be entered through the fourth or fifth interspace at the top of the
rib to avoid the intercostal neurovascular bundle. A partial rib resection may be performed
to facilitate exposure.
Incision
Incision
suprammamary
anterolateral
thoracotomy
Dividing pectoralis
major muscle
Figure 1.4 Figure 1.5
Incision
Latissimus
dorsi muscle
Figure 1.6
Figure 1.4 Supramammary anterolateral thoracotomy. Excellent exposure of the aortic valve could be obtained with reduced incidence of
wound healing disturbance.
Figure 1.5 Submammary anterolateral thoracotomy. The most common approach for minimal invasive mitral and tricuspid valve surgyer.
An assistance with video thoracoscope facilitates the procedure and enables minimization of the skin incision.
Figure 1.6 Posteolateral thoracotomy and the possible extension of the skin incision for extended aortic surgery. The patient is positioned
in lateral decubitus position. The groin is slightly rotated to maintain access to the femoral vessels.
Thoracotomy Closure
◆ Chest drains are placed two rib spaces below the entry site. It is helpful to grab the muscle
with a clamp and hold it under retraction by insertion to keep enough muscle in the proper
position for closure. Pericostal sutures are placed around the ribs, avoiding the under edge
of the ribs and intercostal neurovascular bundle. Loosening of this suture could lead to a
lung hernia or invagination of the lung if it is not tied properly.
◆ The divided muscle layers are reapproximated using Vicryl sutures. It is important to identify
the firm fascia of the muscle to secure the reapproximation. The skin is closed with subcuticular
sutures or skin staples.
Further Considerations
Step 1. Combination of Minimally Invasive Incisions
◆ An intrapericardial implantation of a left ventricular assist device in the younger patient could
be performed through a combination of an upper partial sternotomy and a left anterolateral
thoracotomy. This procedure possibly reduces intrapericardial adhesion and facilitates the
heart transplantation.
Step 2. Other Incisions
◆ Other incisions are used occasionally for extended exposure of the great vessels. The clamshell
approach (Fig. 1.7) enables access to the hilum of each lung and is an option for bilateral
lung transplantation or heart-lung transplantation. This approach provides an excellent exposure
of the heart and descending aorta, and may be used for select cases that require extended
aortic surgery.
Figure 1.7
Figure 1.7 By the clamshell approach, the sternum is transversally divided at the level between the 3rd and 5th intercostal space. The
upper part of the thorax is opened like a clamshell with retractors. Sternum wires and PDS pericostal sutures are used to close and stabilize
the thorax at the end of the procedure.
References
1. Dalton ML, Connally SR, Sealy WC. Julian’s reintroduction of Milton’s operation. Ann Thorac Surg. 1992;53:532–533.
2. Blatchford JW. Ludwig Rehn: the first successful cardiorrhaphy. Ann Thorac Surg. 1985;39:S492–S495.
3. Robicsek F, Daugherty HK, Cook JW. The prevention and treatment of sternum separation following open-heart surgery. J Thorac
Cardiovasc Surg. 1977;73:267–268.
4. Glauber M, Miceli A, Bevilacqua S, Farneti PA. Minimally invasive aortic valve replacement via right anterior minithoracotomy: early
outcomes and midterm follow-up. J Thorac Cardiovasc Surg. 2011;142:1577–1579.
5. Seeburger J, Borger MA, Falk V, et al. Minimal invasive mitral valve repair for mitral regurgitation: results of 1339 consecutive patients.
Eur J Cardiothorac Surg. 2008;34:760–765.
6. Ruel M, Une D, Bonatti J, McGinn JT. Minimally invasive coronary artery bypass grafting: Is it time for the robot? Curr Opin Cardiol.
2013;28:639–645.
CHAPTER
2
Cannulation
Techniques for
Cardiopulmonary Bypass
Hadi Toeg and Fraser D. Rubens
Step 1. Surgical Anatomy
1. Ascending Aorta
◆ Cannulation sites on the ascending aorta should be as high as safely possible. Surgeons today
more frequently perform complete arterial revascularization, which in some cases may require
delicate proximal anastomoses of arterial conduits (e.g., free internal thoracic arteries, radial
arteries) directly to the aorta. These anastomoses are more difficult to construct if the aorta
is under tension and distorted, such as may occur with a partial occluding clamp. A landmark
for cannulation that is consistently successful for this approach is the pericardial reflection
on the left anterolateral surface of the aorta, just below the innominate vein (Fig. 2.1). This
reflection can be divided to expose an area approximately 1 cm in diameter.
◆ Higher sites of cannulation (arch) may be desirable in cases of demonstrated aortic disease,
and this form of cannulation may be associated with fewer neurologic problems.1 If there is
extensive aortic disease or a hemiarch replacement is considered, the innominate artery can
also be cannulated.2
2. Femoral and Iliac Vessels
◆ It is essential that all trainees be familiar with the anatomy of the common femoral artery,
with emphasis on its branches and its relationship to the inguinal ligament and common
femoral vein (Fig. 2.2). We believe that it is critical to identify the superficial femoral and
profunda femoris arteries to ensure cannulation of the common femoral artery proper.
◆ In some cases, part of the inguinal ligament may need to be divided to provide safe control
of the proximal aspect of the vessel. However, this is not commonly required because of the
availability of easier sites for cannulation (e.g., axillary artery).
14
Chapter 2 • Cannulation Techniques for Cardiopulmonary Bypass 14.e1
Keywords
cannulation techniques
cardiopulmonary bypass
Chapter 2 • Cannulation Techniques for Cardiopulmonary Bypass 15
Pericardial
reflection
excised
Figure 2.1
External Common
iliac artery iliac artery
Femoral Internal
nerve iliac artery
Inguinal
ligament
Common
femoral
artery
Profunda Superficial
femoris femoral
artery artery
Figure 2.2
3. Axillary Artery
◆ Cardiac surgeons should also be familiar with the pertinent anatomy of the axillary artery. In
particular, the axillary vein is anterosuperior to the artery, and the brachial plexus is posterolateral
(Fig. 2.3).
Step 2. Preoperative Considerations
◆ It is essential to identify prospective cannulation sites, even when off-pump surgery is con-
templated, and to communicate this plan with the anesthetist to allow for appropriate monitoring
(e.g., arterial monitoring of both upper extremities).
◆ The surgeon must anticipate vascular access problems in patients with vascular pathology
and in those with cerebrovascular disease. Bilateral blood pressure recording to detect subclavian
stenosis is essential for every patient. The lower extremity vascular assessment should also
be thorough to prepare for a potential femoral artery cannulation. Patients with absent femoral
pulses should undergo vascular imaging to evaluate the size and quality of the lower vessels
and patency of the abdominal aorta. A previous history of lower or upper extremity deep
vein thrombosis must be elicited.
◆ The surgeon should assess the ascending aorta on the chest radiograph and angiogram. If
there is any concern, echocardiography or computed tomography of the ascending aorta

should be used liberally. Intraoperative epiaortic scanning, which is used by some teams
routinely to guide cannulation,3 should also be considered. Although an aortic plaque may
be palpated—often at the base of the innominate artery—it is the presence of mobile plaque
that is most concerning, and an off-pump so-called no-touch aorta approach should be
considered in this situation, if possible.4
◆ High-risk patients should be appropriately draped to access alternative sites, such as the
axillary artery, and the surgeon should discuss all potential approaches and strategies with
the anesthetist and perfusionist before starting to ensure readiness of cannulation and appropriate
monitoring lines.
◆ Finally, with regard to venous cannulation, our practice has been to use two single-stage
cannulae for all cases except simple coronary artery bypass. This provides the greatest flexibility
if the operative strategy has to be modified midway through surgery (e.g., open insertion of
a retrograde cannula, retrograde cerebral perfusion, control of an inadvertent opening of the
right atrium with a left atriotomy).
Brachial plexus
Axillary
artery
Pectoralis
minor muscle
Axillary vein
Figure 2.3
1. Arterial Cannulation
Ascending Aortic Cannulation
◆ The target area should be digitally palpated. The cannula should be inserted so that its flow
direction and jet are away from the arch vessels (Fig. 2.4).
◆ Two sets of purse-string sutures (braided nonabsorbable 2-0) are placed around the target (8
to 10 mm diameter), with the free ends controlled with tourniquets on each side.
◆ There are several options for the actual cannulation, using a no. 15 or no. 11 blade. Some
surgeons prefer to incise transmurally and control the opening with their finger, passing the
tip of the cannula under the digit into the aortic opening (Fig. 2.5). Some cut in an oblique
manner but control the resulting flap with the forceps, directing the cannula under control
into the opening. Another elegant method involves incising only the adventitia and media,
leaving the paper-thin intima to be punctured by the cannula (Fig. 2.6).
Femoral Artery Cannulation
◆ The safest skin incision for femoral cannulation is a vertical incision overlying and just slightly
medial to the femoral pulse (Fig. 2.7). An alternative incision is a slightly oblique incision
aligned with the inguinal ligament to facilitate healing.
◆ Lymphatic vessels should be carefully cauterized or ligated to prevent the formation of a
lymphocele and persistent drainage.

Alternative method
Incision through
adventitia Adventitia
and media
Media Incision A
Intima
Incision B

◆ Proximal and distal control of the femoral artery should be obtained. A target site for the
arteriotomy should be chosen after considering where the proximal clamp may be safely
placed and how the repair will be accomplished when the cannula is removed (Fig. 2.8, A).
The distal vessels may be occluded with separate clamps or tapes (see Fig. 2.8, B).
◆ The arteriotomy should be made in a transverse fashion and the femoral cannula gently
introduced while an assistant releases the proximal clamp. The cannula is then secured by
tying it to the proximal snare, with a second suture securing the tubing to the surface of the
thigh.
Axillary Artery Cannulation
◆ A 5- to 8-cm transverse incision is made about 2 cm below the clavicle, overlying the delto-
pectoral groove (Fig. 2.9). The dissection is continued between the fibers of the pectoralis
major. There is often soft fat in this space, and the area should be dissected gently to avoid
tearing of vessels and blood staining. The exposure is further aided by two self-retaining
retractors. In an emergency, it is often necessary to sacrifice small nerves to the pectoralis
major.
◆ The cephalic vein is identified in this space, where it penetrates the fascia to join the axillary
vein. The clavipectoral fascia is incised, and the pectoralis minor muscle is retracted laterally
or partially dissected. The axillary vein should be encircled with loops and gently retracted
cephalad.
◆ The artery, which lies superior and deep to the vein, can be identified by palpation and then
exposed and controlled proximally and distally with tapes. Arterial branches of the thora-
coacromial trunk may be encountered and should be controlled with silk snares. Care must
be taken to avoid touching the medial and lateral brachial plexus cords.
◆ After heparin is administered, the artery can be controlled with clamps, but we prefer to use
a partial occluding clamp at the arteriotomy site. An 8-mm tube graft should be anastomosed
to this site (Fig. 2.10) and the arterial cannula inserted into the tube graft. The cannula is
not advanced into the axillary artery proper, but rather perfuses from within the graft.5
◆ At the end of the procedure, the stump can be controlled with several very large hemoclips
applied transversely and then oversewn with 4-0 polypropylene sutures.

Site of
arteriotomy
Femoral
artery
Femoral
vein
A B
Figure 2.8
Incision
Figure 2.9
A B
Figure 2.10
Transapical Cannulation
◆ This technique is extremely useful in situations of severe atherosclerotic disease of the aorta
(porcelain aorta) or for a type A dissection in an emergency (Fig. 2.11).
◆ Venous (right atrial) cannulation should be obtained first to allow for the rapid institution of
bypass after cannulating the apex. Similarly, if possible, the right superior pulmonary vein
should be cannulated first for venting because it is difficult to mobilize the heart after the
cannula is in place for fear of left ventricular tearing. An easy alternative is to vent the pulmonary
artery.
◆ Manipulation of the apex may cause instability, so the equipment should be ready before
proceeding.
◆ A 14 F needle is inserted in the apex, and a guidewire is passed across the aortic valve with
transesophageal echocardiography (TEE) guidance. A laparotomy pad is placed under the left
ventricular apex to stabilize the heart.
◆ There is no need to predilate the opening. A wire-reinforced cannula with an inner dilator
is passed over the guidewire and positioned across the aortic valve. The cannula is then
connected to the circuit and de-aired, and bypass is commenced. Its position can be verified
by TEE (Fig. 2.12).
◆ It is not recommended to place purse-string sutures in the epicardium until after bypass has
started because beating of the heart may cause tearing. Once the heart is on bypass, however,
with the heart decompressed, we place two large, braided, pledgeted purse strings, controlled
with a tourniquet. The cannula is tied to these tourniquets and is also fixed to the skin to
prevent motion.
◆ The strategy to deal with the relevant aortic pathology (e.g., dissection) should include provision
of an alternative cannulation site (e.g., side graft to ascending aortic tube graft) to allow the
apical cannula to be removed and the purse strings tied while the heart is flaccid. We further
buttress this repair with biologic glue.
2. Venous Cannulation
Femoral Vein Cannulation
◆ We prefer to use a long double-stage or multi-stage venous cannula because it may be used
for definitive perfusion. We do not routinely place tapes proximally and distally, thus avoiding
posterior dissection. Two purse-string sutures (4-0 polypropylene) are placed around the
target, and a 14 F needle is inserted approximately 3 mm from the caudal apex of the diamond.
A guidewire is inserted cephalad, up to the superior vena cava (SVC). The cannula is inserted
over the wire, with further minor opening of the vein wall with a scalpel superiorly, up to
3 mm from the apex of the diamond. Further advancement of the cannula is guided by TEE
to ensure that the tip is just inside the SVC.
◆ At the completion of the procedure, the purse strings can be gently snared as the cannula is
removed and then tied, with little compromise of the femoral vein lumen.
Cannula passed
through aortic valve
Right
atrium
Laparotomy pad
Figure 2.11
Figure 2.12
Right Atrial Cannulation
◆ Usually, a double-stage venous cannula is inserted through the right atrial appendage. The
edges of the atrium can be gently grasped on each side, with an incision made using a scalpel
or scissors. The cannula is introduced with the tip directed posteriorly so that it is gently
guided into the inferior vena cava (IVC). Occasionally, digital manipulation at the level of the
IVC below the heart is necessary to guide the cannula into the correct position, with or
without confirmation by TEE.
◆ If two single-stage venous cannulae are required, we generally place one cannula (IVC) through
the atrial appendage. The second purse string is placed approximately 1.5 cm posterior and
caudal to this point so that the second cannula (SVC) crosses the IVC cannula. This orientation
facilitates exposure of the tricuspid valve and coronary sinus and provides good retraction of
a left atriotomy when the caval cannulae are pulled to the left side of the incision. During
preparation for orthotopic heart transplantation, both purse strings should be placed as
posterior in the atrial wall as comfortably possible (without a crossover orientation) to allow
for the preparation of an appropriate cuff of native right atrium to facilitate the atrial
anastomosis.
◆ If necessary, snares can be placed around the SVC and IVC after gentle circumferential dis-
section. We do not routinely snare for mitral valve surgery.

◆ Direct cannulation of the SVC may be necessary, particularly with high atrial septal defects
(e.g., sinus venosus). The purse string should be placed in a diamond fashion on the anterior
surface of the SVC, well above the sinoatrial node, but in a location such that the snare will
include flow through the azygos vein. The two sides of the purse string are held with forceps
by the surgeon and assistant, and a vertical venotomy is completed. A right-angled cannula
is inserted directly and twisted cephalad, and the purse strings are tightened. For orthotopic
heart transplantation using bicaval cannulation, SVC cannulation can be achieved as described
previously; IVC cannulation can be achieved by venous cannulation arising from the femoral
vein.
3. Cardioplegia Cannulation and Venting
Retrograde Coronary Sinus Cannulation
◆ A purse-string suture (4-0 polypropylene) is placed on the right atrial wall, caudal to the IVC
cannulation site and about 1 cm from the atrioventricular junction, at the level of the acute
margin of the right ventricle (Fig. 2.13).
◆ The cannula is passed through a stab in the purse string and is rotated so that the tip abuts
on the atrial septum at a point just medial to the IVC and curls toward the left shoulder as
the cannula is advanced. Proper placement is indicated by easy passage of the cannula tip
and by external palpation of the cannula in the coronary sinus medial to the IVC. The pressure
tracing from the tip of the cannula will also be characteristic, and the position can be confirmed
using TEE.
◆ If the cannula cannot be easily inserted, after snaring down the two single-stage cannulae, a
small transverse atriotomy (1.5 cm) may be made and a purse-string suture placed around
the coronary sinus ostium to secure the retrograde cannula after insertion under direct vision.
B
Figure 2.13
Right Superior Pulmonary Vein Cannulation for Venting
◆ A purse-string suture (4-0 polypropylene) is placed on the right superior pulmonary vein
with the medial suture line placed into the left atrium (Fig. 2.14).
◆ The vent can be placed prior to or after cross-clamp application. If the vent is placed prior
to application of the cross-clamp, the surgeon must ensure that the left ventricle is not ejecting
to avoid possible air embolization during vent placement.
◆ The venting cannula can be tailored by creating a question mark curve to allow for placement
of the cannula into the left ventricle through the left atrium and mitral valve. The cannula is
passed through a no. 11 blade stab in the pulmonary vein purse string, and the cannula is
gently advanced in a left inferolateral direction. If feasible, the surgeon’s hand can be placed
behind the heart in the oblique sinus and can palpate and guide the cannula through the
mitral valve.
◆ To achieve effective venting and minimize bleeding during aortic procedures, the cannula
should sit in the left ventricle.
◆ Less common alternative sites for ventricular venting include the superior aspect of the left
atrium, the pulmonary artery, and the foramen ovale.
4. Percutaneous Cannula Placement
Venous-Venous Extracorporeal Membrane Oxygenation
◆ Prior to performing venous-venous extracorporeal membrane oxygenation (ECMO), appropriately

sized vessels and ECMO configuration (e.g., femoral-femoral, femoral-jugular) must be chosen
to achieve maximum ECMO flow to support the patient.
◆ The femoral vein is punctured with an 18-G needle by palpating the femoral artery and
directing the needle just medial to the artery or via ultrasound. A J-tipped guidewire is
advanced through the needle and should be visualized in the right atrium–IVC junction. A
series of graduated dilators are used, and the venous cannula is placed over the guidewire.
A similar approach is achieved for the jugular vein.
◆ A novel method of achieving venous-venous ECMO is via a double-lumen catheter, which
can be placed in the right jugular vein. Ultrasound-guided venous puncture of the right
jugular vein is achieved with an 18-G needle, and a stiff, J-tipped guidewire is placed and
should be anchored deep into the IVC. TEE is essential, but to minimize complications, fluo-
roscopy is required.6 A series of graduated dilators are used, and the double-lumen catheter
is placed so that the upper and lower drainage holes are located at the SVC and IVC, respectively
(Fig. 2.15). The return (oxygenated blood) port is found in the mid–right atrium, and the
oxygenated blood is directed toward the tricuspid valve.
Superior
pulmonary
vein
Vent
catheter
Figure 2.14
Avalon
catheter
Figure 2.15
Chapter 2 • Cannulation Techniques for Cardiopulmonary Bypass 27.e1
Figure 2.14 Similar image to Figure 2.13 but showing the right superior pulmonary vein and a cannula being advanced to the apex of
the LV. A gloved hand can be placed behind the heart.
Figure 2.15 Double lumen “Avalon” catheter through the superior vena cava with guidewire showing inflow upper and lower ports in
the superior vena cava and inferior vena cava and a small jet of blood flowing through the mid-port directed at the tricuspid valve. See
image of Avalon catheter as well.
Venous-Arterial Extracorporeal Membrane Oxygenation
◆ Venous cannulation is achieved as described previously, generally in the femoral vein.

◆ Arterial cannulation is achieved via the ultrasound-guided Seldinger technique in the common
femoral artery. A small 15 F or 17 F arterial cannula should be used to allow some distal
limb perfusion.
◆ To ensure adequate distal limb perfusion, an antegrade catheter can be placed in the superficial
femoral artery, or a small retrograde catheter can be placed in the posterior tibial artery
(Fig. 2.16).7
Step 4. Postoperative Care
◆ Surgeons should understand the pathophysiology of cardiopulmonary bypass to recognize

the broad impact of this technology on virtually every organ system.
◆ Effective bypass should be married to proactive blood conservation strategies, including cell
salvage and the use of appropriate antifibrinolytics. Surgeons may also be expected to supervise
novel related techniques, such as ultrafiltration5 and retrograde autologous priming,8 and
must understand the importance of well-executed cannulation to the success of these
modalities.
Step 5. Pearls and Pitfalls
◆ Sites of arterial cannulation should be chosen with consideration about how the site of vascular
entrance can be repaired should complications such as bleeding or tearing occur. For example,
in the ascending aorta, the surgeon should consider whether the site chosen would be amenable
to a partial occluding clamp to repair this area.
◆ Communication among the surgeon, perfusionist, and anesthetist is essential, particularly in
complex cases. Potential strategies should be well prepared, with the appropriate equipment
available in the room, in case cannulation sites change or emergency bypass needs to be
initiated.
◆ Atrial cannulation sites should be chosen carefully, particularly in fragile tissues, in anticipation
of inadvertent tearing, which can extend to the atrioventricular junction, into the second
cannulation site or, if too far inferiorly, into the IVC. On the insertion of the IVC cannula,
always err on directing the cannula posteriorly, “marching” the cannula slowly forward, because
initial anterior forced misplacement may lead to coronary sinus perforation, which can be
lethal.
◆ Care must be taken when encircling the SVC and IVC to prevent posterior damage of these
vessels. With the SVC, the tissue overlying the right pulmonary artery between the aorta and
SVC can be divided with cautery, and a right-angled instrument can be used to create the
plane. Damage to the azygos vein may be extremely difficult to repair. The SVC cannula tip
should be inserted only so far so that when encircled, complete drainage will occur. Similarly,
care must be taken with encircling the IVC to ensure that damage to the posterior wall does
not ensue. If the seal with the snare is inadequate, often a second snare will accomplish the
task.
◆ Placement of the retrograde cannula can be facilitated by restricting venous return somewhat
to fill the right atrium. This will allow entrance of the catheter into the coronary sinus by
palpation or via assistance with TEE.
Superficial
femoral
artery
Distal
perfusion
catheter
Figure 2.16
References
1. Borger MA, Taylor RL, Weisel RD, et al. Decreased cerebral emboli during distal aortic arch cannulation: a randomized clinical trial. J
Thorac Cardiovasc Surg. 1999;118:740–745.
2. Preventza O, Bakaeen FG, Stephens EH, et al. Innominate artery cannulation: an alternative to femoral or axillary cannulation for
arterial inflow in proximal aortic surgery. J Thorac Cardiovasc Surg. 2013;145:S191–S196.
3. Zingone B, Rauber E, Gatti G, et al. The impact of epiaortic ultrasonographic scanning on the risk of perioperative stroke. Eur J
Cardiothorac Surg. 2006;29:720–728.
4. Gaudino M, Glieca F, Alessandrini F, et al. The unclampable ascending aorta in coronary artery bypass patients: a surgical challenge of
increasing frequency. Circulation. 2000;102:1497–1502.
5. Boodhwani M, Williams K, Babaev A, et al. Ultrafiltration reduces blood transfusions following cardiac surgery: A meta-analysis. Eur J
6. Rubino A, Vuylsteke A, Jenkins DP, et al. Direct complications of the Avalon bicaval dual-lumen cannula in respiratory extracorporeal
membrane oxygenation (ECMO): single-center experience. Int J Artif Organs. 2014;37:741–747.
7. Rupprecht L, Lunz D, Philipp A, et al. Pitfalls in percutaneous ECMO cannulation. Heart Lung Vessel. 2015;7:320–326.
8. Rosengart TK, DeBois W, O’Hara M, et al. Retrograde autologous priming for cardiopulmonary bypass: a safe and effective means of
decreasing hemodilution and transfusion requirements. J Thorac Cardiovasc Surg. 1998;115:426–438.
II·
'
SECTION
Operations
for Coronary Artery
Disease
CHAPTER
3
On-Pump Coronary
Artery Bypass Grafting
Frank W. Sellke and Neel R. Sodha
◆ The named epicardial coronary arteries that serve as the distal anastomotic targets for coronary
artery bypass grafting (CABG) are most commonly located just deep to the epicardial fat and
superficial to the myocardium. The arteries, usually the left-sided vessels, may be located
more deeply within the myocardium (intramyocardial). A straighter course on coronary
angiography may suggest an intramyocardial location.
◆ The left anterior descending (LAD) coronary artery courses superficially to the interventricular
groove, providing diagonal branches to the anterior wall.

◆ The ramus intermedius (RI) artery arises between the LAD and left circumflex artery (LCx)
and can often be identified near the base of the left atrial appendage.
◆ The LCx arises from the left main coronary artery as the left main artery bifurcates to give
off the LAD in the atrioventricular groove. The LCx provides obtuse marginal branches that
supply the lateral and inferolateral myocardium, usually terminating near the lateral margin
of the left ventricle.
◆ The right coronary artery (RCA) originates anteriorly from the aortic root and courses in the
atrioventricular groove prior to crossing the acute margin of the heart and bifurcating into
the posterior descending artery (PDA) and posterolateral ventricular branch (PLVB).
◆ Right or left coronary dominance refers to the artery from the which the PDA originates.
◆ The most commonly used conduits for CABG include the left and right internal mammary
arteries (alternatively termed the internal thoracic artery), radial artery, and reversed greater
saphenous vein (GSV).
◆ The left internal mammary artery (LIMA) originates from the proximal left subclavian artery
opposite the thyrocervical trunk and courses approximately 1.5 cm lateral to the sternocostal
junction. Proximally, the LIMA passes inferiorly and medially behind the subclavian vein,
where the phrenic nerve usually crosses from lateral to medial as it courses to the pericardium.
Care must be taken during proximal harvest of the LIMA to avoid phrenic nerve injury
and resultant diaphragmatic dysfunction. The midportion of the LIMA is superficial, lying
just deep to the endothoracic fascia, and can be visualized or palpated most easily in this
location. Below the sixth rib, the transversus thoracis muscle covers the posterior aspect
of the internal mammary artery (IMA). Near the junction of the xiphoid process and body
of the sternum, the IMA bifurcates into the musculophrenic and superior epigastric arteries.
The IMA is accompanied by paired internal mammary veins that combine to form a single
vein proximally.
33
Chapter 3 • On-Pump Coronary Artery Bypass Grafting 33.e1
Keywords
coronary artery bypass graft

CABG
anastomosis
34 Section II • Operations for Coronary Artery Disease
◆ The radial artery originates from the brachial artery, coursing under the brachioradialis muscle
proximally and in the lateral forearm deep to the distal deep fascia. From the antecubital
fossa, the artery courses from medial to lateral. Care must be taken during harvest of the
distal radial artery to avoid injury to the superficial radial nerve and lateral antebrachial
cutaneous nerve.
◆ The GSV is located on the medial side of the lower extremity, coursing superficial to the
medial malleolus at the ankle and running deep to the subcutaneous fat as it courses more
proximally. At its most proximal portion, the GSV drains into the common femoral vein at
the saphenofemoral junction.
1. Preoperative Preparation
◆ The medical history should focus on comorbid conditions that could increase perioperative
risk and conduit selection (e.g., history of stroke, gastrointestinal bleeding, liver disease,
diabetes mellitus, obesity, chronic obstructive pulmonary disease, renal failure, peripheral
arterial disease).
◆ The surgical history should delineate any prior chest surgery and procedures that could affect
conduit selection (e.g., radial artery catheterization, varicose vein stripping).

◆ The physical examination should aim to identify any comorbid conditions not obtained during
the history and to identify any potential caveats that could alter surgical planning. Bilateral
upper extremity blood pressures should be obtained to identify possible subclavian stenosis,
which could impair IMA flow. The skin overlying the chest wall and conduit harvest sites
should be examined for any evidence of infection, prior irradiation, and scars from prior
procedures. Auscultation for a carotid bruit may indicate the presence of stenosis. Radial
pulses should be palpated and, in case radial artery harvest is planned, an Allen test should
be performed. The presence of an arteriovenous fistula for hemodialysis has been reported
to cause steal from the ipsilateral IMA and should be taken into consideration. Femoral, pedal,
and posterior tibial pulses should be identified in case an alternative cannulation strategy is
needed or for placement of an intraaortic balloon pump. The lower extremities should be
inspected for venous stasis changes and large varicosities.
Chapter 3 • On-Pump Coronary Artery Bypass Grafting 35
◆ Routine complete blood counts, coagulation studies, and serum chemistry tests should be
performed. A baseline electrocardiogram should be obtained. Preoperative transthoracic
echocardiography will provide data regarding ventricular function and any additional valvular
pathology that might require concomitant intervention. In addition to providing the coronary
anatomy for bypass planning, left heart catheterization can also serve to delineate left ventricular
function, aortic valve pathology, and mitral regurgitation. A baseline chest x-ray can identify
possible aortic calcification, and a noncontrast computed tomography (CT) scan of the chest
may be obtained to evaluate for the presence of a porcelain aorta definitively. Routine carotid
duplex ultrasonography is not mandated, but should be considered in patients with symptoms
of stroke or a transient ischemic attack, presence of a carotid bruit, or significant left main
coronary artery stenosis. If there is concern based on the history or physical examination
regarding the radial artery or GSV conduit, duplex ultrasonography can aid in identifying the
suitability of these conduits preoperatively.
2. Intraoperative Preparation
◆ Patients are placed in the supine position on the operating table. The upper extremities should
be secured parallel to the torso and appropriately padded to prevent compressive nerve injury.
In the case of planned radial artery harvest, the ipsilateral arm should be abducted 45 to 60
degrees from the patient.
◆ Hemodynamic monitoring should include placement of a noninvasive blood pressure cuff,
radial arterial catheter (opposite the site of the planned radial arterial harvest site), and central
venous catheter in the internal jugular vein. Placement of a pulmonary artery Swan-Ganz
catheter should be based on discussion between the surgeon and anesthesiologist and is
generally used for higher-risk patients. A transesophageal echocardiography probe may be
passed after induction of general endotracheal anesthesia. Near-infrared spectroscopy (NIRS)
monitoring may be performed if there are risk factors or significant cerebrovascular disease.
All hair should be removed from incision sites with an electric razor. Electrocardiographic
leads, defibrillator pads, and electrocautery grounding pads should be placed away from all
potential incision sites. Placement of a roll perpendicular to the spine across the scapulae
may facilitate sternotomy and IMA harvest. Bolsters placed under the knees or lower extremities
with slight external rotation of the legs may facilitate GSV harvest.
◆ Perioperative antibiotics such as a first-generation cephalosporin, with the addition of vancomycin
if methicillin-resistant Staphylococcus aureus (MRSA) colonization is documented, should be

administered within 30 minutes prior to incision. Skin preparation with an iodophor solution
or chlorhexidine gluconate should be performed from the chin to the toes, with circumferential
preparation of the lower extremities.
◆ The following discussion details the procedure of CABG using a pedicled IMA graft, with
reversed GSV or free radial artery grafting. Alternative conduits, including the gastroepiploic
artery, inferior epigastric artery, and lesser saphenous vein may be used, but are not described
here. Alternative strategies and approaches for CABG are described elsewhere in the text.
◆ A standard median sternotomy is performed. To facilitate harvest of the IMA, a variety of
self-retaining sternal retractors are available to elevate the ipsilateral sternal edge. Once the
sternum has been elevated, the mediastinal pleura is freed from the endothoracic fascia. The
pleura may be opened widely into the pleural space to facilitate exposure or may be left intact
once it has been freed several centimeters beyond the lateral edge of the IMA. The IMA can
be harvested using a pedicled technique in which the IMA is harvested with the endothoracic
fascia and paired veins or using a skeletonized technique.1 Using a pedicled technique, the
endothoracic fascia is opened laterally to the paired mammary veins, creating a 1.5- to 2-cm
pedicle. Dissection can be carried out using electrocautery or with scissors. The IMA and its
paired veins should be gently dissected free from the chest wall using hemoclips to ligate
intercostal branches. Care should be taken to avoid thermal injury with excess use of elec-
trocautery or IMA dissection with excessive manipulation of the artery. Dissection of the
proximal 3 cm of the IMA is where phrenic nerve injury is most likely to occur. Both the left
IMA and right IMA can be harvested in a similar fashion, but the harvester should be aware
that the mammary vein may cross medially earlier on the right side, and intersection of the
phrenic nerve and IMA occurs more proximally on the right side. The skeletonized approach
is preferred when bilateral IMA harvest is planned to avoid devascularization of the sternum
and when IMA length may be an issue. Sharp dissection and avoidance of electrocautery is
preferred during skeletonization of the IMA to minimize the risk of thermal injury. When
skeletonizing the IMA, the endothoracic fascia is incised sharply, and the IMA is dissected
free from the paired veins. The fascia is opened longitudinally under the IMA proximally and
distally along the course of the artery. The artery may be bathed in a vasodilator solution
such as papaverine until ready for use. The chest wall should then be inspected for hemostasis
(Fig. 3.1).
◆ GSV harvest should take place concurrently with IMA harvest. Three techniques are commonly
used: full open harvest with a longitudinal leg incision, a semiopen (bridged) technique with
interrupted sequential leg incisions, and an endoscopic approach. Most GSV harvests performed
currently use an endoscopic approach. Once the vein has been isolated, the proximal and
distal ends are ligated with silk suture, and the vein is transected and removed from the leg.
The distal aspect of the vein is cannulated to allow for gentle pressurization of the vein and
branches and areas of leak, or it is clipped or oversewn with fine polypropylene sutures. A
longitudinal mark may be applied with a skin marker to prevent unrecognized torsion of the
vessel when constructing proximal anastomoses (Fig. 3.2).
Electrocautery
Internal
mammary
artery
Figure 3.1
Interrupted skin incisions
Saphenous vein
Figure 3.2
◆ The radial artery is usually harvested from the nondominant arm to minimize functional
consequences should nerve injury occur.2 The artery may be harvested endoscopically, as
with GSV, or an open technique may be used. Here we describe the open technique. A
longitudinal incision is created from 2 cm proximal to the styloid process of the radius and
extended proximally to 2 cm proximal to the antecubital fossa, extending medially toward
the biceps tendon. The artery lies between the flexor carpi radialis muscle and brachioradialis
muscle. The subcutaneous tissue is divided with electrocautery, and the deep fascia is incised
sharply. The distal end of the radial artery (closest to the wrist) should gently be occluded
transiently to ensure good collateral flow to the hand, which can be monitored with a pulse
oximetry probe on the finger. The deep fascia should be incised sharply over the artery.
Vascular branches are divided in sequence using clips, electrocautery, or a harmonic scalpel.
As dissection proceeds proximally toward the brachial artery, the brachioradialis muscle can
be retracted laterally. Care must be taken to avoid the lateral antebrachial cutaneous and
superficial radial nerves. After systemic heparinization, the proximal and distal ends of the
artery are ligated, and the vessel is placed in a heparinized solution with nitroglycerin and/
or a calcium channel blocker to minimize vasospasm (Fig. 3.3).
◆ After harvesting of the conduit, a sternal retractor is placed, and the pericardium is opened
in an inverted T fashion. The edges of the pericardium are secured to the retractor or sub-
cutaneous tissue to create the pericardial well (Fig. 3.4). The aorta should be palpated for
calcium plaques and visually inspected for anticipated cannulation, cross-clamp, and proximal
anastomotic site placement. Systemic heparin should be administered. Two concentric purse-
string sutures are placed in a diamond shape in the distal ascending aorta, sized to match
the appropriately selected arterial cannula. Once appropriate levels of systemic anticoagulation
have been achieved, the systemic blood pressure should be lowered to between 100 and
110 mm Hg systolic and the ascending aortic cannula inserted and secured with tourniquets.
Radial artery Harmonic scalpel
Figure 3.3
Figure 3.4
Venous drainage may be obtained by cannulation of the right atrial appendage after placement
of a circumferential purse-string suture and transection of the appendage tip. An antegrade
cardioplegia catheter is next placed in the ascending aorta, proximal to the aortic cannula
and anticipated location of the aortic cross-clamp. Depending on the surgeon’s preference for
cardioprotection, a retrograde cardioplegia catheter may be placed in the coronary sinus via
the right atrium. Echocardiographic guidance, manual palpation, return of dark deoxygenated
blood, and pressure tracing are used to confirm appropriate retrograde catheter position.
Prior to initiation of cardiopulmonary bypass (CPB), all conduits should be inspected for
usability (Fig. 3.5).
◆ After confirmation of appropriate systemic anticoagulation and aortic cannula line pressure,
CPB is initiated; once venous drainage is sufficient, ventilation is discontinued. Systemic

cooling may be initiated at the discretion of the surgeon.
◆ An atraumatic aortic cross-clamp should be placed on the ascending aorta just proximal to
the aortic cannula and distal to the antegrade cardioplegia catheter. Prior to clamping the
aorta, CPB flow should be lowered to decrease systemic blood pressure and decompress
the aorta. On confirming adequate clamp placement, cardioplegia is administered. The aortic
root should be palpated to confirm adequate pressure when antegrade cardioplegia is
administered. If using retrograde cardioplegia, coronary sinus pressure should not exceed
40 mm Hg. Topical cooling can be performed using iced saline slush, wet laparotomy pads,
cooling jackets, or continual cold saline irrigation of the operative field. On completion of
the initial dose of antegrade cardioplegia, any vent lines may be opened to suction.
◆ As noted previously, the sequence of distal anastomotic completion is surgeon-dependent.
Our standard approach involves creation of right-sided distal anastomoses, followed by the
LCx, RI, diagonal, and LAD arteries. On completion of distal anastomoses, proximal anastomoses
are completed.
Aorta
Right
atrium
Coronary
sinus
Figure 3.5
◆ After clearing the epicardial fat from the anterior surface of the target vessel, any vents should
be be clamped temporarily to allow for slight distention of the vessel. A no. 15 blade or
alternative should be used to incise the vessel, taking care to remain in the midline and avoid
the back wall. Pott’s scissors can then be used to extend the arteriotomy proximally and
distally. The arteriotomy should be at least 1.5 times the diameter of the target vessel and
match the conduit size. A slight bevel of 30 degrees can be created on the conduit to decrease
the risk of kinking, and a small longitudinal notch can be created at the heel of the conduit
to allow for increased length. Distal anastomoses are generally performed using 7-0 polypropylene
running sutures or, in certain cases, 8-0 polypropylene sutures for the IMA anastomosis. On
completion of the anastomosis, cardioplegia or heparinized saline may be injected by hand
or via a pressurized line to test graft flow and to test for leaks (Fig. 3.6).
◆ When performing an IMA anastomosis with a pedicled graft, proximal inflow may be inter-
rupted with a soft bulldog-style clamp. An incision in the pericardium may be created to
allow for the IMA to pass to the distal target without kinking or stretching. Care should be
taken to avoid injuring the phrenic nerve when creating the pericardial opening. Once the
arteriotomy site for the distal anastomosis has been selected, the graft should be transected
after delineating the appropriate length to avoid redundancy. The IMA anastomosis is performed
in a similar fashion as described previously. Prior to completing the anastomosis, the IMA
clamp should be transiently released to confirm good flow in the conduit. On completion of
the anastomosis, release of the IMA clamp may allow for visualization of distal target artery
filling, although this is not always visible. If a pedicled graft is used, the lateral edges of the
graft may be secured to the epicardial fat with polypropylene sutures to prevent later torsion
(Figs. 3.7 and 3.8).
Coronary
artery
End-to-side
anastomosis
Figure 3.6
Atheroma
Left anterior
descending
coronary
artery

◆ On occasion, when distal targets are small, the conduit is limited, or proximal anastomotic
sites are limited, sequential anastomotic techniques should be considered. Sequential grafting
uses a single conduit with multiple distal anastomoses (usually two) and one proximal
anastomosis—the source of inflow. Although offering the aforementioned advantages, sequential
grafting does rely on a single inflow source of blood to supply multiple targets and may result
in competitive flow imbalance if the proximal outflow is greater than the distal outflow, and
it can be subject to kinking or graft torsion if the targets are not aligned properly.3 Sequential
grafting can be performed with a free conduit such as a radial artery graft, GSV graft, or a
pedicled IMA. Ideally, the most distal target should be the largest of the targets with the best
outflow, and the targets should lie in an anatomic position to the minimize risk of kinking,
as can occur with sequential grafting of obtuse marginal targets or diagonal-LAD artery target
combinations. When performing sequential grafting using a free graft, we perform the distalmost
target anastomosis first, using the technique described previously. The graft and heart are
then filled to identify the optimal position of the more proximal distal anastomosis. Both the
conduit and target are then incised longitudinally, taking into consideration the size of the
prior anastomosis. Depending on the location of the target vessel, an eight-stitch, side-to-side
anastomosis can be fashioned with the conduit perpendicular to the target (Fig. 3.9), creating
a diamond-shaped anastomosis. Alternatively, a larger side-to-side anastomosis, with the
vessels parallel to one another (Fig. 3.10), can be fashioned to avoid a gull wing deformity.
Figure 3.9
Figure 3.10
◆ As noted previously, in certain cases for which insufficient conduit is available, and there is
concern over conduit to aortic mismatch between the conduit and aorta or there is limited
room on the aorta for proximal anastomosis, consideration should be given to Y or T grafting
techniques.4 These use an end-to-side anastomosis on a bypass graft for proximal inflow with
a standard distal anastomosis for outflow, resulting in a Y- or T-shaped appearance of the
proximal anastomosis (Fig. 3.11).
◆ Proximal anastomoses may be fashioned after the completion of each distal anastomosis or
after the completion of all distal anastomoses. If done after the completion of all distal
anastomoses, they may be performed with the initially placed aortic cross-clamp in place to
avoid additional aortic manipulation or with a partially occlusive side-biting aortic clamp to
minimize ischemic time. Each graft should be measured to ensure appropriate length to avoid
excess stretching when the heart is filled and the lungs are inflated and for appropriate
anatomic positioning to avoid kinking with excess length. A no. 11 blade is used to create a
small incision in the aorta, taking care to avoid too deep an entry, which could injure the
back wall of the decompressed aorta. Some surgeons prefer to use the aortic root vent–antegrade
cardioplegia catheter site as a location for a proximal anastomosis. After creating the initial
incision, an aortic punch of 4 to 5 mm is used to create a circular aortotomy. Proximal
anastomoses can be fashioned with running polypropylene sutures, ranging from 5-0 to 7-0
in size, depending on the thickness of the conduit vessel. The grafts should be inspected for
air and a fine 25-G needle can be used for de-airing vein grafts, if necessary (Figs. 3.12 and
3.13).
◆ During the reperfusion period, metabolic parameters and hemodynamics should be optimized.
All anastomotic sites and conduits should be inspected for hemostasis and kinking because
visualizing the inferior and lateral walls of the heart may be difficult after separation from
CPB. Once all parameters are optimized, the electrocardiographic tracing is reviewed, and
hemodynamics and echocardiographic imaging are satisfactory, weaning from CPB should
commence. During weaning from CPB, the grafts should be monitored closely as anatomic
positioning may change with lung insufflation and ventricular filling. After separation from
CPB, protamine may be administered and the patient decannulated in standard fashion. The
IMA harvest sites should be secondarily inspected for hemostasis with retraction of the sternal
edge. Standard sternal closure may then be performed, with particular attention to hemodynam-
ics, because alterations in graft positioning may occur with sternal closure.
◆ Initial postoperative management in the intensive care unit centers around hemodynamic
support. Early neurologic evaluation should be performed to ensure that intraoperative stroke
has not occurred. In the hemodynamically stable patient without active bleeding, all attempts
should be made for early extubation. Hemodynamic support with goal-directed weaning of
inotropic agents and vasopressors should occur early. Chest tube output should be monitored
closely for signs of bleeding. Aspirin is given within 6 hours of surgery, and a beta blocker
is administered if hemodynamics allow. Glucose control is maintained with an insulin infusion
until stabilization. Statins should be initiated early in the postoperative period in the absence
of contraindications. Nitrates or calcium channel blockers may be used to decrease the risk
of arterial spasm if a radial conduit has been used. Early mobilization should be the goal,
with anticipated transfer from the intensive care setting by postoperative day 1 or 2. Chest
tubes are generally ready for removal by day 2 or 3, depending on output. Diuresis can be
initiated by postoperative day 1 and continued until normal fluid balance has been achieved.
LIMA
Figure 3.11

◆ Preoperative evaluation should focus on identifying comorbid conditions, which may affect
the operative plan. Specifically, care should be taken to ensure the suitability of distal targets
for revascularization, presence of sufficient quality conduit, and absence of severe aortic
calcification.
◆ Excess sternal retraction during IMA harvest may result in sternal or rib fracture or brachial
plexus injury.
◆ Care should be taken during conduit harvest to avoid excess manipulation of IMA conduits,
which may result in dissection, thrombosis, or intimal injury, the latter of which may only
become evident with late graft failure.
◆ Excessive pressurization or thermal injury of saphenous vein conduits may result in intimal
injury, leading to graft failure.

◆ Early planning for aortic cannula, cross-clamp, and cardioplegia catheter placement should
be performed with the heart full to determine placement of proximal anastomoses.

◆ Epicardial targets may not be readily visible on the surface of the heart and require extensive
dissection of the epicardial fat or myocardium to be identified. Care should be taken to ensure
excellent hemostasis of any dissected fat or myocardium because these may result in significant
bleeding after release of the aortic cross-clamp.
◆ If the proximal or midportion of the target vessel is not visible or is difficult to identify, careful
passage of a coronary probe retrograde from the distal aspect of the vessel may be useful.
References
1. Sá MP, Ferraz PE, Escobar RR, et al. Skeletonized versus pedicled internal thoracic artery and risk of sternal wound infection after
coronary bypass surgery: meta-analysis and meta-regression of 4817 patients. Interact Cardiovasc Thorac Surg. 2013;16:849–857.
2. Tranbaugh RF, Dimitrova KR, Lucido DJ, et al. The second best arterial graft: a propensity analysis of the radial artery versus the free
right internal thoracic artery to bypass the circumflex coronary artery. J Thorac Cardiovasc Surg. 2014;147:133–140.
3. Mehta RH, Ferguson TB, Lopes RD, et al, Project of Ex-vivo Vein Graft Engineering via Transfection (PREVENT) IV Investigators.
Saphenous vein grafts with multiple versus single distal targets in patients undergoing coronary artery bypass surgery: one-year graft
failure and five-year outcomes from the Project of Ex-Vivo Vein Graft Engineering via Transfection (PREVENT) IV trial. Circulation.
2011;124:280–288.
4. Rankin JS, Tuttle RH, Wechsler AS, et al. Techniques and benefits of multiple internal mammary artery bypass at 20 years of follow-up.
Ann Thorac Surg. 2007;83:1008–1014.
CHAPTER
4
Off-Pump Coronary
Artery Bypass Grafting
Igo B. Ribeiro, Juan B. Grau, Jacqueline H. Fortier,
and David Glineur
◆ The ability to perform coronary artery bypass grafting (CABG) competently without the use
of cardiopulmonary bypass is an important skill for all cardiac surgeons. There are cases in
which a safe coronary revascularization procedure can only be performed as an off-pump
procedure. Although off-pump coronary artery bypass (OPCAB) has a steeper learning curve
than on-pump revascularization, there are clear benefits to it.
◆ After an initial surge in popularity following its widespread adoption, the frequency of OPCAB
has declined. In 2012, only 17% of all coronary artery bypass surgery was performed as an
off-pump procedure.1 Much of this decline could be attributed to the results of several cohort
studies and clinical trials, which showed no survival benefit for off-pump surgery.2,3 Despite
this, OPCAB has consistently been shown to decrease blood transfusions and lower the risks
of postoperative bleeding and renal and respiratory failure. OPCAB performed with the aorta
no–touch technique also seems to lower the risk of postoperative stroke.4
◆ The results of the initial large trials have also highlighted potential pitfalls of OPCAB. Results
suggested a higher proportion of incomplete revascularization with off-pump cases and a

lower graft patency rate.5,6 This reinforces the notion that this procedure has a significant
learning curve, and surgeons must ensure that the choice to use an off-pump approach does
not affect the overall quality of the surgical revascularization.
◆ Understanding when an off-pump approach is not in the patient’s best interest is also critical;
severe ventricular dysfunction, left main disease, ongoing ischemia, and pulmonary hypertension
are associated with poorer outcomes and the need to convert to on-pump procedures.7
◆ To perform OPCAB, a keen understanding of cardiac physiology is essential, because it allows
more careful positioning of the heart to visualize the targets without affecting hemodynamics.
◆ In this chapter, we describe a systematic, step by step approach to performing complete
myocardial revascularization using an OPCAB technique. We discuss and illustrate key

maneuvers, major pitfalls, and important strategic considerations for off-pump coronary
revascularization. We also highlight the importance of total arterial revascularization and
strategies to decrease aortic manipulation.
49
Chapter 4 • Off-Pump Coronary Artery Bypass Grafting 49.e1
Keywords
OPCAG
coronary artery bypass surgery
off-pump surgery
surgical technique
Step 1. Preoperative Assessment and Planning
◆ The benefits of complete revascularization are well established, and surgeons should bypass
all vessels 1.5 mm or larger with stenosis of 70% or more. The off-pump approach should
never jeopardize the ability to perform complete revascularization. Careful OPCAB planning
should have a composite goal of a safe, complete revascularization without the use of cardio-
pulmonary bypass.
◆ Planning an OPCAB begins at the time of the preoperative assessment. Patients presenting
for isolated CABG should be carefully and thoroughly examined and undergo a complete
diagnostic imaging workup. Particular attention should be paid to congenital anomalies of
the chest, such as pectus excavatum, which may affect the feasibility of the operation.
◆ A comprehensive preoperative assessment and diagnostic imaging workup should be carried
out, as with any cardiac operation.

◆ A noncontrast computed tomography (CT) of the chest to rule out aortic calcification is recom-
mended for patients with advanced age (> 75 years), chronic renal disease, severe vasculopathy,
and a history of heavy smoking. Ascending aorta calcification might make cross-clamping
the aorta inadvisable or, in the case of a porcelain aorta, impossible.
◆ Aortic manipulation likely increases the risk of stroke,8-10 and an off-pump approach allows
myocardial revascularization without aortic manipulation. The aortic no–touch technique

should be strongly considered for patients at increased risk for stroke.
◆ Aortic calcification is one of the more common reasons to choose OPCAB, but there are other
indications. Patients who decline blood transfusions (e.g., Jehovah’s Witnesses), and have
borderline kidney and respiratory dysfunction likely benefit from OPCAB.
◆ Just as some preoperative findings might make OPCAB the preferred choice, other findings,
such as severe left ventricular dysfunction, ongoing ischemia, pulmonary hypertension, and
valvular heart diseases will strongly suggest an on-pump approach to surgical revascularization.
On-pump CABG is the safest approach in these scenarios.
Step 2. Conduit Assessment
◆ With any surgical coronary revascularization, the choice of conduits should be tailored to the
patient. In the case of OPCAB, careful consideration of the patient’s coronary anatomy, targets
to be grafted, and availability of conduits is required.
◆ The use of the left internal thoracic artery (LITA) to graft the left anterior descending (LAD)
territory has long been the standard of care for surgical revascularization. For patients with
multivessel coronary artery disease, the remaining targets may be grafted with either arterial
or venous grafts.
◆ For patients younger than 75 years, the literature has demonstrated a survival benefit for
multiarterial revascularization.11-13 In general, high-grade stenosis (> 80%) will be the preferred
target for either radial or gastroepiploic arteries due to their susceptibility to competitive
flow.14
◆ The internal thoracic arteries are less prone to competitive flow and can be considered for
stenosis of 60% to 80%.

◆ Venous grafts will tolerate almost any degree of stenosis, although their suboptimal durability
and patency remain a major drawback, particularly in younger patients.

◆ A composite graft of a LITA with a radial artery grafting seems to confer the same benefits
as for a bilateral internal thoracic artery (BITA) and may be preferable in diabetic patients,
who may be at greater risk for sternal wound complications.15-17
Chapter 4 • Off-Pump Coronary Artery Bypass Grafting 51
1. General Strategies, Tools, and Tactics
◆ OPCAB is a team effort. The anesthesia team should be engaged prior to surgery for better
support of the patient’s hemodynamics during induction and conduit harvesting and at the
time of grafting.
◆ The operating room should be kept warm during these operations, similar to the practice in
pediatric operating rooms. If this is not done, the patient’s temperature can drop to a dangerous
level, where spontaneous, malignant ventricular arrhythmias, such as ventricular fibrillation
and ventricular tachycardia, could occur.
◆ The availability of pacing wires, atrial and ventricular, can help maintain normal hemodynamics
in patients with heart block or extreme bradycardia.

◆ Both the surgical and anesthesia teams should carefully monitor hemodynamic changes during
heart positioning. If inadequate hemodynamics are observed, the best course of action is to
return the heart into the pericardium for optimal functioning. The surgeon should then
consult with the anesthesia team while the heart is allowed to recover. Once hemodynamics
stabilizes, an attempt may be made to carefully reattempt the required positioning.
◆ Off-pump CABG has been made possible by the development of many specialized tools. Two
of the most important tools are vacuum-based devices that are used to position the heart or
stabilize the segment of coronary artery to be anastomosed. For the purposes of this text, the
former will be referred to as positioning devices, and the latter will be referred to as stabilization
devices. In addition to adequately placed pericardial sutures, these allow for optimal exposure
of the target vessels.
◆ Enhanced visualization devices, such as the Blower/Mister (Clear View Misted Blower; Medtronic,
Minneapolis), have also been adopted, and they allow a safe construction of the anastomosis.
We routinely use a Blower/Mister to optimize visualization. It delivers a jet of CO2 under
pressure in the middle of a jet of a pH-balanced saline solution, resulting in atomization of
the liquid. The resulting stream of mist and CO2, when directed over the arteriotomy, clears
the blood from the anastomosis without resulting in air embolism because the CO2 is rapidly
resorbed. The device does not prevent blood loss but improves visualization during the
anastomosis.
◆ Table tilt maneuvers can aid with visualization and allow adequate filling of the heart. If table
tilting is not sufficient to correct preload, fluid infusion should be initiated by anesthesia.
The Trendelenburg position and rotating the operating table toward the surgeon may also
optimize lateral wall visualization. Changes to the operating table should be performed slowly
and incrementally to allow the heart to adapt to different loading conditions.
2. Incision, Conduit Harvesting, and Pericardium Preparation
◆ Most OPCAB procedures are performed through the standard median sternotomy.
◆ An extensive inverted-T pericardial incision is usually required. The opening should reach
the cardiac apex on the left side and reach the pericardial reflection on the right side (Fig.
4.1). This allows heart positioning without any compressions or deformity.
◆ When harvesting the internal thoracic arteries, we strongly recommend complete skeletonization.
This approach decreases the rate of pleural effusions postoperatively and decreases the incidence
of ischemic injury to the chest wall and subsequent mediastinitis. This is particularly important
during BITA harvesting.
Right phrenic
nerve
Left phrenic
nerve
Reverse (“T”)
incision
Pericardium
Diaphragm
Pericardial
fat pad
Figure 4.1
Figure 4.1 Inverted-T pericardial incision.

◆ The lie of the conducts is critical to avoid kinking and compression by the lungs. An incision
is made on the pericardium to accommodate the internal thoracic artery (ITA). This pericardial
incision starts at the edge and is located at the level of the base of the left appendage for the
LITA and at the level of the transverse sinus for the right internal thoracic artery (RITA). It
is posteriorly directed toward the phrenic nerve. At 1 cm anterior to the phrenic nerve, the
incision extends 2 cm superiorly and inferiorly, creating a T-inverted incision. This trench
accommodates the in situ ITAs where they enter the pericardium.
◆ The radial artery can be harvested endoscopically or using an open approach, and either
pedicled or skeletonized, depending on the surgeon’s preferences. The gastroepiploic artery

should be harvested in a skeletonized manner for better patency. Veins can be harvested
endoscopically or using an open approach. Veins harvested through an endoscopic approach
have shown lower patency rates than those harvested in an open manner.18,19
◆ There are several possibilities for graft configuration, and the approach should be tailored to
the number and location of targets to be grafted:

◆ In situ grafts do not require aortic anastomosis, but they offer fewer distal anastomoses,
and their length is constrained.

◆ Free grafts are less constrained by length but require aortic manipulation for the inflow
creation.
◆ Composite grafts pair an in situ graft, usually a LITA, with another conduit branching in
a Y or T fashion. Composite grafts offer greater length and flexibility for grafting. In all
cases, the graft configuration should be planned to take into consideration the availability
of conduits and degree of stenosis in the target vessel.
◆ For a full arterial revascularization in a patient with multivessel coronary artery disease, the
plan should almost always include composite grafts due to the limited length of arterial
conduits.
3. Inflow Preparation
◆ Once the surgical plan has been made, conduits harvested, and the pericardium prepared,
graft inflows should be considered.
◆ Lateral pericardial sutures should be placed on each edge of the pericardium. These should
be attached to the drapes using hemostats to keep the lungs away from the operative field
and to expose the aorta for proximal anastomosis.
◆ Side-biting clamping is safe for aortas with a wall thickness less than 3 mm throughout the
clamp length and the anastomotic site. Plaques that are more than 3 mm in thickness increase
the risk of adverse neurologic events during aortic manipulaton20-22 (Table 4.1). We recommend
the use of epiaortic scanning to assess the quality of the ascending aorta.22,23
◆ When manipulation of the ascending aorta is not advisable, the use of proximal anastomosis
sealing devices, such as the Heartstring Proximal Seal System (Maquet Cardiovascular, Wayne,
NJ), is recommended. They allow for minimal manipulation of a severely diseased aorta.
Table 4.1 Katz classification (grading) of aortic atheroma

GRADE DESCRIPTION INCIDENCE OF STROKE (%)
1 Normal aorta 0
2 Extensive intimal thickening < 3 mm 0
3 Protrudes < 5 mm into aortic lumen 5
4 Protrudes > 5 mm into aortic lumen 10.5
5 Mobile atheroma 46.5
Patil TA, Nierich A. Transesophageal echocardiography evaluation of the thoracic aorta. Ann Card Anaesth. 2016;19(Suppl 1):S44-S55.
◆ In patients for whom this is not an option, and an aortic no–touch technique is the only
possible course of action, composite grafting allows for multiple anastomoses.
◆ When the aorta can be manipulated without concern, the standard sequence of events is as
follows: (1) blood pressure is brought below 90 mm Hg; (2) an atraumatic side-biting clamp
is applied; (3) small aortotomies are made with an aortic punch, followed by direct anastomosis
of each of the free grafts to the ascending aorta; and (4) the partial clamp to fill the graft is
released, avoiding a purse-string effect of the proximal anastomosis as one ties the suture.
◆ If the surgeon plans to use a composite graft approach, the ideal site of the Y- or T-graft
anastomosis is 1 cm distal the point of entry of the LITA into the pericardial sac, at the level
of the left atrial appendage. This can be constructed in a Y or a T configuration, depending
on which sequential anastomosis will be constructed first. For high proximal branches, such
as a high diagonal (diagonal-LAD angle ≥ 90 degrees), ramus intermedius, or high marginal,
a T approach is ideal because it allows an optimal lie of conduct once it is anastomosed in a
diamond shape on those vessels (Fig. 4.2A). For more distal branches of the circumflex and
right coronary artery, either a Y or a T graft will suffice, depending on the length of the
available conduit (see Fig. 4.2B).23
4. Heart Positioning
◆ Skillful heart positioning is vital to maintaining stable hemodynamics while still allowing
visualization of target arteries. The heart should move freely inside the pericardial sac and
should not be squeezed or compressed against taut pleurae and the sternal borders. This can
be achieved by releasing some of the pericardial sutures that hold the pericardial cradle up,
specifically the right-sided sutures.
◆ The heart can be elevated using three methods: (1) pericardial stitches (Lima stitch); (2) the
deep stitch–sling technique; and (3) the use of suction-driven positioning devices.
T-anastomosis
Diamond-shaped
anastomosis
Y-anastomosis
B
Figure 4.2
Figure 4.2 T and Y configurations of the composite graft.

◆ Posterior pericardial stitches (Lima stitches) can be used to enucleate the heart; the number
of stitches and location is a matter of surgeon preference. We place three sutures to the
posterior pericardium. The first suture is placed anterior to the left superior pulmonary vein
(LSPV) and below the phrenic nerve, the second is anterior to the left inferior pulmonary
vein (LIPV) and inferior to the phrenic nerve, and the third suture is placed on the medial
aspect of the inferior vena cava (IVC; Fig. 4.3). A Rummel tourniquet is then passed through
each of these sutures to avoid injury to the epicardium. If each tourniquet is sequentially put
under tension, the heart will lift incrementally and rotate medially. This will cause a broad
posterior pericardial ridge, which helps herniate the heart from the pericardial sac, with its
apex pointing to the ceiling. In most cases, these sutures allow for complete elevation of the
heart without hemodynamic consequences.
◆ An alternative to the three-tourniquet approach described previously is the single deep
suture–sling technique, which is placed in the oblique sinus medial to the right inferior
pulmonary vein.24 In between the two ends of this suture, an open 4- × 8-inch gauze is passed
through the suture loop, and then a Rummel tourniquet is applied, creating a sling. The deep
stitch is put under tension by pulling it inferiorly at the patient’s midline. This maneuver
creates a pericardial ridge deep in the oblique sinus. The two arms of the 4- × 8-inch gauze
work as a sling that rotates and lifts the heart by giving extra support to the base of the heart.
Different tension can be applied to either arm of the sling, allowing variable heart exposures
(Fig. 4.4).
◆ Suction-driven heart positioning devices allow for complete enucleation of the heart. The
heart positioner is clipped onto the chest retractor, and the silicone cup is applied to the
epicardium, immobilizing an area of the myocardium approximately 3 × 2 cm in size. Once
the cup has been applied, the heart can be slowly displaced. When in the working position,
the device arm is tightened, and it becomes immobile. The ideal suction applied by these
devices is 100 to 250 mm Hg, and the silicone cup should be placed onto a smooth, fat-free
region of the pericardium to avoid epicardial avulsions and unnecessary bleeding.
◆ The operator must never pull the suction cup off the epicardial layer while under negative
pressure; this will invariably cause an epicardial avulsion and bleeding. To release the device,
support the heart with one hand, and turn the suction off by opening the stopcock to air.
Then place the heart gently back into the pericardial sac.
◆ During heart positioning, particular attention should be given to patients with enlarged hearts,
decreased ventricular function, and pulmonary hypertension because they are more likely
not to tolerate aggressive displacement maneuvers. A common mistake in OPCAB is to occlude
inflow to the right-sided chambers due to inadvertent tenting and occlusion of both venae
cavae.
◆ Optimal heart positioning can be achieved using more than one method that allows herniation
of the heart with normal hemodynamics. We favor a combination of suction devices and
pericardial stitches, which, when combined, seems to allow for the maintenance of normal
hemodynamics.
◆ In the following, we describe different maneuvers to expose each wall of the heart.
Anterior Wall
◆ These are the most straightforward targets to expose, with minimal rotation of the heart
required. This can be easily achieved by applying traction on the first and second Lima
stitches. This pericardial traction brings the LAD and diagonal branches anteriorly and superiorly
(see Video 4.1 for anterior wall exposure).
◆ Alternatively, one or two lap pads can be placed posteriorly to lift and rotate the heart, moving
the LAD toward the midline. Suction devices are not necessary to expose these targets.
Inferior left
pulmonary vein
Inferior
Pericardium
vena cava
Figure 4.3
Tourniquet
Sling
Figure 4.4
Figure 4.3 Location of the three Lima stitches. (1) Anterior to the LSPV; (2) anterior to the LIPV; and (3) halfway between the IVC and
LIPV.
Figure 4.4 The deep stitch–sling technique.

Lateral Wall
◆ Exposure of the lateral wall poses a significant challenge during OPCAB. Proper heart positioning
technique is critical to allow optimal visualization without hemodynamic instability. Many
OPCAB surgeons advocate the use of a combination of pericardial stitches and positioning
device.
◆ The pericardial retention sutures should all be relaxed to allow broad heart mobilization
toward the right side. A right pleural opening might be needed to accommodate enlarged
hearts.
◆ The pericardial manipulation, in either form described previously, is the cornerstone of this
exposure if one seeks to maintain normal hemodynamics. For the sling-aided method, the
tourniquet is kept under traction at the midline, attached to the drapes. The right arm of the
rolled 4- × 8-inch gauze is put on traction at the midline, and the left side is pulled slowly
toward the assistant’s side. This maneuver creates a platform to keep the heart chambers
aligned while it lifts the apex and rotates the heart simultaneously, exposing the lateral wall.
Once the lateral wall is exposed, the left arm of the gauze is tethered on the drapes under
traction (Fig. 4.5; see Video 4.2).
◆ For the pericardial stitches method, the stitches are pulled under maximum traction, allowing
the heart to herniate superiorly through the mediastinum. We favor the use of either a small
lap pad or unfolded gauzes to protect the heart against injuries when using this technique.
◆ At the conclusion of either maneuver for lateral wall exposure, the base of the heart is exposed,
permitting the visualization of the atrioventricular (AV) groove. As the heart is lifted and
freely floats within the pericardial sac, the suction positioning device is used to stabilize the
most apical aspect of the heart and elongate the cardiac chambers. This prevents inflow
disturbances, squeezing of the right ventricle, and bending of the heart. The positioning
device must be clipped on the right side of the chest retractor in the most cephalad position.
This allows ample manipulation of the heart within the pericardial sac, without disturbing
the surgeon’s movements.
◆ The Trendelenburg position and table rotation toward the operators help optimize target
visualization and cardiac loading conditions. If positioning does not correct preload, fluid
should be initiated by anesthesia.
◆ At this point, the surgeon should be able to see the targets and safely apply the coronary
stabilization device.
Figure 4.5
Figure 4.5 Sling-aided technique to herniate the heart for lateral wall exposure.
Inferior Wall
◆ The targets of the inferior wall can be separated into two areas: (1) the distal right coronary
artery (RCA); and (2) the posterior descending artery (PDA) and posterolateral branches
(PLB). Each of these requires a fundamentally different exposure.
◆ For the distal RCA, all that is required is tilting the table into the Trendelenburg position
and, if the surgeon wishes, use of the suction device to rotate the free wall of the right ventricle.
It should be noted that not all surgeons use a suction device to graft this territory. If a suction
device is to be used, it should be positioned as cranially as possible on the right side of the
retractor. Cranial retraction is applied until the distal RCA is optimally visualized and the
working position is obtained. Whether or not a suction device is used, the coronary stabilization
device helps exposure. In addition to stabilization of the segment of the coronary artery to
be exposed, it retracts the inferior wall superiorly, allowing visualization of the distal RCA.
◆ For the PDA or PL branches, a combination of table positioning, pericardial maneuvers, and
use of a positioning device may be required. The first step is to place the patient in the
Trendelenburg position. Then, the two arms of the sling or the pericardial sutures are put
under traction, toward the patient’s left, to herniate the heart without medial rotation. The
inferior wall is then visualized; the positioning device must be applied to gain adequate
exposure and stabilization. The positioning device is applied adjacent to the apex, never
directly on the apex itself. For optimal epicardial suctioning, the silicone cup fingers should
be placed so that the three fingers are on the anterolateral surface. No finger should be placed
on the inferior wall because it makes suctioning inefficient. Also, attention should be taken
to avoid suctioning on the LAD. Because the sling supports the heart inferiorly, a low suction
setting should (≤ 200 mm Hg) suffice. This maneuver allows for elevation of the apex and
traction of the heart toward the patient’s head (Fig. 4.6).
5. Coronary Stabilization
◆ Coronary stabilizers have evolved tremendously, from first-generation stabilizers that used
compression as the method of stabilization to the latest generation of suction-based stabilizers.
Their primary goal is to decrease motion at the anastomotic site.
◆ All coronary stabilizers have flexible prongs in a fork-shaped configuration. Each prong has
four small silicone cups, connected to suction, that can be adjusted as necessary. This suction-
based stabilization allows OPCAB to be performed with less aggressive fluid administration,
which decreases volume overload and reduces the need to open the right pleural cavity.
Moreover, the malleable prong allows for different shapes to mold the irregularities of the
heart wall.
◆ Once the heart is in the working position, the coronary stabilizer is applied over the anastomotic
site. The target coronary artery should lie in between the two prongs. The suction prongs are
applied first, and then the mechanical arm of the stabilizer is tightened. The anastomotic site
should not be compressed because this might lead to a paradoxic increase in motion.
◆ Once applied, the stabilizer prongs may be spread apart slightly to increase the epicardial
tension over the target. This facilitates coronary dissection with a no. 15 blade.
◆ The optimal heart rate during coronary anastomoses is controversial. Although bradycardia
leads to decreased visualization of the lateral wall by increasing the heart size during diastole,
the lower the heart rate, the more stable the anastomotic site.
◆ Next we will describe different maneuvers to achieve coronary stabilization on each wall of
the heart.
Figure 4.6
Figure 4.6 Inferior wall exposure for the PDA and PL branches. Note the two arms of the sling toward the left side and the proper position
of the silicone cup.
Anterior and Lateral Wall Stabilization
◆ The stabilizer is positioned on the right side of the chest retractor, usually midway on the
retractor arm. The prongs are slightly bent inferiorly to create a convex shape. This allows
for optimal adherence of the stabilizer to the epicardium (Figs. 4.7 and 4.8).
Inferior Wall Exposure (Posterior Descending Artery and Posterolateral Branches)
◆ The stabilizer is placed on either side of the chest retractor, per surgeon preference. The
prongs are left straight and facing down to optimize inferior wall coronary stabilization
(Fig. 4.9).
Obtuse marginal
branch
Lateral branch from
right coronary artery
Posterior
descending
artery
Acute marginal
A B branch
Figure 4.9
Figure 4.7 The stabilizer is clipped on the right side. Note the convex pod shaping for anterior wall vessel stabilization.
Figure 4.8 Right side stabilizer position and convex shape of the stabilizer prongs to achieve optimal pericardial suctioning for lateral wall
stabilization.
Figure 4.9 Coronary stabilizer on the right side (A) and left side (B). Prongs are left straight and facing down.
Distal Right Coronary Artery
◆ The stabilizer is usually placed on the left side. The arm makes a curve superiorly, and the
prongs are kept straight and placed facing leftward (Fig. 4.10).
6. Prevention of Ischemia and Shunting
◆ During OPCAB, the surgical team must pay extra attention to hemodynamics and myocardial
ischemia. Maneuvers to avoid hemodynamic instability have been described previously. Preven-
tion of myocardial ischemia requires careful planning of the sequence of target vessels to be
revascularized and the use of ischemia prevention strategies, such as shunts.
Sequence of Revascularization
◆ The sequence of revascularization is key to a successful OPCAB. It allows optimizing blood

supply to the myocardium during challenging heart positions.
◆ We strongly recommend grafting the LAD territory first for a number of reasons. Exposure
of the LAD territory requires the least manipulation of the heart. Revascularizing the LAD
also protects the largest proportion of myocardium from ischemic damage and improves blood
supply to collateral territories in subsequent repositioning. Finally, the LAD offers some of
the most technically straightforward anastomoses during OPCAB.
◆ It should be noted, however, that grafting the LAD territory first is not always the best
approach; for example, when the LAD feeds occluded vessels through collaterals. In this situ-
ation, the choice to graft the LAD first may cause extensive ischemia during the coronary
arteriotomy, and it is preferable to graft the occluded vessels before addressing the LAD.
◆ As a general rule, we recommend revascularizing the inferior wall vessel (PDA or PL branch)
as the next step. The positioning of the heart required to expose the inferior wall is less likely
to induce hemodynamic instability than the lateral wall. This anastomosis is also less technically
challenging than those required for more lateral exposures, such as the obtuse marginals
(OMs).
◆ After revascularization of the anterior and inferior walls, there is less risk of hemodynamic
instability when repositioning the heart to expose the lateral wall. It is of paramount importance,
however, to be aware of (and avoid) the tension that may be applied to the LITA to LAD graft
during this positioning maneuver.
◆ When constructing composite grafts, the LAD should be grafted first as well. However, the
sequence of anastomoses should be the ramus intermedius (RI), OMs, PLB, and finally PDA.
This approach precludes the need for intermittent clamping of the graft, allowing immediate
and continuous reperfusion of each target vessel.
Acute margin
Acute marginal branches

Posterior descending
of right ventricle coronary artery
Distal right
coronary artery
Right atrium
Figure 4.10
Figure 4.10 Coronary stabilizer positioning for the distal RCA. Note the use of positioning device to rotate the right ventricular (RV) free
wall.
Ischemia Prevention Strategies
◆ The use of temporary intracoronary shunts is the most reliable method to prevent myocardial
ischemia. These shunts allow distal perfusion of the coronary artery while the anastomosis
is being constructed. Shunts also improve the ability to visualize the target and greatly facilitate
the construction of anastomoses. We recommend the use of shunts for every anastomosis.
◆ Shunts are flexible, tubelike structures that permit the flow of blood when they are inserted
into a coronary artery. Shunts have a short tether attached asymmetrically that can be used
to remove the shunt prior to the completion of the anastomosis. The asymmetric placement
of the tether creates short and long arms, and the long arm should be introduced into the
artery first. Shunts range in size from 1 to 3 mm. We recommend the use of silicone-based
shunts, rather than plastic, because they are more flexible and less likely to damage the coronary
wall.
◆ Care should be taken not to oversize the shunt. An oversized shunt can damage the coronary
endothelium. It also can impair visualization and therefore the construction of the anastomosis.
◆ The shunt should be sized to allow smooth insertion, with minimal loss of blood through
the anastomosis. Adequate visualization should be maintained at all times.

◆ Undersizing is less of an issue with shunts. Visualization may be improved with smaller
shunts, keeping in mind that an element of benign coronary vasoconstriction will likely occur.
◆ Coronary arteriotomy usually requires proximal control for adequate visualization of the
anastomotic site after coronary opening. However, for severely stenotic vessels, proximal
control may not be necessary because the amount of blood inside the vessel does not preclude
visualization.
◆ There are different methods to occlude the coronary artery intermittently before the arteriotomy.
We use silicone (Silastic) tapes looped around the coronary artery for blood flow control
before opening and shunting the artery. Each arm of the silicone tape is passed through one
pledget, which works as an outside occluder. Once the tape is put under tension, the pledget
is pushed against and occludes the coronary artery, with minimal trauma (Fig. 4.11).
◆ The temporary occlusion of the coronary artery allows for a safe arteriotomy and placement
of a coronary shunt. After the shunt is inserted, the temporary coronary occlusion should be
reversed by the removal of the Silastic tapes or the sutures.
◆ Distal RCA grafting usually requires shunting because its occlusion frequently leads to AV
node ischemia and bradycardia. A jumper cable for ventricular pacing is useful to overcome
bradycardia should it occur during the temporary RCA occlusion and shunting.
◆ Shunt insertion follows several principles. It is performed using two forceps, with the long
arm inserted first, which allows more shunt mobilization during shunt bending. The long
arm should be inserted proximally in most cases, which decreases the amount of blood in
the anatomic field. After insertion of the long arm proximally, blood control is achieved by
pinching the shunt with one forceps. Then the other forceps bend the shunt, and the short
arm is inserted distally. Final adjustments may be required (Fig. 4.12; Video 4.3)
Figure 4.11
Figure 4.12
Figure 4.11 Coronary occlusion with silicone tape for proximal blood vessel control.
Figure 4.12 Coronary shunt in place.

◆ Patients who have an uneventful OPCAB are extubated shortly after arrival to the intensive
care unit. Some centers even extubate patients in the operating room. Because of less inflam-
matory response and less blood loss, patients have a smoother postoperative course, with
less fluid and pressor requirements.
◆ Most patients are transferred to the cardiac step-down unit the morning after the surgery.
◆ The anesthesia and surgical teams should work in close collaboration to anticipate hemodynamic
changes during heart positioning.
◆ The pulmonary artery catheter is a useful adjunct to understanding loading conditions and
pulmonary pressures during OPCAB.

◆ The combination of the deep stitch–sling technique and the use of suction-based positioning
devices allows for less hemodynamic changes during lateral wall exposure. The sling prevents
ventricular underfilling, and the suction-based heart positioner elongates the heart, reshaping
the cardiac chambers, which improves heart performance.
◆ Common mistakes during heart positioning and coronary stabilization include the following:
◆ Not enough opening of the pericardium. The inverted-T pericardiotomy should extend past
the apex of the heart.

◆ Taut pericardium. The lateral pericardial stay sutures that create the initial pericardial cradle
should be taken down before manipulating the heart.

◆ Impaired right ventricular filling during lateral wall exposure. Suction devices and deep pericardial
sutures should be used to avoid distortion of the inflow of blood to the heart. Do not bend
or squeeze the heart. To this effect, the Trendelenburg position and right lateral rotation
are helpful maneuvers.
◆ Compressing the heart with the stabilizer. This is more common when the heart is underfilled
and may paradoxically increase the heart’s mobility. Before applying any compression with
a stabilization device, optimization of heart filling pressures should be achieved. Do not
push down on the stabilizer; this will avoid impaired filling of the heart and hemodynamic
collapse.
◆ The sequence of the revascularization strategy should aim to decrease myocardial ischemia
and hemodynamic instability. The LAD territory should be grafted first in most patients.
◆ The use of intracoronary shunts is the safest approach to avoid ischemia and should be used
routinely in most cases. For severely stenotic and occluded vessels, shunting may not be
necessary. Shunts greatly facilitate the safe completion of any anastomotic off-pump procedure.
◆ Myocardial ischemia should be promptly corrected. If ischemia develops after coronary occlu-
sion, shunting is warranted. When myocardial ischemia secondary to hemodynamic instability

occurs, the heart back should be released into the pericardial sac. The heart should be allowed
to recover, and manipulation can be reattempted in incremental moves.
◆ The goal of CABG is to achieve complete revascularization with conduits that have good
long-term patency. OPCAB should not compromise the overall quality of the revascularization
procedure.
◆ Conversion to an on-pump technique is sometimes needed, and the surgeon should perform
it electively. Emergency conversion to an on-pump procedure leads to increased morbidity

and mortality rates and therefore should be avoided at all costs.
◆ OPCAB requires meticulous planning and evaluation of targets, distances, and angles. If the
operator feels that completing the operation will be compromised by the use of a pumpless
technique, a strong argument can be made to plan the procedure, from the beginning, as
on-pump CABG.
References
1. Bakaeen FG, Shroyer ALW, Gammie JS, et al. Trends in use of off-pump coronary artery bypass grafting: results from the Society of
Thoracic Surgeons Adult Cardiac Surgery Database. J Thorac Cardiovasc Surg. 2014;148(3):856–864.e1.
2. Lamy A, Devereaux PJ, Prabhakaran D, et al. Five-year outcomes after off-pump or on-pump coronary-artery bypass grafting. N Engl J
Med. 2016;375(24):2359–2368.
3. Diegeler A, Börgermann J, Kappert U, et al. Off-pump versus on-pump coronary-artery bypass grafting in elderly patients. N Engl J
Med. 2013;368(13):1189–1198.
4. Pawliszak W, Kowalewski M, Raffa GM, et al. Cerebrovascular events after no-touch off-pump coronary artery bypass grafting,
conventional side-clamp off-pump coronary artery bypass, and proximal anastomotic devices: a meta-analysis. J Am Heart Assoc.
2016;5(2).
5. Hattler B, Messenger JC, Shroyer AL, et al. Off-Pump coronary artery bypass surgery is associated with worse arterial and saphenous
vein graft patency and less effective revascularization: results from the Veterans Affairs Randomized On/Off Bypass (ROOBY) trial.
Circulation. 2012;125(23):2827–2835.
6. Sousa Uva M, Cavaco S, Oliveira AG, et al. Early graft patency after off-pump and on-pump coronary bypass surgery: a prospective
randomized study. Eur Heart J. 2010;31(20):2492–2499.
7. Novitzky D, Baltz JH, Hattler B, et al. Outcomes after conversion in the Veterans Affairs randomized on versus off bypass trial. Ann
Thorac Surg. 2011;92(6):2147–2154.
8. Daniel WT, Kilgo P, Puskas JD, et al. Trends in aortic clamp use during coronary artery bypass surgery: effect of aortic clamping
strategies on neurologic outcomes. J Thorac Cardiovasc Surg. 2014;147(2):652–657.
9. Moss E, Puskas JD, Thourani VH, et al. Avoiding aortic clamping during coronary artery bypass grafting reduces postoperative stroke.
J Thorac Cardiovasc Surg. 2015;149(1):175–180.
10. Zhao DF, Edelman JJ, Seco M, et al. Coronary artery bypass grafting with and without manipulation of the ascending aorta: a network
meta-analysis. J Am Coll Cardiol. 2017;69(8):924–936.
11. Lytle BW, Blackstone EH, Loop FD, et al. Two internal thoracic artery grafts are better than one. J Thorac Cardiovasc Surg.
1999;117(5):855–872.
12. Grau JB, Ferrari G, Mak AWC, et al. Propensity matched analysis of bilateral internal mammary artery versus single left internal
mammary artery grafting at 17-year follow-up: validation of a contemporary surgical experience. Eur J Cardiothorac Surg.
2012;41(4):770–775.
13. Grau JB, Johnson CK, Kuschner CE, et al. Impact of pump status and conduit choice in coronary artery bypass: a 15-year follow-up
study in 1412 propensity-matched patients. J Thorac Cardiovasc Surg. 2015;149(4):1027–1033.e2.
14. Glineur D, D’hoore W, de Kerchove L, et al. Angiographic predictors of 3-year patency of bypass grafts implanted on the right
coronary artery system: a prospective randomized comparison of gastroepiploic artery, saphenous vein, and right internal thoracic
artery grafts. J Thorac Cardiovasc Surg. 2011;142(5):980–988.
15. Taggart DP, Altman DG, Flather M, et al. Associations between adding a radial artery graft to single and bilateral internal thoracic
artery grafts and outcomes: insights from the arterial revascularization trial. Circulation. 2017;136(5):454–463.
16. Tranbaugh RF, Dimitrova KR, Lucido DJ, et al. The second best arterial graft: a propensity analysis of the radial artery versus the free
right internal thoracic artery to bypass the circumflex coronary artery. J Thorac Cardiovasc Surg. 2014;147(1):133–140.
17. Hoffman DM, Dimitrova KR, Lucido DJ, et al. Optimal conduit for diabetic patients: propensity analysis of radial and right internal
thoracic arteries. Ann Thorac Surg. 2014;98(1):30–36.
18. Lopes RD, Hafley GE, Allen KB, et al. Endoscopic versus open vein-graft harvesting in coronary-artery bypass surgery. N Engl J Med.
2009;361(3):235–244.
19. Zenati MA, Shroyer AL, Collins JF, et al. Impact of endoscopic versus open saphenous vein harvest technique on late coronary artery
bypass grafting patient outcomes in the ROOBY (Randomized On/Off Bypass) Trial. J Thorac Cardiovasc Surg. 2011;141(2):338–344.
20. Katz ES, Tunick PA, Rusinek H, et al. Protruding aortic atheromas predict stroke in elderly patients undergoing cardiopulmonary
bypass: experience with intraoperative transesophageal echocardiography. J Am Coll Cardiol. 1992;20(1):70–77.
21. Patil TA, Nierich A. Transesophageal echocardiography evaluation of the thoracic aorta. Ann Card Anaesth. 2016;19(suppl 1):S44–S55.
22. Glas KE, Swaminathan M, Reeves ST, et al. Guidelines for the performance of a comprehensive intraoperative epiaortic
ultrasonographic examination: recommendations of the American Society of Echocardiography and the Society of Cardiovascular
Anesthesiologists; endorsed by the Society of Thoracic Surgeons. J Am Soc Echocardiogr. 2007;20(11):1227–1235.
23. Glineur D, Hanet C, D’hoore W, et al. Causes of non-functioning right internal mammary used in a Y-graft configuration: insight from
a 6-month systematic angiographic trial. Eur J Cardiothorac Surg. 2009;36(1):129–135.
24. Mair H, Daebritz S, Reichart B, Sergeant P. Pericardial sling increases OPCAB safety and applicability. Ann Thorac Surg.
2005;80(4):1565–1566.
CHAPTER
5

Minimally Invasive
Coronary Artery
Bypass Grafting
Maria Lorena Rodriguez and Marc Ruel
See Videos 5.1 to 5.10 on ExpertConsult.com.
Minimally Invasive Cardiac Surgery–Coronary Artery Bypass Grafting (MICS CABG)
◆ This technique enables revascularization with a similar configuration as that in a sternotomy

technique, using left internal thoracic artery (LITA) harvesting and hand-sewn proximal and
distal anastomoses under direct visualization.1,2 Complete revascularization is achieved in
95% of cases,1 allowing access to the anterior, lateral, and inferior walls of the heart, with or
without the use of pump assistance.
◆ Anatomic considerations are the same as those for a standard median sternotomy, except that
the view is now from the apical position through a small left thoracotomy window.
1. Indications
◆ These follow the current guidelines for coronary revascularization.
70
Chapter 5 • Minimally Invasive Coronary Artery Bypass Grafting 70.e1
Abstract
Minimally invasive cardiac surgery–coronary artery bypass grafting (MICS CABG) was developed
to decrease morbidity associated with the standard median sternotomy approach. In experienced
hands, this technique offers good graft patency rates and excellent clinical outcomes. This
chapter describes the relevant anatomy, patient selection, operative techniques, and postoperative
care for MICS CABG.
Keywords
coronary artery
bypass grafting
minimally invasive
MICS CABG
Chapter 5 • Minimally Invasive Coronary Artery Bypass Grafting 71
2. Contraindications
◆ Hemodynamic instability or acute ischemia

◆ Chest wall deformities and significant pleural adhesions
◆ Obesity
◆ Intolerance to single-lung ventilation
◆ Significant ascending aorta calcification, if aortic proximal anastomoses are planned
◆ Poor status of the femoral vessels for peripheral cardiopulmonary bypass (CPB) cannulation,
whether planned or not

◆ Inadequate distal target size and quality. The right coronary artery and proximal posterior
interventricular (PIV), posterolateral (PL), and proximal obtuse marginal (OM) targets are not
easily accessible.
Step 3. Operative Technique
1. Anesthesia
◆ Paravertebral block is optional but may be preferred, especially for patients who are being
planned for immediate extubation postoperatively.
◆ Single-lung ventilation is instituted either through a double-lumen endotracheal tube or
through a bronchial blocker.

◆ Transesophageal echocardiography (TEE) may provide additional guidance if the patient
develops instability. It can identify wall motion abnormalities and recovery. In the case of
peripheral CPB cannulation, TEE must guide wire and cannula placement.
◆ Ensure that the endotracheal tube is still in the correct position after repositioning the patient.
2. Positioning
◆ The patient is placed in a semi–right lateral decubitus position (Fig. 5.1). The right arm may
be tucked at the patient’s side or extended to enable harvest of the right radial artery. The
left arm is placed in a sling held above the patient’s head.
◆ The hips are placed in a nearly supine position to enable access to the groin in case of CPB,
as well as to harvest the saphenous vein.

◆ External defibrillator pads are placed on the right anterior chest and the left back. Internal
defibrillators will not fit through the small surgical access.

◆ The chest may be marked to identify the area of the LITA bed easily.
◆ Prepare the skin and place the sterile drapes in such a way that the sternum is easily accessible
in case sternotomy conversion is needed.

Sternum
Incision plan
Defribillator
pads
A B
Figure 5.1
Figure 5.1 (A) Patient positioning in MICS CABG. (B) Sterile draping in MICS CABG.
3. Incision
◆ A 5-cm incision is made in the fifth intercostal space (ICS) at the left midclavicular line,
usually located just below the nipple in this positioning.
◆ The fascia and muscles are transected layer by layer. The left lung should begin deflating at
this stage.
◆ Palpation as to the location of the cardiac apex is done to check adequacy of the position.
The apex should be around 2 cm caudal to the intercostal opening. This decision should be
tailored based on the planned procedure; an incision that is placed too caudally will enable
a relatively easy distal anastomosis, but will restrict access to the aorta for the proximal
anastomoses and a more difficult mobilization of the proximal portion of the LITA. The ICS
opening may be revised as needed.
◆ A retractor is placed and is spread gently. The pericardial fat is removed and the pericardium
is opened. If a multivessel bypass and an aortic anastomosis are planned, the pericardium is
opened from the diaphragmatic surface to the pericardial reflection on the aorta. The distal
targets are inspected as a last feasibility check when using the MICS CABG approach.
◆ The LITA is harvested throughout its full length, from the bifurcation to the level of the
subclavian vein. This is facilitated using ThoraTrak (Medtronic, Minneapolis) and Rultract
(Rultract, Independence, OH) retractors (Fig. 5.2). Other necessary accessories are headlights,
long fine instruments, and long cautery blades. The LITA may be harvested in a skeletonized
or nonskeletonized fashion. Adequate hemostasis is ensured at all times.
◆ Systemic heparin is given. We target for an activated clotting time (ACT) of 250 to 300
seconds for an off-pump CABG case (OPCAB) and 480 seconds for a CPB case.
4. Cardiopulmonary Bypass
◆ An option for beating heart CPB-assisted MICS CABG is available to decompress the heart
or to maintain hemodynamic stability.
◆ Peripheral cannulation is through the femoral vessels.
5. Grafting
◆ We prefer the sequence of placing all the proximal anastomoses first, followed by the distal
grafting.
Internal
mammary
artery
B
Figure 5.2
Figure 5.2 LITA harvest setup. (A, B) Cephalad traction on the retractor to harvest the midproximal LITA. (C) Caudal retraction on the
retractor to harvest the distal LITA (patient’s head is toward the right).
Proximal Anastomoses
◆ The aorta is exposed and brought toward the surgical window (Fig. 5.3A and B):
◆ Pull up the pericardium using stitches.
◆ Place a small sponge to the right of the aorta, pushing it toward the left.
◆ Place continuous positive airway pressure (CPAP) on the right lung.
◆ Place an Octopus on top of the pulmonary artery (PA) to retract and depress it.
◆ Place the patient on CPB.
◆ For blood pressure (BP) control, aim for a systolic pressure of 80 to 90 mm Hg.
◆ Mobilize the aorta-PA junction and place a side-biting clamp (see Fig. 5.3C).
◆ A hand-sewn anastomosis of a conduit to the aorta is similar to the sternotomy approach.
Challenges include a deep surgical field and often the inability of the assistant to help because
of the restricted field.
◆ In patients for whom an aortic anastomosis is not feasible, other options include T-grafting
to the LITA or the left subclavian artery.

◆ Ensure adequate hemostasis because these will be difficult to re-access further on in the
procedure.
Octopus over
PA
A B
C
Figure 5.3
Figure 5.3 (A, B) Proximal anastomosis setup (patient’s head is toward the bottom). (C) Aortotomy as seen through the small thoracotomy.
Distal Anastomoses
◆ The sequence of the distal anastomosis will depend on the surgeon’s judgment. We generally
prefer doing the posterior vessels first, followed by the lateral and then the anterior wall
vessels. It is important to individualize this based on the patient’s anatomy and clinical status.
◆ A Starfish nonsternotomy heart positioner (Medtronic) is prepared. We prefer to use it in a
flexible way (armless) whereby we place a tape and suspend the suction tip by clipping it to
the outside structures, instead of using the rod. We suspend the heart toward the left shoulder
when accessing the posterior vessels and toward the right hip when accessing the lateral
vessels (Fig. 5.4). See Video 5.1.
◆ An Octopus nonsternotomy tissue stabilizer is placed through a small incision on the left
anterior axillary line of the sixth or seventh ICS. Care is taken to push this into the cavity
safely using a Seldinger technique, with a red rubber catheter to avoid penetrating injuries
to the heart. The Octopus is placed parallel to the target vessel, just as with routine CABG
cases, and the rod is anchored solidly to the operating room (OR) table.
◆ It is important that the systolic BP be raised to 140 mm Hg prior to manipulating the heart.
Once the heart is positioned, its status is observed for a few seconds to ensure that the
hemodynamics are stable.
LAD
Non-sternotomy Octopus rod

tunneled through the
intercostal space
B
Figure 5.4
Figure 5.4 Distal anastomosis setup (with video). (A) Exposure of anterior wall vessels. (B) Left anterior descending (LAD) artery
arteriotomy, with proximal Silastic control (patient’s head is toward the right). (C) Exposure of lateral wall vessels. (D) Exposure of posterior
wall vessels.
OM
Starfish securing
the heart apex
PIV
D
Figure 5.4, cont’d
◆ To provide bleeding control, we prefer to place a Silastic proximal to the planned anastomosis
site prior to opening the vessel. In case of ischemia, a coronary shunt is placed, and the
Silastic is removed.
◆ Distal anastomoses are performed similar to what is done in routine sternotomy cases (Fig.
5.5). Exposure is facilitated by using a blow mister device and occasionally by the coronary
shunt.
◆ Immediate graft patency is routinely checked using a transit time flow probe.
6. Closure
◆ Heparin reversal is carried out with protamine.

◆ A thoracic drain is placed in the small incision where the Octopus was passed. This is hooked
to low suction.
◆ There is the option of placing intercostal bupivacaine and muscle blockade prior to closing
the intercostal space (ICS).

◆ The thoracotomy is closed using one heavy suture, with routine closure of the fascia and
skin.
Step 4. Postoperative Considerations
◆ Perioperative mortality is low, at 1.3%.1

◆ Other advantages include decreased need for blood transfusion, lower surgical site infection
rates, and earlier return to full physical function.1,3,4

◆ Postoperative pain can be an issue initially after the procedure but it is transient and control-
lable. It rapidly abates by the third postoperative day and is associated with an overall improved
postoperative pain picture, with improved pulmonary function.5,6
◆ The anastomotic patency results have been validated to be very good up to short- and
intermediate-term follow-up.7,8
◆ The rate of sternotomy conversion is 3%.
◆ A left-sided pleural effusion can be an issue, and we maintain the thoracic drain for 3 days.
Step 5. Pearls
◆ Communication between the surgeon and anesthesiologist is key.

◆ The surgeon and team should first be facile with sternotomy OPCAB before proceeding to
doing MICS CABG.
◆ CPB assistance helps mitigate the learning curve.
Figure 5.5
Figure 5.5 LITA-LAD and saphenous vein–diagonal artery grafts (patient’s head is toward the right).
References
1. McGinn J, Usman S, Lapierre H, et al. Minimally invasive coronary artery bypass grafting. Circulation. 2009;120(suppl 1):S78–S84.
2. Chan V, Lapierre H, Sohmer B, et al. Handsewn proximal anastomoses onto the ascending aorta through a small left thoracotomy
during minimally invasive multivessel coronary artery bypass grafting: a stepwise approach to safety and reproducibility. Semin Thorac
3. Lapierre H, Chan V, Sohmer B, et al. Minimally invasive coronary artery bypass grafting via a small thoracotomy versus off-pump: a
case-matched study. Eur J Cardiothorac Surg. 2011;40:804–810.
4. Une D, Lapierre H, Sohmer B, et al. Can minimally invasive coronary artery bypass grafting be initiated and practiced safely? A
learning curve analysis. Innovations (Phila). 2013;8(6):403–409.
5. Lichtenberg A, Hagl C, Harringer W, et al. Effects of minimally invasive coronary artery bypass on pulmonary function and
postoperative pain. Ann Thorac Surg. 2000;70(2):461–465.
6. Walther T, Falk V, Metz S, et al. Pain and quality of life after minimally invasive versus conventional cardiac surgery. Ann Thorac Surg.
1999;67(6):1643–1647.
7. Ruel M, Shariff M, Lapierre H, et al. Results of the minimally invasive coronary artery bypass grafting angiographic patency study.
J Thorac Cardiovasc Surg. 2014;147:203–209.
8. Hoff S, Ball S, Leacche M, et al. Results of completion arteriography after minimally invasive off-pump coronary artery bypass.
Ann Thorac Surg. 2011;91:31–37.
CHAPTER
6
Hybrid Coronary
Revascularization
Bob Kiaii, Vincenzo Giambruno, Patrick Teefy,
Michael W.A. Chu, and Kumar Sridhar
Definition and Rationale
◆ Hybrid coronary revascularization (HCR) is defined as the combination of coronary artery

bypass grafting (CABG) and percutaneous coronary intervention (PCI) to treat multivessel
coronary artery disease (CAD). HCR most commonly combines a minimally invasive CABG
procedure involving a left internal thoracic artery (LITA) to the left anterior descending coronary
artery (LAD) anastomosis with PCI to non-LAD vessels. This technique offers and combines
the advantages of surgical and percutaneous revascularization, eliminating at the same
time the disadvantages of both procedures. In fact, this evolving revascularization technique
uses the survival benefits conferred by the LITA to LAD graft while providing the patient with
complete and minimally invasive coronary artery revascularization with PCI to the non-LAD
vessels. The sequence and timing of the surgical and interventional components of hybrid
therapy can be in three different ways: PCI first followed by surgery, surgery followed by PCI
(two-stage HCR), or both carried out during the same setting (single-stage HCR). In the era
of primary PCI for ST-segment elevation myocardial infarction (MI), it is probable that patients
requiring immediate PCI of the right coronary artery (RCA) or circumflex artery as the culprit
lesion may require subsequent surgical revascularization of a complex LAD or left main lesion
at some time in the future. Hence, HCR, by definition, generally refers to a revascularization
strategy that has been strategically planned in a coordinated fashion by interventional cardiolo-
gists and cardiac surgeons.
◆ The optimal revascularization strategy for multivessel CAD is still debated. Although there
are survival benefits of complete arterial coronary revascularization, in practice only a fraction
of patients referred for CABG actually receive this; most of them receive at least one saphenous
vein graft (SVG). If it is true that recent trials, including SYNTAX,1 have helped establish
which anatomic categories are best addressed with traditional CABG versus multivessel PCI
with a drug-eluting stent (DES), it is also true that there is still potential for prognostic and
symptomatic improvement from coronary revascularization in certain patients with multivessel
CAD. The modality depends on many factors, the most important of which is the coronary
anatomy itself. Other crucial factors include the clinical setting (e.g., emergent, acute, chronic);
left ventricular function; degree of myocardial viability; and presence or absence of comorbidities,
assessed through the risk score of the Society of Thoracic Surgeons (STS) or EuroScore (e.g.,
diabetes, associated valvular heart disease, presence of calcification of the ascending aorta,
which could preclude safe cross-clamping during surgical intervention, age, patient preference,
availability of bypass conduits). Outcomes in diabetic patients, in particular, seem to favor a
surgical strategy over PCI for multivessel disease, although first-generation sirolimus-eluting
and paclitaxel-eluting stents were the predominant types of DESs used in the FREEDOM trial
and may underestimate the benefits of current (third-generation) stenting.2
83
Chapter 6 • Hybrid Coronary Revascularization 83.e1
Abstract
Hybrid coronary revascularization (HCR) is defined as the combination of coronary artery bypass
grafting (CABG) and percutaneous coronary intervention (PCI) to treat multivessel coronary artery
disease. HCR most commonly combines a minimally invasive CABG procedure involving a left
internal thoracic artery (LITA) to the left anterior descending coronary artery (LAD) anastomosis
with PCI to non-LAD vessels. This technique offers and combines the advantages of both surgical
and percutaneous revascularlization, eliminating at the same time the disadvantages.
Keywords
coronary revascularization
hybrid
PCI
minimally invasive CABG
robotic
◆ However, CABG is still considered the gold standard treatment for patients with multivessel
CAD.3-5 The major therapeutic benefits of CABG arise from the graft of the LITA to LAD,
which has been shown to have excellent long-term results in terms of patency, event-free
survival, and relief of angina.6,7 On the other hand, SVGs have shown a high incidence of
failure8 as opposed to multivessel PCI with a DES, which has shown lower restenosis rates,
lower failure rates than SVG, and lower stroke rates compared with CABG. In addition, PCI
is less invasive and has a shorter recovery time.9,10 HCR thus represents a promising coronary
revascularization option due to the fact that it offers the advantages of the best of both
treatment options. It takes advantage of the survival benefit conferred by the LITA to LAD
graft while minimizing the invasiveness of revascularization therapy and providing a complete
revascularization with PCI to the non-LAD vessels. Additionally, the use of the robotic-assisted,
coronary artery bypass grafting (RA-CABG) graft of the LITA to the LAD minimizes surgical
trauma further.
◆ Several studies have already demonstrated similar results in terms of mortality, patency, and
major adverse cardiac event rates—between a hybrid revascularization strategy and similar
conventional on- and off-pump coronary bypass surgery.11-14 However, the safety and effective-
ness of HCR is still understudied and further studies, especially randomized trials, are necessary
before stronger recommendations can be made for this revascularization therapy.
History of Hybrid Coronary Revascularization
◆ HCR was first described by Angelini et al. in 1996.15 They used the classic minimally invasive
direct coronary artery bypass (MIDCAB) procedure, in which the LITA is harvested by direct
vision through a fourth interspace left minithoracotomy; the LITA is sutured to the LAD on
the beating heart. After the pioneering work of Benetti et al.16 on minimally invasive CABG,
MIDCAB was adopted by several groups in the mid-1990s.17-20 HCR then evolved as a result
of the desire to treat patients with multivessel disease effectively while at the same time lowering
procedure-related morbidity by combining minimal access coronary artery surgery with
percutaneous techniques.
◆ This was a very innovative and visionary new concept in the field of coronary revascularization,
representing a mix and the natural evolution of the two disciplines, cardiac surgery and
interventional cardiology. Interventional cardiologists were progressively more aggressive in
their percutaneous treatment of CAD; surgeons were developing minimally invasive techniques
with a smaller incision, avoidance of sternotomy, and beating heart surgery technique. Addition-
ally, throughout the 1990s, endoscopic, video-assisted, and finally robot-assisted LITA dissection
were performed. Successful endoscopic harvesting of LITA has been a crucial step in the
performance of minimal access coronary artery bypass surgery through minithoracotomy
incisions,21 and video-assisted LITA takedown has been further facilitated by the use of robotic
assistance. In the last 15 years, telemanipulation surgical systems have significantly improved,
and currently RA-CABG encompasses the use of robotic assistance to varying degrees, from
robotic-assisted LITA harvest to manual anastomosis through a mini anterior non-rib spreading
incision procedures to total endoscopic coronary artery bypass (TECAB). On the other hand,
there has been a continuous improvement of DES performance and, in low-risk patients and
those with single-vessel disease, PCI can now provide comparable short- and mid-term outcomes
to those of CABG.22,23
Chapter 6 • Hybrid Coronary Revascularization 85
Indications for Hybrid Coronary Revascularization and Patient Selection
◆ According to the 2011 American College of Cardiology/American Heart Association guidelines

for CABG,24 HCR is a suitable coronary revascularization strategy for patients with multivessel
CAD (e.g., LAD and one or more non-LAD stenoses) and an indication for revascularization:
Hybrid revascularization is ideal in patients in whom technical or anatomic limitations to CABG or
PCI alone may be present and for whom minimizing the invasiveness (and therefore the risk of morbidity
and mortality) of surgical intervention is preferred (e.g., patients with severe preexisting comorbidities,
recent MI, a lack of suitable graft conduits, a heavily calcified ascending aorta, or a non-LAD coronary
artery unsuitable for bypass but amenable to PCI, and situations in which PCI of the LAD artery is
not feasible because of excessive tortuosity or chronic total occlusion).
1. Recommendations From 2011 American College of Cardiology/American Heart

Association Guidelines for Coronary Artery Bypass Surgery24
Class IIa
◆ HCR, defined as the planned combination of LITA to LAD artery grafting and PCI of one or
more non-LAD coronary arteries, is reasonable in patients with one or more of the following
(level of evidence: B):
◆ Limitations to traditional CABG, such as heavily calcified proximal aorta or poor target
vessels for CABG (but amenable to PCI).
◆ Lack of suitable graft conduits.
◆ Unfavorable LAD artery for PCI (i.e., excessive vessel tortuosity or chronic total
occlusion).
Class IIb
◆ HCR, defined as the planned combination of LITA to LAD artery grafting and PCI of one or
more non-LAD coronary arteries, may be reasonable as an alternative to multivessel PCI or
CABG in an attempt to improve the overall risk-benefit ratio of the procedures (level of
evidence: C). According to the 2014 European Society of Cardiology/European Association
for Cardio-Thoracic Surgery guidelines on myocardial revascularization25:
Hybrid procedures consisting of LITA to LAD and PCI of other territories appear reasonable when PCI
of the LAD is not an option or is unlikely to portend good long-term results or when achieving a
complete revascularization during CABG might be associated with an increased surgical risk.
◆ HCR may be clinically indicated in the following cases25:
1. Select patients with single-vessel disease of the LAD, or in those with multivessel disease
but with poor surgical targets, except for the LAD territory, in whom minimally invasive
surgery can be performed to graft the LAD using the LITA. The remaining lesions in other
vessels are subsequently treated by PCI.
2. Patients who had previous CABG and now require valve surgery and who have at least
one important patent graft (e.g., LITA to LAD) and one or two occluded grafts with a
native vessel suitable for PCI.
3. Combination of revascularization with nonsternotomy valve intervention (e.g., PCI and
minimally invasive mitral valve repair, or PCI and transapical aortic valve implantation).
In addition, some patients with complex multivessel disease presenting with STEMI initially require
primary PCI of the culprit vessel, but subsequently may require complete surgical revascularization.
A similar situation occurs when patients with combined valvular and CAD require urgent revascularization
with PCI. Finally, when a heavily calcified aorta is found in the operating room, the surgeon may elect
not to attempt complete revascularization and to offer delayed PCI.25
◆ In the Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology/
Canadian Society of Cardiac Surgery Position Statement on Revascularization—Multivessel
Coronary Artery Disease,26 it is stated that HCR:
1. Is typically performed with minimally invasive incisions.
2. Combines the advantage of the LITA to LAD graft with the less invasive nature of PCI.
3. Has been demonstrated by studies to date to be safe and effective, but definitive data (e.g.,
randomized trials) are lacking.
◆ However, the lack of randomized controlled clinical trials does not allow the identification
of an HCR target group of patients. Therefore, HCR should be considered an alternative

treatment strategy that should be tailored to the individual patient based on the patient’s
anatomy and patient-related variables through a collaborative heart team approach. The ideal
patient is a patient with multivessel CAD, with a complex proximal LAD lesion suitable for
LITA-LAD grafting, associated with non-LAD lesions suitable for PCI, and no contraindications
for dual antiplatelet therapy (Fig. 6.1). Careful attention should be focused on the quality
and size of the LAD, epicardial or intramyocardial LAD course (Fig. 6.2), presence of large
diagonal vessels, which can be mistaken as the LAD and inadvertently grafted, complexity of
non-LAD vessel lesions for PCI, and number of stents necessary to treat the non-LAD stenosis
effectively. PCI of overly complex non-LAD vessels (e.g., long lesions, bifurcations of major
branches) will increase the risk of restenosis and may diminish the benefits of a percutaneous
strategy over saphenous vein or other arterial grafting.
◆ Other important factors in patient selection for HCR are patient variables, including clinical
presentation, comorbidities, body habitus, chest wall anatomy, and surgeon experience with
minimally invasive CABG procedures. Chest wall anatomy, obesity, and thoracic size may
have a significant impact on the surgical part of the procedure. Patient comorbidities, such
as chronic obstructive pulmonary disease and pulmonary hypertension, also have a significant
impact. For a robotic-assisted approach, the patient must be able to tolerate single-lung ventila-
tion and physiologic changes related to carbon dioxide insufflation. HCR could then serve
patients at the two extremities of the risk spectrum—young and relatively healthy patients
who prefer to avoid the sternotomy but do not want to renounce the durability of the LITA-
LAD graft, and older and/or high-risk patients who may benefit from a less traumatic, minimally
invasive but full and complete coronary revascularization. In the end, it is quite intuitive that
the experience of the surgeon is a key factor in the successful outcome of this revascularization
strategy, given the challenging nature and steep learning curve of the minimally invasive
CABG techniques (from RA-CABG to TECAB).
Figure 6.1
Figure 6.2
Figure 6.1 This coronary angiogram shows an example of an ideal candidate for hybrid coronary revascularization. (A) Focal lesion of
the circumflex artery. (B) Complex, tandem lesion of the left anterior descending coronary artery. (C) Focal lesion of the right coronary
artery.
Figure 6.2 The arrow indicates the epicardial course of the left anterior descending coronary artery.
Methods and Techniques
2. Procedural Stages
Single-Stage Procedure
◆ A minimally invasive coronary artery bypass procedure is done first (Fig. 6.3). The patient
remains on aspirin preoperatively, intraoperatively, and postoperatively. After harvest of the LITA,
bivalirudin at a loading dose of 0.75 mg/kg is administered; infusion at a rate of 1.75 mg/kg/hr
is continued throughout the rest of the procedure, including the surgical revascularization and
PCI. After the surgical revascularization is completed, the hybrid operating room is then reset
to a cardiac catheterization configuration. The LITA graft check is performed. After hemostasis
is confirmed, with evidence of minimal drainage from chest tubes, clopidogrel, 600 mg, or
ticagrelor, 180 mg via a nasogastric (NG) tube, is administered (Fig. 6.4). PCI is performed on
non-LAD targets. The bivalirudin infusion is continued and overlapped with the clopidogrel over
the next hour. Postoperatively, the patient is continued on aspirin and clopidogrel or ticagrelor.
Two-Stage Procedure
◆ If PCI has already been performed on the culprit non-LAD vessel, then after 3 months the clopidrogrel
or ticagrelor are held for 2 days prior to the surgery but not the ASA. The dual antiplatelet therapy
is restarted the day after surgery. Minimally invasive surgical revascularization is performed as per
routine using heparin and protamine for reversal. If PCI is to be performed postoperatively, the
evening after surgery the patient is given a loading dose of clopidogrel or ticagrelor; the patient
undergoes PCI on the next day. Postoperatively, the patient is continued on aspirin and clopidogrel
or ticagrelor.
3. Operative Technique
Anesthesia Considerations
◆ A paravertebral or intrathecal block with epimorphine is used for pain control.

◆ Defibrillator pads on the left scapula and inferior and medial to the right breast are placed.
◆ Intubation is performed with a double-lumen endotracheal tube (ETT) to deflate the left lung.
◆ Alternatively, a single-lumen ETT and bronchial blocker may be placed under fiberoptic guidance.
◆ Lines are routine; they include an arterial line and pulmonary artery catheter (PAC), if required.
If peripheral access is limited, 16-G IV tubing should at least be placed. A triple-lumen

catheter is placed if no PAC is inserted.
◆ After intubation, place a bronchial blocker into the mainstream bronchus with fiberoptic
guidance. Place the proximal end of the balloon approximately 1 to 2 cm below the carina.
◆ A warming blanket should be used to avoid hypothermia.
◆ CO2 insufflation is provided to maintain an intrathoracic pressure of 5 to 10 mm Hg (watch
blood pressure).
◆ Hemodynamic support for off-pump coronary artery bypass (OPCAB) surgery may be necessary.
Stage Hybrid Logistics
HCR Candidate
Single-Stage
Candidate?
YES
Single-Stage
HCR
NO
Culprit Lesion
LAD Indeterminate Non-LAD

Two-Stage Two-Stage Two-Stage
HCR with HCR with HCR with
CABG first CABG first PCI first
Figure 6.3
Single-Stage Anticoagulation/Antiplatelet Consideration

Intraoperative
ASA 81 mg
Preop 15 Discharge
Bivalirudin Drip
minutes
MICS
Clopidogrel 600 mg
30
minutes
PCI
Closure device or
LITA
sheaths pulled
Angiography
in 2 hours
Figure 6.4
Figure 6.3 The flow chart indicates the procedural algorithm of the single- or two-stage hybrid coronary revascularization.
Figure 6.4 Anticoagulation and antiplatelet therapy strategy in single stage hybrid coronary revascularization.
Single-Lung Ventilation
◆ Deliver approximately 10 mL/kg of tidal volume prior to and during single-lung ventilation.
Tidal volume may need to be decreased because large tidal volumes can cause shifting of the
mediastinum, which may cause the stabilizer to slip and effect the stabilization.
◆ Keep the O2 saturation greater than 90%. If the saturation begins to decrease, the following
should be carried out:

◆ Add continuous positive airway pressure (CPAP) of 5 cm H2O to the deflated lung. This
can be performed through the bronchial blocker by inserting a 7 Fr endotracheal tube
(ETT) connector into the barrel of a 3-mL syringe. Insert the syringe tip into the lumen of
the bronchial blocker. Attach the 7 ETT connector to a CPAP circuit.
◆ CPAP can be increased but if it is increased too much it will cause the lung to inflate and
obscure the surgeon’s view.
Perfusion Considerations
◆ The need for extracorporeal support is rare. A supported coronary revascularization would
only require a system with a venous reservoir, arterial pump, oxygenator, and filter. It is recom-
mended that the extracorporeal support system and devices be on standby. The use of a cell
saver is recommended. Percutaneous cannulae are necessary if femoral cannulation is used
for hemodynamic support.
4. Surgical Technique
Preparation, Positioning, and Draping
◆ Initialpositioning of the patient can have a considerable effect on the operative procedure
because proper positioning minimizes interference from internal and external body structures
by the robotic equipment. Judicious care at this stage ensures the necessary landmarks for
port placement to maximize intraoperative robotic arm maneuverability.
◆ The patient is positioned at the left edge of the operating room table. A comfortable support
is placed under the distal two-thirds of the left side of the patient’s thorax. This usually takes
the form of a rolled-up towel and should elevate the patient’s thorax by 6 to 8 inches superiorly.
The left arm is positioned at the side of the operating room table to allow the left shoulder
to drop posteriorly. Rotate the table 30 degrees up so the patient is in the partial left lateral
position (Fig. 6.5). Leads and external defibrillator pads are positioned on the patient’s chest,
away from the left lateral and midclavicular areas of the thorax, so as not to interfere with
port placement. Place one pad on the right anterior lateral thorax and the other on the left
posterior thorax. The patient is prepped in a routine manner for conventional CABG and
saphenous vein harvesting, safeguarding against the possibility of having to convert the case
to an open procedure. The only variation in preparation is exposure of the patient’s thorax
and axilla on one side for port placement.
Figure 6.5
Figure 6.5 Proper patient positioning.

Direct Internal Thoracic Artery Harvest
Step 1. Patient Setup

◆ Lines and airway—double-lumen ETT with internal jugular central line.
◆ Positioning is 30 degrees right lateral decubitus, with a roll under the left shoulder.
Step 2. Thoracotomy Incisions

◆ Perform a 5- to 7-cm anterolateral minithoracotomy.
◆ Male patients—over the fifth or sixth intercostal space (ICS), one-third medial to the nipple.
◆ Female patients—inframammary incision in similar location.
◆ Medial two-thirds of the window incision medial to the anterior axillary line.
◆ Deflate left lung while making incision.
◆ Divide intercostal muscles laterally to reduce risk of rib fracture, then divide them medially
to avoid damage to LITA.

◆ Soft tissue retractor may be placed in incision to maximize access.
Step 3. Direct Internal Thoracic Artery Harvest

◆ Place a large Kelly clamp with a sponge in the sixth ICS to assist with harvesting the LIMA.
Use the sponge to push away tissue for better internal thoracic artery (ITA) visualization.
◆ Insert the ThoraTrak (Medtronic, Minneapolis) retractor system into the ICS incision; then
hook the ThoraTrak retractor system to the Rultract Skyhook surgical retractor (Pemco,
Cleveland) to facilitate the LITA harvest.
◆ To prevent crush injury to the LIMA, make sure that the superior portion of the retractor is
placed and maintained in the lateral aspect of the incision.

◆ Care should be taken not to fracture a rib.
◆ The ThoraTrak MICS retractor system should be opened slowly, which allows tissue and bone
to acclimate to the change in position to minimize the potential for rib fracture and pain.
◆ Start the LITA harvest at the third ICS using direct vision through the window incision.
◆ Use an extended electrocautery instrument, endoscopic forceps, suction, endoscopic clip
applier, and small clips for the harvest.

◆ Complete the harvest up to the subclavian vein and down past the left fifth ICS.
◆ Take care to identify and avoid the phrenic nerve.
◆ During the LITA harvest, flexing the table may facilitate access to the superior portion of the
LITA.
◆ Anchor the pedicle of the LITA with silk ties to maintain the proper orientation.
◆ Give intravenous bivalirudin or heparin prior to LITA division.
Endoscopic Robotic Harvesting of the Left Internal Thoracic

Artery and/or Right Internal Thoracic Artery
Step 1. Patient Setup

◆ Positioning is 30 degrees right lateral decubitus, with a roll under the left chest to allow the
shoulders to fall.
Port Placement and Intrathoracic Visualization

◆ Proper port placement is fundamental to the success of the operation. Placement of each
port is centered on constructing an ideal configuration that ensures mobilization of the ITAs
from the first to the sixth ribs, with the least amount of impedance to the robotic arms. It is
imperative that the surgeon be meticulous with each individual patient, taking the necessary
time needed to ensure proper completion of port placement prior to surgery. Suboptimal port
placement can frequently result in dangerous internal and/or external robotic arm collisions.
◆ The lack of intrathoracic visualization is the premiere challenge to determining port placement.
Careful review of the coronary angiogram, chest radiographs, and computed tomography
(CT) scans of the heart with contrast preoperatively, along with direct examination of the
anatomic structures of the individual patient in the operating room, help alleviate this problem.
Chest Radiography
◆ Evaluate the chest radiograph in an orderly manner. Identify pertinent thoracic landmarks—
suprasternal notch; angle of Louis; xiphoid; second to fifth ICSs; LITA and right internal
thoracic artery (RITA) locations, 1 to 3 cm lateral to the sternum.
◆ Note the position of the heart in the mediastinum. Note the size of the heart in relation to
the pleural space on the port access side of the chest. On the lateral view, observe the degree
of space between the anterior surface of heart and underside of the thorax.
Computed Tomography of the Heart

◆ Assess the intrathoracic space. The distance from the pleural surface to the mediastinum
cannot be less than 1.7 cm at the camera port space, which is usually the fifth ICS (Fig. 6.6).
A distance less than 1.7 cm will not provide adequate intrathoracic space for adequate degrees
of freedom of the robotic instrument.
◆ Rule out any other anatomic abnormalities, such as asbestos plaques.
◆ Determine the anteroposterior (AP) measurement and transverse (Trv) distance of the chest
cavity. If the AP/Trv ratio is less than 45%, it reduces the success of robotic-assisted coronary
artery revascularization.26 In addition, the vertical distance from the LAD to the chest wall
is also a factor in the success of the operation. If this distance is less than 15 mm, there is
a lower chance of being able to perform the operation robotically27 (Fig. 6.7).
◆ Assess the location of the coronary arteries if intramyocardial. Access to intramyocardial
vessels for revascularization is challenging and can result in conversion (Fig. 6.8).
Figure 6.8
Figure 6.6 Computed tomography showing the distance from the pleura to the mediastinum.
Figure 6.7 Anteroposterior (AP), transverse measurement (TVR), and left anterior descending (LAD) to chest wall distance.
Figure 6.8 Intramyocardial location of left anterior descending (LAD) coronary artery.
Direct Examination of the Patient Thorax

◆ Evaluate the external anatomic characteristics of the patient’s thorax, and conceptualize the
internal anatomic characteristics based on the previously viewed chest x-ray, CT scans, and
preoperative coronary angiogram.
◆ With a felt marker, outline precisely where each port is to enter the thoracic cavity, using the
standardized guidelines discussed in the following (see Fig. 6.5). Make necessary adjustments
for individual patients based on information acquired from diagnostic imaging and the patient
examination.
Step 2. Endoscopic Port Insertion

◆ The left lung is deflated, and the 12-mm port is inserted in the fifth ICS.
◆ CO2 insufflation is provided to maintain an intrathoracic pressure of 5 to 10 mm Hg (watch
blood pressure).
◆ A 30-degree endoscope is inserted. Under guidance of the endoscope, two 7-mm ports are
inserted in the third and seventh ICSs.

◆ The LITA is harvested from the first to the sixth rib endoscopically or robotically.
◆ Prior to ligation of the LITA, the patient is given intravenous bivalirudin or heparin depending
on the stage of the procedure (1 or 2).

◆ The LITA pedicle is transected. To avoid torsion, using a clip, it is attached to the edge of
the pericardium in the normal anatomic orientation at the site where the anastomosis is to
be performed.
Step 3. LITA-LAD Anastomosis (Applies to Direct and Robotic Harvest Techniques)
◆ The LITA-LAD anastomosis is performed under direct vision through the minithoracotomy.
◆ Only soft tissue retraction is generally required, minimizing trauma.
Pericardiotomy
◆ Pericardialfat is first removed.

◆ The pericardium is opened down to the diaphragm and toward the right pleura, 2 to 3 cm
anterior to the phrenic nerve.
Anastomosis28,29
◆ The LAD artery is identified based on its location on the ventricular septum, going to the
apex.
◆ Insert the long needle under direct visualization of the endoscope to identify the optimal ICS
to perform a thoracotomy for best exposure of the LAD.

◆ Insufflation can be momentarily stopped to take away the shift in the mediastinum.
◆ Mark the intercostal space from the inside using electrocautery.
◆ If robotic assistance is used, the robot is undocked and instrument ports are removed.
◆ A mini anterior thoracotomy is performed.
◆ Identify the pericardiotomy site and ITA pedicle.
◆ Detach the ITA, deliver through an incision, and immediately place two suspension sutures
to prevent the pedicle from twisting.

◆ Assess ITA length and flow and prepare for anastomosis.
◆ Select the port site for the endoscopic Octopus Nuvo stabilizer (Medtronic, Minneapolis; Fig.
6.9)—sixth ICS if the LITA is harvested directly or the fifth ICS port site if the LITA is
robotically harvested.
◆ Achieve stabilization.
◆ Apply proximal and distal occlusion snares or an intravascular shunt, depending on the
patient’s hemodynamics.
◆ Perform anastomosis in the usual fashion.
◆ Check graft flow using an intraoperative flow-measuring device.
◆ Carry out intraoperative angiography to check ITA patency and PCI of other coronary vessels
at the same time (if one-stage procedure) in the specialized hybrid operating room (Fig. 6.10).
Figure 6.9 © Medtronic 2017. All rights reserved. Used with the permission of Medtronic.
Figure 6.10
Figure 6.9 Octopus Nuvo stabilizer.
Figure 6.10 Hybrid cardiac operating room at the London Health Sciences Centre and Canadian Surgical Technologies and Advance
Robotics (CSTAR). The room is fully equipped for robotic surgery, angiography, and percutaneous coronary intervention.
Results, Institutional Experience, and Current Evidence
◆ Since 2004, at the London Health Sciences Centre, a total of 153 consecutive patients (age,
61.4 ± 11.1 years; 118 males and 35 females) underwent HCR (robotic-assisted MIDCAB
graft of the LIMA to the LAD and PCI in a non-LAD vessel), 120 of which were a single
simultaneous procedure. Of the remainder undergoing staged procedures, 19 patients underwent
PCI before surgery, and 14 patients underwent PCI at a separate setting after surgery. Successful
HCR occurred in 146 of the 153 patients; 7 patients required intraoperative conversion to
conventional coronary bypass. DESs were used in 139 patients, and 14 patients were treated
with bare metal stents. In the series of patients who underwent successful HCR, no perioperative
mortality occurred; there was only one perioperative MI (0.6%), two cerebral vascular accidents
(1.3%), and one respiratory failure with prolonged ventilation (0.65%). The rate of reoperation
for bleeding was 2.6% (n = 4). Only 13.0% of patients (n = 20) required a blood transfusion.
None of the patients developed acute kidney injury (AKI) with a need for kidney replacement
therapy. The average intensive care unit (ICU) stay was 1 ± 1 days and the average hospital
stay was 4 ± 2 days. Coronary angiography follow-up at 6 months was performed in 95
patients. Angiographic evaluation demonstrated an LITA anastomotic patency of 97.9% and
a PCI vessel patency of 92.6%. Clinical follow-up at 83.6 ± 11.1 months demonstrated 93.9%
survival, 91.2% freedom from angina, and 88.5% freedom from any form of coronary revas-
cularization. PCI to LITA to LAD anastomosis was performed in 5 patients; in one case, the
anastomosis was surgically revised, and PCI was repeated to non-LAD vessels in 11 patients.
◆ We also performed a comparative analysis of HCR to conventional on-pump CABG with an
adjusted analysis using inverse probability weighting (IPW) based on the propensity score of
undergoing on-pump CABG or HCR from patients in our institution. We considered all double
on-pump CABG (n = 682) and HCR (147 RADCAB grafts of the LITA to the LAD and PCI
to one of non-LAD vessels) procedures between March 2004 and November 2015. We performed
IPW-adjusted analysis of the outcomes using the teffects ipw package (for estimating treatment
effects) using the average treatment effect (p < 0.05 was considered significant). In the two
groups, there were no statistically significant difference in the rate of re-exploration for bleeding
(CABG, 1.7%; HCR, 2.8%; p = 0.44), perioperative MI (CABG, 1.1%; HCR, 1.4%; p = 0.79),
stroke (CABG, 2.4%; HCR, 2.1%; p = 0.83), need for hemodialysis (CABG, 0.4%; HCR, 0%;
p = 0.16), prolonged mechanical ventilation (CABG, 2%; HCR, 0.7%; p = 0.15), ICU length
of stay (CABG, 1.7 ± 2.3 days; HCR, 1.0 ± 0.8 days; p = 0.23). HCR was associated with a
lower blood transfusion rate (CABG, 25%; HCR, 14%; p = 0.002), lower in-hospital mortality
(CABG, 1.3%; HCR, 0%; p = 0.008), shorter hospital length of stay (CABG, 6.7 ± 4.7 days;
HCR, 4.5 ± 2.1 days; p < 0.001). After the median follow-up period of 70 months (37–106
months; CABG group), and 96 months (53–114 months; HCR group) there was no significant
difference in survival (CABG, 92%; HCR, 97%; p = 0.13) and freedom from any form of
revascularization (CABG, 93%; HCR, 91%; p = 0.27). HCR was superior in freedom from
angina (CABG, 70%; HCR, 91%; p < 0.001). Using the same methodology, we also performed
a comparative analysis to off-pump CABG. Our sample consisted of all double off-pump
CABG (n = 216) and HCR (147 RA-CABG grafts of the LITA to the LAD and PCI to one of
non-LAD vessels) procedures performed between March 2004 and November 2015.
◆ We found that in the two groups, there were no statistically significant differences in the rate
of re-exploration for bleeding (CABG, 1.5%; HCR, 3.5%; p = 0.36), postoperative atrial
fibrillation (CABG, 19%; HCR, 12%; p = 0.13), perioperative MI (CABG, 0.5%; HCR, 1.4%;
p = 0.36), stroke (CABG, 1.0%; HCR, 2.1%; p = 0.88), renal failure with need for hemodialysis
(CABG, 0.5%; HCR, 0%; p = 0.31), blood transfusion (CABG, 28%; HCR, 15%; p = 0.60),
in-hospital mortality (CABG, 1.0%; HCR, 0%; p = 0.15), ICU length of stay (CABG, 1.8 ±
1.3 days; HCR, 1.0 ± 0.8 days; p = 0.10). There was a higher rate of in-hospital re-intervention
in the HCR group in order to revise the LITA-LAD graft after intraoperative angiography
(CABG, 0%; HCR, 3.4%; p = 0.029). HCR resulted in a lower incidence of postoperative
prolonged mechanical ventilation (CABG, 4%; HCR, 0.7%; p = 0.017). The hospital length
of stay was significantly shorter in patients who underwent HCR (CABG, 8.1 ± 5.8 days;
HCR, 4.5 ± 2.1 days; p < 0.001). After the median follow-up periods of 81 months (48–113
months; CABG group) and 96 months (53–115 months; HCR group) there was no significant
difference in survival (CABG, 85%; HCR, 96%; p = 0.054) and freedom from any form of
revascularization (CABG, 92%; HCR, 91%; p = 0.80). HCR was superior in terms of freedom
from angina (CABG, 73%; HCR, 90%; p < 0.001).
◆ Our experience and that of others has suggested that a hybrid revascularization strategy is
safe and provides excellent short- and long-term results, with a low rate of postoperative
complications, shorter hospital stay, fast recovery time, and very good rates of freedom from
angina, freedom from any revascularization, and long-term survival. In recent years, there
has been an increasing trend toward hybrid revascularization procedures due to a continuous
improvement of DES performance and a broader use of minimally invasive techniques, especially
with robotic assistance.
◆ The major advantages of HCR when compared with conventional CABG are the avoidance
of cardiopulmonary bypass, aortic clamping, and sternotomy while still providing the survival
benefit of the LITA-LAD anastomosis. With the addition of PCI, complete revascularization
of all significantly diseased arteries is ensured.
◆ However, if the rationale behind this alternative form of coronary revascularization is well
established, HCR has failed to be broadly adopted so far. The STS adult cardiac surgery
database has shown that from July 2011 to March 2013, HCR represented only 0.48% of the
total CABG volume (950 of the total of 198,622 patients who underwent CABG).30 The
reasons why physicians and surgeons have not currently embraced this in routine clinical
practice could be related to the fact that minimally invasive LITA-LAD anastomosis construction
is technically demanding, and there are still costs and logistical problems associated with
performing two procedures with different periprocedural management protocols. There is
also a lack in validation from randomized clinical trials comparing HCR with conventional
CABG. However, a few recent studies have highlighted the good preliminary results of this
technique, including its advantages and disadvantages. Harskamp et al. reported the first
meta-analysis of more than 1100 patients who underwent HCR from six observational cohort
studies.31 They observed that patients undergoing HCR have a similar risk of the composite
of death, MI, stroke, and repeat revascularization as those treated with CABG during hospi-
talization and follow-up (4.1% of patients after HCR and 9.1% of patients with CABG at
1-year follow-up). Death, MI, and stroke rates were numerically but not statistically lower
with HCR. The need for repeated revascularization occurred more frequently with HCR (8.3%
of patients after HCR and 3.4% of patients after CABG at 3-year follow-up; p < 0.001). These
findings were similar when HCR was performed as a single- or dual-stage procedure.
◆ The data generated by this meta-analysis also support the finding that HCR performed without
conventional sternotomy results in a shorter duration of hospital stay, earlier return to work,
and fewer in-hospital complications. It also showed that self-reported quality of life is significantly
higher at follow-up. These data are in line with our findings. In our analysis, we observed a
shorter length of stay in the ICU (1 ± 1 days) and average hospital stay of 5 ± 2 days. None
of our patients developed renal failure with the need for dialysis, and only 13.2% of patients
required a blood transfusion. We also observed a lower rate of repeat revascularization, with
a very good long-term freedom from any revascularization (in 90.7% of patients at clinical
follow-up of 77.8 ± 41.4 months). The results of new-generation DESs are playing an important
role in coronary revascularization and could contribute to a wider diffusion of HCR. The use
of newer DESs show favorable outcome,32-34 especially if compared with the results of first-
generation stents and venous grafts, which are more prone to atherosclerotic degeneration
and progressive narrowing, with high early and long-term failure rates, as shown in the
PREVENT IV study.8
◆ In another meta-analysis, Zhu et al. analyzed data from 10 cohort studies involving 6176
patients.11 They calculated the summary odds ratio (OR) for primary endpoints (e.g., death,
stroke, MI, target vessel revascularization, major adverse cardiac or cerebrovascular events)
and secondary endpoints (e.g., atrial fibrillation, renal failure, length of stay in the ICU, length
of stay in hospital, red blood cell transfusion). They found that HCR was noninferior to CABG
in terms of major adverse cardiac or cerebrovascular events during hospitalization (OR, 0.68;
confidence interval [CI], 0.34–1.33) and at 1-year follow-up (OR, 0.32; CI, 0.05–1.89). No
significant difference was found between the HCR and CABG groups in regard to in-hospital
and 1-year follow-up, outcomes of death, MI, stroke, atrial fibrillation, and renal failure.
However, HCR was associated with a lower requirement for blood transfusions and shorter
length of stay in the ICU and length of stay in hospital than CABG (weighted mean difference,
−1.25; 95% CI, −11.62–10.88; −17.47, −31.01–3.93; −1.77, −3.07 to −0.46, respectively).
Harskamp et al. compared HCR versus standard CABG using a propensity score matching
algorithm.12 They studied 306 patients who underwent HCR and matched them in a 1 : 3
ratio to 918 patients who underwent standard CABG. They found that the 30-day composite
of death, MI, or stroke after HCR and CABG was 3.3% and 3.1%, respectively (OR, 1.07;
95% CI, 0.52–2.21; p = 0.85). HCR was associated with lower rates of in-hospital major
morbidity (8.5% vs. 15.5%; p = 0.005), lower blood transfusion use (21.6% vs. 46.6%, p <
0.001), lower volume of chest tube drainage (690 mL; 25th–75th percentile—485–1050 mL
vs. 920 mL, 25th to 75th percentile; 710–1230 mL; p < 0.001), and shorter postoperative
length of stay (<5-day stay—52.6% vs. 38.1%; p = 0.001). during the 3-year follow-up period.
Mortality was similar after HCR and CABG (8.8% vs. 10.2%; hazard ratio = 0.91; 95% CI,
0.55–1.52; p = 0.72).
◆ Only one small randomized controlled trial comparing HCR with CABG has recently emerged
in the medical literature.35 In this study, a total of 200 patients with multivessel CAD involving
the LAD and a critical lesion in at least one major epicardial vessel amenable to PCI and
CABG and referred for conventional surgical revascularization were randomly assigned to
undergo HCR or CABG in a 1 : 1 ratio. The primary endpoint was the evaluation of the safety
of HCR. The feasibility was defined by the percentage of patients with a complete HCR
procedure and the percentage of patients with conversion to standard CABG. They also
assessed the occurrence of major adverse cardiac events such as death, MI, stroke, repeated
revascularization, and major bleeding within a 12-month follow-up period. Of the patients
in the HCR group, 93.9% had complete HCR, and 6.1% patients were converted to standard
CABG. At 12 months, the rates of death (2.0% vs. 2.9%, p = not significant [NS]), MI (6.1%
vs. 3.9%; p = NS), major bleeding (2% vs. 2%; p = NS), and repeat revascularization (2% vs.
0%; p = NS) were similar in the two groups; no cerebrovascular accidents were observed.
◆ Patient selection is another crucial factor for HCR. We cannot emphasize enough the importance
of the heart team in guiding appropriate patient selection for HCR. The ideal patient is a
patient with multivessel CAD with a complex proximal LAD lesion suitable for LITA-LAD
grafting, associated with significant but not overly complex non-LAD lesions suitable for PCI,
with no contraindications for dual antiplatelet therapy. The high likelihood of achieving a
complete revascularization with such an approach is certainly one of the most important
guiding factors. Complex distal left main lesions may be suitable and ideal for HCR if the
circumflex artery territory is amenable for PCI. As noted, the lack of large randomized controlled
trials, however, does not allow the identification of an optimal HCR target group of patients.
◆ Another important factor is the choice of proper timing for the two procedures. In other
words, it should be determined if it is better to perform the one-stage treatment of CAD

(simultaneous HCR) or in two separate settings (two-stage HCR). Most of our patients (71.9%)
underwent single-stage HCR. The decision is guided by patient characteristics and available
facilities, but we acknowledge that this approach has several advantages, including that it is
more cost-effective, reduces the length of stay, increases patient satisfaction, and allows the
immediate confirmation of the patency of the LITA graft. The main disadvantage is the risk
of bleeding due to the use of dual antiplatelet therapy. For this approach, an equipped hybrid
operating room is mandatory. The two-stage procedure is generally favored based on clinical
presentation and anatomy. PCI as the initial procedure, followed by CABG, is usually encountered
in the setting of acute coronary syndrome when the non-LAD culprit lesion is initially addressed
in the catheterization laboratory.
◆ Another disadvantage is the risk of bleeding due to the uninterrupted antiplatelet therapy
when the patient undergoes the subsequent surgical LITA anastomosis. In the two-stage
approach, we generally prefer performing LITA-LAD bypass grafting before PCI when clinically
appropriate. The main advantages of this strategy are the immediate angiographic check of
the LITA-LAD anastomosis at the same time as the PCI, protection of the anterior wall of the
left ventricle, which lowers the risk of PCI and, theoretically, the decreased risk of bleeding,
considering that full antiplatelet therapy is not initiated prior to surgery. One of the major
perioperative concerns of HCR is management of antiplatelet therapy, with the related risk
of bleeding or stent thrombosis. In our series, we observed only one subacute stent thrombosis;
this occurred in our early experience, when heparin was overlapped with bivalirudin. One
of the arguments against HCR has been that the LITA-LAD anastomosis is technically highly
demanding, and this could interfere with its patency rates. We previously reported two studies
with angiographic follow-up of patients who underwent HCR. In the first study of 58 patients
undergoing HCR,36 at a mean follow-up of 20.2 months, the LITA-LAD anastomosis was
patent in 49 of the 54 patients who had repeat catheterization (91%). Later, in 2014, we
published a series of 94 patients who underwent HCR and had angiographic follow-up at 6
months illustrating a 94% anastomotic patency of the LITA-LAD.37 This compares favorably
with the LITA patency seen with conventional surgery.
Conclusion
◆ Current evidence suggests that HCR is a feasible, safe, and effective coronary artery revascu-
larization strategy in select patients with multivessel CAD and favorable coronary anatomy.
HCR appears to offer complete coronary revascularization with a faster recovery, lower incidence
of postoperative complications, and at least similar long-term outcomes. However, randomized
prospective trials comparing HCR with conventional CABG procedures or multivessel PCI
will be necessary to evaluate the effectiveness of this alternative and complementary technique
of coronary artery revascularization further.
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2014;45:438–442.
CHAPTER
7
Robotic Coronary Artery

Bypass Grafting
Johannes Bonatti, Faisal Hasan, Dominique Prud’Homme,
and Stephanie Mick
Introductory Considerations
◆ The goal of any minimally invasive procedure is to achieve the least surgical trauma possible
and to carry out the intervention in a port-only approach. After unsuccessful attempts to
perform endoscopic coronary bypass surgery using long-shafted thoracoscopic instrumentation,
the first totally endoscopic coronary bypass grafting (TECAB) was carried out in 1998 using
a surgical robot. Since then, TECAB has been further developed from single-vessel to multivessel
surgical revascularization1,2 and is performed in beating heart and stopped heart versions.
TECAB can be combined with percutaneous coronary intervention in so-called integrated or
hybrid procedures. A second, third, and fourth generation of surgical robots is available, and
procedure-specific robotic instrumentation has improved vision, exposure of target vessels,
and overall ergonomic features of the procedure.
1. Patient Selection, Indications, and Contraindications
◆ At the current stage, any patient with a clear indication for surgical coronary revascularization
can be considered for TECAB. It is, however, highly important to respect the contraindications
listed in Box 7.1. In general, TECAB is elective surgery, and redo procedures are difficult
using open techniques and are long and tedious in the endoscopic setting. Any factor that
leads to distortion or reduction of the pleural cavities, such as thoracic deformities, a severely
enlarged heart, or reduced lung volume, needs to be respected. Wise judgment needs to be
applied as to whether to expose patients to a potentially longer pump time, myocardial
ischemic time, and overall procedure time. This is especially true for patients with multiple
comorbidities. Because TECAB involves a significant technical learning curve, we strongly
recommend to start with simpler versions of the operation in low-risk patients.
103
Chapter 7 • Robotic Coronary Artery Bypass Grafting103.e1
Abstract
Totally endoscopic coronary artery bypass grafting (TECAB) represents an advanced form of
coronary bypass surgery with a minimum level of surgical trauma involved. It can only be
performed in a reproducible manner using a surgical robot. Using five portholes on the chest,
the bypass harvesting and grafting processes are carried out endoscopically. The procedure can
be performed on the arrested heart using remote access heart-lung machine perfusion and
endocardioplegia or on the beating heart using endostabilization and local coronary artery
occlusion. To date, all coronary artery territories can be reached, and single- and multivessel
TECAB are technically feasible.
Keywords
coronary artery disease

coronary artery bypass grafting
minimally invasive surgery
endoscopic surgery
robotic surgery
Box 7.1 Contraindications for Totally Endoscopic Coronary Bypass Grafting (TECAB)
Absolute Contraindications
Cardiogenic shock and hemodynamic instability
Severely reduced lung function (VC < 2.5 L; FEV1 < 70% predicted value)
Pulmonary hypertension
Chest deformities (e.g., pectus excavatum)
Multimorbid patients with generalized vasculopathy
Very small, diffusely diseased and calcified target vessels or intramyocardial target vessels in beating heart TECAB
Ascending aortic diameter > 3.8 mm and severe aortoiliac atherosclerosis in endoballoon-arrested heart TECAB
Relative Contraindications
Unstable patients on intraaortic balloon pump (IABP)
Significantly reduced left ventricular function (left ventricular ejection fraction [LVEF] < 30%)
Significantly enlarged hearts (< 25 mm distance between left ventricle and chest wall)
Previous cardiac surgery
Previous significant chest trauma
Previous chest radiation
FEV1, Forced expiratory volume in 1 second; VC, vital capacity.
Box 7.2 Parameters Assessed in Pre–Totally Endoscopic Coronary Bypass Grafting Computed Tomography
Angiography of the Chest, Abdomen, and Pelvis
Heart
Size of the heart (cardiothoracic ratio, distance of left ventricular lateral border to chest wall)
Distance between internal mammary arteries and target vessels
Course of target vessels (intramyocardial vs. epicardial)
Size of the pericardial fat pad
Lung
Size of the lung (intrathoracic workspace)
Lung pathology
Pleural pathology (e.g., clear evidence of adhesions, calcifications)
Aorta, Iliofemoral Vessels
Ascending aortic diameter at the level of right pulmonary artery crossing
Grade of aortic atherosclerosis on all levels
Iliofemoral atherosclerosis
Other aortic pathology (e.g., aneurysms, chronic dissections)
2. Preoperative Workup
◆ All patients should receive the same workup as for open coronary artery bypass grafting
(CABG). The usual battery of preoperative examinations consists of the clinical history and
physical examination, basic blood tests (complete blood count [CBC], basic metabolic panel
[BMP], international normalized ratio [INR], type, and screen), carotid Doppler studies,
ankle-brachial index (ABI), pulmonary function studies, and echocardiography. To address
TECAB-specific questions, computed tomography (CT) angiography of the chest, abdomen,
and pelvis is carried out. The parameters that should be assessed for this procedure by the
surgeon, surgical team, and radiologist on this CT are listed in Box 7.2.
Chapter 7 • Robotic Coronary Artery Bypass Grafting 105
Box 7.3 Specific Anesthesia Aspects

Double-lumen tube intubation or bronchial blocker
Percutaneous defibrillator patches
Transesophageal echocardiography monitoring throughout the entire procedure
Near-infrared spectroscopy monitoring of cerebral and lower extremity perfusion
3. Anesthesia
◆ Basic cardiac anesthesia principles are applied but experienced anesthesiologists with specific
skills should lead the case. Box 7.3 lists specific anesthesia aspects. Transesophageal echo-
cardiography (TEE) is necessary for monitoring heart function and regional wall motion, as
well as for adequate positioning of the endoballoon in arrested heart TECAB. Good communica-
tion with the anesthesia team is key, especially in regard to when to start single-lung ventilation,
level of CO2 inflation pressure, occurrence of leg ischemia if femoral arterial heart-lung
machine perfusion is chosen, migration of the endoballoon in arrested heart TECAB, heart
rate control and assessment of regional wall motion in beating heart TECAB, and respiratory
management after a longer heart-lung machine run under single-lung ventilation.
4. Necessary Hardware and Procedure Versions
◆ Currently, only one surgical robot is available on the market that allows performance of
TECAB (Intuitive Surgical, Sunnyvale, CA; see www.intuitivesurgical.com). Surgeons who
perform TECAB mostly use the third generation (Si version) of the da Vinci system. Fig. 7.1
shows the surgeon sitting behind the robotic console. Using so-called masters, the surgeon
performs maneuvers with his or her hands, which are translated into intrathoracic movements
of a robotic three-dimensional (3D) camera and the robotic instruments. Foot pedals are part
of the machine for switching between camera and instrument control, as well as for electrocautery.
The surgeon looks into a 3D binocular. At the time of this writing, not all instruments used
for TECAB are available for the fourth generation (Xi version).
◆ TECAB can be performed with and without use of the heart-lung machine. The former version
is usually called AH (arrested heart) TECAB; the latter is commonly referred to as BH (beating
heart) TECAB. We strongly recommend developing both methods because it gives a robotic
surgery team the best level of flexibility and allows for best tailoring of the operation to the
patient’s needs.
◆ BH-TECAB can avoid side effects of the heart-lung machine but target vessel exposure and
anastomotic suturing are technically more demanding than in AH-TECAB. Surgeons should
master anastomotic techniques in the arrested heart version before moving to the beating
heart technique. We also recommend cannulating the patient prophylactically for a potential
heart-lung machine run in BH-TECAB, which may be necessary if there is limited intrathoracic
space and if the patient develops myocardial ischemia, hemodynamic instability, or ventricular
arrhythmia. Installing the heart-lung machine acutely in these situations is difficult with the
robot docked, may take too much time if there is significant hemodynamic compromise, and
may be associated with additional vascular complications. In our experience, having the
immediate safety net of a heart-lung machine available has proven to be very valuable.
Figure 7.1
Figure 7.1 The surgeon operates the robotic instruments from a console. A third and fourth generation of operation robots are currently
available.
◆ In AH-TECAB, anastomotic suturing is easier, but AH-TECAB requires specific skill sets in
remote access perfusion and the use of endoballoon or transthoracic clamping. These skills
should be developed in procedures other than TECAB (e.g., atrial septal defect [ASD] II repair
or minithoracotomy mitral valve repair) before application in totally endoscopic CABG. In
our hands, placement of bypass grafts to the right coronary artery (RCA) and circumflex
coronary artery territories only works reasonably using the arrested heart technique because
the heart is completely flaccid and can be adequately rotated.
Procedural Steps
Step 1. Positioning, Prepping, and Draping
◆ The patient is placed on the operating table in the supine position. The arms are tucked to
the body, and the left chest is slightly elevated using a towel roll. Because the team needs to
be prepared for conversion to an open procedure, the patient is prepped and draped as for
open CABG, and the equipment for conducting open CABG should always be available.
Step 2. Port Placement and Robot Docking
◆ The ports are usually placed on the patient’s left chest and should be inserted by the most
experienced team member, because correct port placement plays a key role in the operation.
Insertion requires complete left lung collapse and must be confirmed by the anesthesia team
before placement. The camera port is placed in the fifth intercostal space on the anterior
axillary line, and CO2 is insufflated at a pressure of 8 mm Hg. Should hemodynamic compromise
(e.g., hypotension) occur during this phase, the CO2 pressure should be lowered. The thoracic
cavity is then inspected and, under scope vision, the left and right instrument ports are
inserted cranially and caudally four fingerbreadths away from the camera port, midway between
the anterior axillary line and midclavicular line. The surgical robot is then docked and a
robotic cautery spatula (right arm) and DeBakey forceps (left arm) are inserted. Fig. 7.2
depicts the port arrangement and instruments inserted, and Fig. 7.3 shows the robotic arms
docked to the patient.
Step 3. Internal Mammary Artery Takedown
◆ Using the camera-up view with the 30-degree angled robotic camera, the internal mammary
artery (IMA) is identified by its visible pulsations. The electrocautery is set at 15 to 20 W,
and the endothoracic fascia and muscle covering the IMA are removed (Fig. 7.3). The IMA
is then harvested in a skeletonized fashion using mechanical takedown and cauterization of
the side branches close to the chest wall (Fig. 7.4). Clipping is necessary only for large
branches and in case of side branch bleeding. If both IMAs are harvested, the right pleura is
entered via generous robotic endoscopic retrosternal dissection and opening of the right
pleura. In double-IMA harvesting, the right IMA should be taken down before the left IMA.
After heparinization, the IMA can be clipped distally, divided using robotic Pott’s scissors,
and dropped into the left chest for autodilation.
Figure 7.2

Figure 7.2 Port arrangement in TECAB.
Figure 7.3 The robotic arms are docked to the patient’s left chest, with the camera port inserted into the fifth intercostal space on the
anterior axillary line and the right instrument port inserted into the third intercostal space midway between anterior axillary line and
midclavicular line. The left instrument port is placed in the seventh intercostal space midway between anterior axillary line and midclavicular
line.
Figure 7.4 The internal mammary artery is harvested in a skeletonized technique using a robotic electrocautery spatula at a power of 15
to 20 Watts and a robotic deBakey forceps.
Step 4. Assistance Port Placement
◆ After IMA harvesting under scope visualization, a 5-mm assistance port is placed in the left
parasternal region, opposite to the camera port. Since introduction of this step, significant
time gains in TECAB have been noted. This port allows the insertion and removal of material
needed throughout the procedure (e.g., bulldogs, suture material, Silastic tapes, suction tubing).
Step 5. Pericardial Fat Pad Removal and Pericardiotomy
◆ To gain access to the pericardial fat pad and the pericardium, the scope view is switched to
the camera-down mode. Using an electrocautery spatula on the right and a long tip forceps
on the left, the fat pad is resected, starting with its cranial sternal portion and then moving
caudally. If the fat pad is large, starting the heart-lung machine can significantly improve
intrathoracic space and facilitate removal. The pericardium is opened above the right ventricular
outflow tract, incised (heading toward the substernal part of the pericardial reflection), and
then taken out laterally. Cranially, the pericardium is opened, moving toward the phrenic
nerve, which needs to be clearly identified. The phrenic nerve and left atrial appendage,
which is close, need to be respected.
Step 6. Remote Access Cardiopulmonary Bypass and Application of the Endoballoon
◆ If the preoperative CT angiogram shows no or only mild grades of aortoiliac atherosclerosis,

we feel comfortable using femorofemoral cannulation for the cardiopulmonary bypass. Usually,
the left groin is exposed. We keep dissection of the femoral artery and vein limited to prevent
lymphatic leaks. A distal leg perfusion line is inserted in all cases, and leg perfusion is monitored
by near-infrared spectroscopy (NIRS) throughout the whole procedure. A 25 F venous drainage
cannula is then advanced into the superior vena cava under TEE guidance and connected to
the heart-lung machine tubing. A 21 F or 23 F arterial perfusion cannula with a side arm is
inserted into the femoral artery and connected to the arterial line of the cardiopulmonary
bypass circuit.
◆ For safe use of the ascending aortic endoballoon for cardioplegia, we specifically look into a
lack of ascending, arch, and descending thoracic aortic atherosclerosis. The maximum ascending
aortic diameter we accept is 38 mm. The aortic valve should be competent and free of
thickening or stenosis. The balloon is completely de-aired and inserted through the side arm
of the arterial perfusion cannula. The guidewire is advanced into the aortic root under TEE
guidance, and the endoballoon is then placed above the aortic valve. The catheter is connected
to the heart-lung machine tubing, and the pressure lines for measurement of aortic root
pressure and balloon pressure are de-aired and connected to corresponding manometers.
Aspiration or injection of air through the catheter into the aortic root has to be avoided by
all means.
◆ The heart-lung machine is started slowly in all procedures. With adequate venous drainage,
low blood pressure, and lack of ventricular ejections, the endoballoon is inflated, and its
correct position in the aortic root is confirmed by TEE. After endoballoon inflation, cardioplegia
is induced. For initial rapid induction, adenosine (6 mg diluted in 20 mL of saline solution)
may be injected. We start cooling only after a stable balloon position has been achieved.
Cardioplegia is repeated every 20 minutes. If a percutaneous retrograde cardioplegia catheter
has been inserted, both antegrade and retrograde cardioplegia can be given following customary
protocols.
◆ In cases of moderate to severe aortoiliac atherosclerosis, we strictly avoid femoral arterial
retroperfusion. Instead, the left axillary artery is exposed in the left infraclavicular region and
an 8-mm prosthetic side arm is anastomosed to the artery and connected to the arterial line
of the cardiopulmonary bypass circuit. Axillary cannulation ensures antegrade perfusion from
the descending thoracic aortic level downstream and may reduce the risk of retrograde aortoiliac
dissection. The endoballoon catheter can in most cases still be inserted through a separate
19 F cannula placed into the common femoral artery.
◆ If severe-grade aortoiliac atherosclerosis is present, or if protruding and mobile atheroma is
seen on TEE, the endoballoon is contraindicated. In these cases, we use a BH-TECAB approach.
BH-TECAB patients are still cannulated, and the cannulae are placed at an activated clotting
time (ACT) level of 300 seconds. Should a pump run become necessary, we raise the ACT
to 480 seconds. Supportive cardiopulmonary bypass is extremely helpful—for example, in
BH multivessel TECAB, in cases of ischemia during target vessel occlusion, if space inside
the chest is limited, or if bleeding problems are encountered. During supportive pump runs,
significant diffuse bleeding from portholes, the IMA bed, and other structures may be observed
and may require intermittent evacuation of pleural blood using transthoracic suction.
Step 7. Exposure of Target Vessels
◆ The robotic endostabilizer can be used as an exposure device in BH-TECAB and AH-TECAB.
For positioning of this device, a 12-mm port is placed subcostally into the left chest using a
port incision two fingerbreadths lateral to the xiphoid angle. Insertion of the port can be
guided by the robotic camera using the up view. The subcostal port is docked to the fourth
arm of the da Vinci system.
◆ For all work on the coronary target vessels, the scope view is camera down. With the subcostally
placed endostabilizer, the left anterior descending artery (LAD) and circumflex coronary artery
systems can be well reached. The endostabilizer is activated using a dedicated foot pedal,
and the suction pods are placed alongside the target area of the target vessel. In this way,
local immobilization can be achieved in BH-TECAB, and the target vessel can be moved into
a comfortable position in both BH-TECAB and AH-TECAB.
◆ The right coronary artery system can be accessed by inserting the endostabilizer through a
12-mm left-sided instrument port. With this port arrangement, the subcostal port can be
used as the left robotic instrument arm. The acute margin of the right ventricle is lifted up
using the endostabilizer, and excellent access to the posterior descending artery and posterolateral
artery can be gained. To date, we have applied this method only in AH-TECAB.
◆ After appropriate exposure of the target vessel, the epicardium is incised with robotic Pott’s
scissors.
Step 8. Robotic Endoscopic Graft to Coronary Anastomosis
◆ Before starting the anastomosis, final preparations are carried out on the bypass graft. After
occlusion with a bulldog, the graft is trimmed in an oblique manner distally and opened
further, to a total length of 4 mm. Free flow must be checked.
◆ For incision of the target vessel, we use a DeBakey forceps and robotic lancet beaver knife.
The incision is enlarged to approximately 4 mm using robotic Pott’s scissors. A 7-cm double-
armed polypropylene suture is then brought in through the assistance port. For suturing the
anastomosis, two robotic black diamond microforceps are used.
◆ The suture is started at the toe of the anastomosis on the back wall with an inside-out stitch.
The needle is parked away in the epicardium. With the other needle, the suture is continued
on the back wall, stitching the graft inside out and the coronary artery outside in. After three
throws in parachute technique, the graft is brought down to the anastomotic level, and
suturing becomes easier. It is very important to apply adequate suture tension to avoid leaks
on the back wall, which are harder to correct than if they occur on the front wall. Fig. 7.5
shows the suturing of the anastomotic back wall. Figs. 7.6 and 7.7 depict the further suturing
sequence. After going around the heel, the needle is parked away again, and the contralateral
needle is taken to suture around the toe of the anastomosis and complete the suture line.
Gentle probing of lumen patency with the tips of the microforceps is possible. The whole
suture line needs to be carefully inspected for slings, which can be corrected using one of
the suture needles. A video of the suturing technique is also available at http://www.youtube.com/
watch?v=l6DiBz2JUnY.
◆ At the current stage, grafts can be placed to all coronary territories. The most common TECAB
versions are left internal mammary artery to left anterior descending artery (LIMA to LAD),
right internal mammary artery (RIMA) to LAD combined with LIMA to the diagonal, ramus,
or circumflex artery branches, and LIMA to LAD combined with RIMA to the RCA territory.
The latter is a Y graft construct.
◆ There are some specifics to consider when suturing on the arrested heart or beating heart.
In AH-TECAB, the target vessel can be incised as cardioplegia is initiated, which may reduce
the risk of injury to the back wall. Backbleeding from the target vessel may be present, caused
by inadequate venous drainage or low endoaortic balloon pressure leading to retrograde aortic
root flow. Correction of the venous drainage cannula position, additional inflation of the
endoballoon, or placement of a Silastic tape is an appropriate measure to take to reduce
backbleeding. Suturing should only be started if a clear view of the target vessel is ensured.
◆ In BH-TECAB, Silastic tapes are placed proximally and distally to the graft landing zone. Only
the proximal one is occluded. The target vessel is then opened and an intraluminal shunt is
inserted first, completely into the distal vessel. It is then pulled into the proximal vessel and
the Silastic tape is loosened. In BH-TECAB, the stitching maneuvers must be very gentle to
avoid lacerations of the coronary artery wall. An esmolol drip may improve the comfort of
suturing. The surgeon has to deal with magnified bouncing movements of the operative field;
intense simulation training in dry and wet laboratory models is strongly recommended before
moving into the clinical setting.
Figure 7.5
Figure 7.6
Figure 7.7
Figure 7.5 Suturing of the back wall of the anastomosis in videoscopic view. Two robotic microforceps are used. Suture material is a
7 cm-long double-armed 7/0 polypropylene suture.
Figure 7.6 After completing the back wall and hell of the anastomosis, the toe and anterior wall suture are complete.
Figure 7.7 The multiwristed robotic instruments allow for comfortable robotic knot tying.
Step 9. Final Maneuvers
◆ Transit time ultrasound flow measurements of the bypass are carried out in all cases using a
specifically designed endoscopic flow probe. The probe is brought in through the subcostal
port. Blood collections in the left pleural space are evacuated using a flexible suction tube
brought in through the assistance port.
◆ After pump runs, the patient is weaned from cardiopulmonary bypass, leaving the robot
docked and leaving instruments parked in the IMA bed. This is done because the heart will
be filled after decannulation, and re-insertion of instruments may be difficult. The combination
of single-lung ventilation and the use of cardiopulmonary bypass may lead to transient,
significant respiratory compromise, which is usually self-limited.
◆ Once the patient is oxygenating stably and pump function is adequate, protamine is given.
A final robotic inspection of the thoracic cavity follows. This phase requires ongoing thorough
attention of the console surgeon and tableside team. Once adequate hemostasis has been
achieved, the robotic system is undocked but the ports are left in place. This is important to
avoid CO2 losses during final manual inspections with the robotic camera. The ports are
removed in a stepwise manner under scope inspection. They are cauterized and packed with
Surgicel. A chest tube is inserted through the camera porthole. This should be done with the
left lung inflated to avoid graft injuries during this last phase of the operation.
Postoperative Care
◆ Postoperative care basically follows the principles of care after coronary bypass surgery through
a sternotomy. After single-lung ventilation, atelectasis may be present, which usually can be
managed with respiratory therapy. Attention should be paid to peripheral arterial and venous
circulation after remote access cannulation. Pain may be quite intense, specifically around
the camera port side area, but usually goes away within the first few postoperative days.
Sternal precautions do not need to be prescribed.
References
1. Bonatti J, Schachner T, Bonaros N, et al. Robotic assisted endoscopic coronary bypass surgery. Circulation. 2011;124:236–244.
2. Bonatti J, Lee JD, Bonaros N, et al. Robotic totally endoscopic multivessel coronary artery bypass grafting: procedure development,
challenges, results. Innovations. 2012;7:3–8.
CHAPTER
8

Postinfarction
Ventricular Septal
Defect Repair
Sharven Taghavi, Abeel A. Mangi, and Arvind K. Agnihotri
◆ Postinfarction ventricular septal defects (VSDs) are classified as occurring in three locations—
apical, anterior, and posteroinferior (Fig. 8.1). Most common is an anterior or apical defect
caused by anterior septal myocardial infarction after occlusion of the left anterior descending
coronary artery. In about one-third of patients, the rupture occurs in the posterior septum
after an inferior septal infarction. The inferior septal infarction is usually due to occlusion of
a dominant right coronary or, less frequently, of a dominant circumflex artery. An apical septal
defect can be considered a variant of an anterior defect, but it presents the opportunity for
a modified, and less involved, surgical technique.1,2
◆ Associated with the septal defect is a variable amount of adjacent myocardial damage, both
septal and free wall. In addition, the posterior papillary muscle is often involved in a posterior
postinfarction septal defect. When the free wall infarction involves the papillary muscle,
special techniques must be used to anchor the repair, or a mitral valve replacement should
be undertaken.1,2
◆ Without surgery, 50% of patients with a postinfarction VSD will die within 24 hours, and
80% will die within 4 weeks. Therefore, the presence of this defect is considered an urgent
indication for operation. The goal of preoperative management is to reduce the left-to-right
shunt by reducing both the systemic vascular resistance and left ventricular pressure.
◆ In addition, efforts are made to maintain cardiac output and arterial pressure to aid in end-
organ perfusion. Placement of an intraaortic balloon pump is greatly beneficial and should
be done as soon as the diagnosis is made. Patients in severe failure who are deemed hopeless
candidates for immediate operation can be managed with an intraaortic balloon pump or
with mechanical circulatory support in an attempt to delay surgery.
114
Chapter 8 • Postinfarction Ventricular Septal Defect Repair114.e1
Abstract
Postinfarction ventricular septal defects (VSDs) classically occur in an apical, anterior, or pos-
teroinferior location. These defects must be treated surgically, although select patients in severe
cardiogenic shock may benefit with initial resuscitation with mechanical circulatory support,
followed by later surgical repair. Operative intervention involves debridement of necrotic tissue
followed by closure of the defect with a prosthesis, although small defects can rarely be closed
primarily. Location of the defect will determine type of exposure. Postoperative care should
involve liberal use of an intraaortic balloon pump and chemical inotropes.
Keywords
postinfarct ventricular septal defect

Chapter 8 • Postinfarction Ventricular Septal Defect Repair 115
Medial papillary
muscle
Posteroinferior
ventricular Interventricular
septal defect septum
Coronary
sinus
Inferior
margin of
interventricular septum
Apical ventricular
septal defect
Anterior papillary
muscle of right ventricle
Anterior ventricular
septal defect
Figure 8.1
◆ The use of a ventricular assist devices and extracorporeal membrane oxygenation (ECMO)
with staged repair of the postinfarct VSD has been described. Left ventricular assist devices
may result in a greater degree of right-to-left shunting; therefore, biventricular assist devices
are preferred. ECMO may allow for support and resuscitation of critically ill patients in
cardiogenic shock. ECMO can be instituted using central or peripheral cannulation. The type
of cannulation should be determined on a case by case basis. Mechanical circulatory support
for a short amount of time can be used to reverse end-organ damage. In addition, it can
provide some time for infarct maturation, allowing for firmer tissue at the time of surgical
repair.3,4
◆ In select patients, percutaneous closure is possible. The primary limitation is the friable condition
of the surrounding septal muscle and proximity to the mitral valve or papillary muscles.
Given reports of frequent early failure, this approach may best be used as an interim measure
before surgery. The approach is more likely to be successful in delayed presentations or as
treatment for recurrent defects that may occur between a repair patch and adjacent noninfarcted
myocardium.5 The advent of the Amplatzer Muscular VSD Occluder (St. Jude Medical,
St. Paul, MN) has shown potential for being an effective percutaneous treatment for extremely
high-risk patients with postinfarct VSD.6
◆ Controversy exists over the role of preoperative coronary angiography and concomitant bypass
surgery. Those who argue against preoperative catheterization have noted that there is no
survival benefit and that it is a time-consuming procedure. In addition, because all patients
present with a completed full-thickness infarction, revascularization of the infarcted territory
is of limited value. A selective approach is appropriate, with catheterization performed in the
subset of patients who are not in shock or severe failure before surgery,7 because some patients
may benefit from revascularization to noninfarcted territories in which flow-limiting coronary
lesions exist.
1. General Principles
◆ A standard median sternotomy is performed. Cardiopulmonary bypass is accomplished through

the distal ascending aorta, with bicaval venous drainage. A variety of myocardial protection
strategies are available. Satisfactory protection has been demonstrated with moderate hypothermia
and frequent administration (every 15 to 20 minutes) of cold oxygenated blood cardioplegia
with a combination of antegrade and retrograde perfusion through the coronary sinus. Other
strategies, including continuous warm cardioplegia, have been used. A flexible left ventricular
vent is placed through the right superior pulmonary vein. To prevent postbypass coagulopathy,
an antifibrinolytic is administered before commencing cardiopulmonary bypass and is continued
as an infusion. The use of surgical sealants on the epicardial surface of the heart at the location
of felt buttresses may be recommended.
◆ Areas of full-thickness myocardial infarction will not hold sutures against pressure. Regardless
of the operative technique or location of the defect, it is critical to anchor suture lines to
noninfarcted tissue. In the endocardium, this is done by taking stitches at least 5 mm from
the zone of necrosis. When this is not possible, stitches are taken through the full thickness
of the free wall, and a buttress of Teflon felt is used. In this way, strength is afforded by the
epicardial portion of the ventricular wall, and the stress is distributed.7
◆ There are two general approaches to the treatment of the necrotic muscle. The first approach
emphasizes débridement of necrotic tissue and tension-free repair, and it usually involves a
prosthetic patch to replace excised tissue. The second approach is to leave the necrotic tissue
in place, but to exclude it by placing a bovine pericardial patch that circumscribes the
infarction. Both techniques are described.
2. Standard Technique: Débridement of Necrotic Tissue
Anterior Apical Defects
◆ The VSD is approached through an incision through the anterior apical left ventricle (LV),
passing through the area of necrosis. After débridement of necrotic tissue, smaller defects,
particularly at the apex, can be closed by approximating the free walls of the right ventricle
(RV) and LV with the septum using interrupted size 0 polypropylene sutures over Teflon felt
strips (Fig. 8.2). It is critical that the stitches pass through healthy muscle.7
◆ Usually, the size of the necrotic tissue prevents a primary tension-free repair, requiring the
use of prosthetic patch material. Low-porosity Dacron is generally used, although glutaraldehyde-
treated bovine pericardium is an alternative. The patch is fashioned to be larger than the
defect. Pledgeted sutures of 1-0 Tevdek are passed from the RV through the intraventricular
septum and then through the patch material (Fig. 8.3A). In the apical portion, pledgeted
sutures are taken through the free wall of the RV (see Fig. 8.3B). The ventriculotomy is then
closed with Teflon felt strips and no. 1 Tevdek, first using interrupted mattress sutures and
then a running suture as a second layer7 (see Fig. 8.3C).
LV
RV
A B
Figure 8.2
A B
LV
RV
C
Figure 8.3
Posteroinferior Defects
◆ Closure of posteroinferior septal defects poses a greater technical challenge. Simple plication
of these defects is rarely possible. With large defects, this results in unacceptable tension and
reopening or catastrophic disruption. Depending on the size and location of the defect, one
or two patches may be required. In addition, rupture of the posterior papillary muscle occasion-
ally requires replacement of the mitral valve.
◆ A transinfarct posterior incision is made just to the left ventricular side of the posterior
descending coronary artery (Fig. 8.4A). This incision is started at the midportion of the
posterior wall and extended toward the mitral annulus and apically. Most commonly, rupture
is found in the proximal half of the posterior septum (see Fig. 8.4B) and involves the pos-
teromedial papillary muscle. The necrotic portion of the ventricular septum is excised, along
with the involved portion of the posterior ventricular free wall (Fig. 8.5A). The free edge of
the RV is shaved back to expose the margins of the defect clearly.
◆ Rarely, repair of a small septal rupture can be undertaken primarily. An appropriate lesion
would appear as an unhinging of the posterior attachment to the septum, with little adjacent
myocardial necrosis. The repair is accomplished by approximating the posterior septum to
the free wall of the RV with felt-buttressed mattress sutures of 1-0 Tevdek. The LV can then
be closed with a separate suture line, again with interrupted mattress sutures of no. 1 Tevdek
buttressed with felt. A second running suture line is then taken to reinforce the ventriculotomy
closure.
Anterior
Posterior
descending
artery
RV LV
LV
Area of
infarct
A B Posterior
Figure 8.4
Anterior
Necrotic
LV wall excised
RV LV
A B Posterior
Figure 8.5
◆ More commonly, patches are required. A single patch can be added to aid in a tension-free
closure of the LV after primary closure of the septum (see Fig. 8.5B). When the defect in the
septum is larger, a two-patch technique is used. Interrupted mattress sutures of buttressed
2-0 Tevdek are placed circumferentially around the defect. The sutures are placed on the
right ventricular side of the septum and then transitioned to the epicardial surface of the
diaphragmatic right ventricular free wall. An appropriately shaped Dacron patch is parachuted
down after passage of the stitches. Use of additional felt on the exterior of the patch cushions
the sutures and aids in the even distribution of forces (Fig. 8.6A). A second patch is now
required for closure of the remaining defect into the LV.
◆ Mattress sutures of buttressed 2-0 Tevdek are placed circumferentially around the margins of
the posterior left ventricular free wall. The stitches are taken from the endocardial surface
through the ventricular wall so that the patch will lie on the epicardial surface when the
repair is complete (Fig. 8.7; see Fig. 8.6B). Again, use of additional felt on the outside of the
patch may be advantageous (Fig. 8.8).
◆ Involvement of the posterior medial papillary muscle may preclude the placement of stitches
through infarcted tissue. In these cases, as in the case of papillary muscle rupture, a mitral
valve replacement is performed after patch placement. The mitral valve is exposed through
a left atriotomy. On occasion, a transseptal approach via the dome of the left atrium may be
required. The valve is excised and replaced with a low-profile prosthesis. Interrupted, felted
2-0 Tevdek sutures are used, with the needle passing from the left atrium through the annulus.
A B
Figure 8.6
Anterior
RV LV
Posterior
3. Modification of Technique: Infarct Exclusion
Anterior Apical Defects
◆ The apical portion of the ventricle is opened through the infarction, with extension onto the
anterior LV. A glutaraldehyde-preserved bovine pericardial patch is secured to noninfarcted
areas of the left ventricular septum using running 3-0 polypropylene sutures. The stitches
should be inserted 5 to 7 mm deep in the muscle and 4 to 5 mm apart. The stitches in the
patch should be 5 mm from its free margin to allow the patch to cover the area between the
entrance and exit of the sutures (Fig. 8.9A).
◆ The suture line is begun at the most proximal part of the septum, and suturing begins traveling
toward the apex. The suture line continues from the septum onto the left ventricular free
wall. If the infarct involves the anterior papillary muscle at its base, the suture is brought
outside the heart at this point and continued as full-thickness interrupted 2-0 polypropylene
sutures buttressed on the epicardial surface with a strip of bovine pericardium or Teflon felt.
The LV is then closed with interrupted mattress sutures of 2-0 polypropylene buttressed by
Teflon felt strips, followed by a running 2-0 polypropylene stitch (see Fig. 8.9B).8
Posteroinferior Defects
◆ A transinfarct incision is made in the inferior wall of the LV, just lateral to the posterior
descending coronary artery, to expose the defect and is extended toward both the mitral valve
and apex. Care is taken to avoid damage to the posterior lateral papillary muscle. A bovine
pericardial patch is tailored in a triangular shape. Its size will be approximately 4 × 7 cm in
most patients. The base of the triangle is sutured to the mitral valve annulus with continuous
3-0 polypropylene sutures. The medial suture line then transitions from the mitral annulus
to the endocardium of the ventricular septum and is continued along that structure apically.
Laterally, the suture line transitions to the endocardium of the posterior LV.
◆ After several stitches, the posterior papillary muscle is encountered. If the area of necrosis is
small, and if healthy tissue allows for continuation, the running sutures are continued toward
the apex. Usually, on reaching the posterior papillary muscle, it is necessary to bring the
running stitch through the muscle to the outside of the LV. The suture line is then continued
with interrupted, full-thickness, 2-0 polypropylene sutures and buttressed with felt on the
outside (Fig. 8.10A). The suture line continues until the patch is completely secured, and
then the ventriculotomy is closed in two layers of full-thickness sutures buttressed on strips
of Teflon felt. The infarcted right ventricular wall is left undisturbed8 (Fig. 8.10B).
Pericardial patch
A B
Figure 8.9
Rupture
in septum
A B
Figure 8.10
Right Ventricular Approach
◆ Hosoba et al.9 have described repairing postinfarct VSDs using a right ventricular approach
and two Dacron patches. For anterior septal defects, an incision is made in the RV wall parallel
to the distal left anterior descending artery. Sutures are placed transseptally from the LV cavity
via the VSD and into the octagonally shaped patch. The patch is placed through the VSD,
into the LV, and secured into place. A second Dacron patch is secured over the defect in the
RV. For posterior VSDs, a similar two-patch technique is used, with an incision in the RV
parallel to the midportion of the posterior descending artery.
◆ If an intraaortic balloon pump was not inserted before surgery, one should be placed. Inotropic
support is instituted with milrinone (phosphodiesterase inhibitor). This drug is preferred
because, in addition to its inotropic properties, it has vasodilatory properties in the pulmonary
vascular bed.
◆ Posterior defects are associated with a right ventricular infarction and more often result in
right heart failure on separation from bypass. In such a case, inhaled nitric oxide (20 ppm)
is instituted before attempted separation. Additional maneuvers may include right-sided infusion
of prostaglandin E1 (0.5 µg/kg/min) and left-sided norepinephrine infusion through a left
atrial line.7,10
◆ For patients who are still in cardiogenic shock despite these maneuvers, mechanical circulatory
support may be warranted.11 ECMO may allow for support and resuscitation of these patients
in the postoperative stage. Central cannulation may be preferred postcardiotomy but the
cannula location should be individualized based on the clinical picture.
◆ Extubation usually requires aggressive early postoperative diuresis. After fully rewarming,
intravenous infusion of furosemide at doses of 5 to 20 mg/hr is used to maintain urine output

greater than 100 mL/hr. Continuous venovenous hemofiltration is used for nonresponders.
◆ The common problems during separation from bypass are low cardiac output, with or without
right ventricular failure and bleeding.
◆ Recurrent or severe ventricular ectopy is common. Before attempted separation from cardio-
pulmonary bypass, amiodarone is begun with a bolus of 150 mg, followed by ongoing infusion
at 1 mg/min. The bolus may be repeated up to six times for malignant ectopy.
◆ Inadequate hemodynamics on separation from cardiopulmonary bypass may require placement
of a ventricular assist device or ECMO. Left ventricular assist devices may result in increased
right-to-left shunting, and biventricular devices may be preferable.
References
1. Cooley DA. Postinfarction ventricular septal rupture. Semin Thorac Cardiovasc Surg. 1998;10:100–104.
2. Daggett WM. Postinfarction ventricular septal defect repair: Retrospective thoughts and historical perspectives. Ann Thorac Surg.
1990;50:1006–1009.
3. Pitsis A, Kelpis T, Visouli A, et al. Left ventricular assist device as a bridge to surgery in postinfarction septal defect. J Thorac
4. Conradi L, Treede H, Brickwedel J, et al. Use of initial biventricular mechanical support in a case of postinfarction ventricular septal
rupture as a bridge to surgery. Ann Thorac Surg. 2009;87:e37–e39.
5. Michel-Behnke I, Trong-Phi L, Waldecker B, et al. Percutaneous closure of congenital and acquired ventricular septal defects:
Considerations on selection of the occlusion device. J Interv Cardiol. 2005;18:89–99.
6. Calvert PA, Cockburn JC, Wynne D, et al. Percutaneous closure of post-infarction ventricular septal defect: in-hospital outcomes and
long-term follow-up of UK Experience. Circulation. 2014;129:2395–2401.
7. Agnihotri AK, Madsen JC, Daggett WM Jr. Surgical treatment of complications of acute myocardial infarction: postinfarction
ventricular septal defect and free wall rupture. In: Cohn LH, ed. Cardiac Surgery in the Adult. 3rd ed. New York: McGraw-Hill;
2008:753–784.
8. David TE, Armstrong S. Surgical repair of postinfarction ventricular septal defect by infarct exclusion. Semin Thorac Cardiovasc Surg.
1998;10:105–110.
9. Hosoba S, Asai T, Suzuki T, Nota H, et al. Mid-term results for the use of the textended sandwich patch technique through right
ventriculotomy for postinfarction ventricular septal defects. Eur J Cardiothorac Surg. 2013;e116-e120.
10. Taghavi S, Mangi AA. Postinfarction ventricular septal defect and ventricular rupture. In: Selke F, del Nido SJ, Swanson SJ, eds.
Sabiston and Spencer Surgery of the Chest. 9th ed. Philadelphia: Elsevier; 2016:1653–1662.
11. Firstenberg MS, Blais D, Crestanello J, et al. Long-term mechanical support for complex left ventricular postinfarct pseudoaneurysms.
Heart Surg Forum. 2009;12:E291–E293.
SECTION
Operations for
Valvular Heart
Disease
CHAPTER
9
Aortic Valve Replacement

Afshin Ehsan and Frank W. Sellke
Introductory Considerations
◆ The aortic valve is the last valve in the heart through which the blood is pumped before it
goes to the body. The purpose of the aortic valve is to prevent backflow of blood from the
aorta into the left ventricle.
◆ The normal aortic valve is tricuspid, with left coronary, right coronary, and noncoronary
leaflets. Each leaflet is supported by a fibrous skeleton with a shallow U-shaped configuration.
The portion of this skeleton that supports the left coronary leaflet is continuous with the
anterior leaflet of the mitral valve, forming the aortic-mitral curtain (annulus fibrosa).
◆ Each leaflet is attached just beneath their corresponding sinus of Valsalva. The sinuses of
Valsalva are slight dilations of the aorta above the valve that act to create the vortex of blood
required for valve closure. The sinuses end at the sinotubular junction, which is the narrowest
portion of the ascending aorta.
◆ The left main coronary artery arises from the left sinus of Valsalva. Its ostium lies directly
posterior, below the level of the sinotubular junction. The left main coronary artery runs to
the left, beneath the pulmonary artery. The right coronary ostium is an anterior structure
located above the right coronary cusp. Its location tends to be more variable than that of the
left main coronary artery.
129
Chapter 9 • Aortic Valve Replacement129.e1
Abstract
Aortic valve replacement remains the gold standard for the treatment of patients with significant
aortic valve stenosis and regurgitation. Successful aortic valve replacement requires careful
preoperative assessment of the patient and an intimate understating of the aortic root anatomy.
The authors understand that the operative steps may vary among surgeons; however, certain
core principals exist that will ensure an optimal outcome.
Keywords
aortic valve
aortic stenosis
valve replacement
130 Section III • Operations for Valvular Heart Disease
◆ The ventricular septum is located beneath the right coronary cusp and contains the atrioven-
tricular conduction system, which passes below the noncoronary cusp near the right-noncoronary
commissure (Fig. 9.1).
Indications for Aortic Valve Replacement for Aortic Stenosis
◆ In the vast majority of adults, aortic valve replacement (AVR) is the only effective treatment
for severe aortic stenosis (AS). Although there is some lack of agreement about the optimal
timing of surgery, particularly in asymptomatic patients, it is possible to develop rational
guidelines for most patients.
◆ In the absence of serious comorbid conditions, AVR is indicated in virtually all symptomatic
patients with severe AS. There are many ways in which AVR benefits these patients. These
depend partly on the patient’s left ventricular (LV) function. The outcome is similar in patients
with normal LV function and in those with moderate ventricular dysfunction. The depressed
ejection fraction in many of these patients is caused by excessive afterload, and LV function
improves after AVR. If LV dysfunction is not caused by afterload mismatch, improvement in
LV function and resolution of symptoms may not be complete after valve replacement,1 but
survival is still improved in this setting.2
◆ Symptomatic patients with angina, dyspnea, or syncope exhibit symptomatic improvement
and an increase in survival after AVR.1-6

◆ In patients who have severe AS, even those with a low transvalvular pressure gradient, AVR
results in hemodynamic improvement and better overall patient functional status.

◆ In summary, symptomatic patients with severe AS should undergo AVR. These patients will
have improved LV function, reduced or resolved symptoms, and increased survival.

◆ Many clinicians are reluctant to proceed with AVR in an asymptomatic patient, whereas others
are concerned about conservative treatment of a patient with severe AS. Insertion of a prosthetic
aortic valve is associated with low perioperative morbidity and mortality. Despite this, some
difference of opinion persists among clinicians regarding the indications for corrective surgery
in asymptomatic patients. Irreversible myocardial depression or fibrosis may develop during
a prolonged asymptomatic stage, and this may preclude an optimal outcome.5,7 Still others
attempt to identify patients who may be at especially high risk of sudden death without
surgery, although evidence supporting this approach is limited. Patients in this subgroup
include those who have an abnormal response to exercise (e.g., hypotension), those with LV
systolic dysfunction, those with marked or excessive LV hypertrophy, and those with evidence
of very severe AS.
◆ We recommend that asymptomatic patients with an aortic valve area of less than 0.8 cm2
undergo valve replacement. Similarly, any evidence of impaired LV function (e.g., decreased
ejection fraction, LV dilation, or significantly elevated LV diastolic pressure at rest or with
exercise) is an indication for AVR. In the absence of symptoms, a peak aortic gradient of
70 mm Hg may be an indication for surgery, but this is controversial.
◆ Patients with moderate or more AS (mean gradient of 20 mm Hg or higher), with or without
symptoms, who are undergoing coronary artery bypass grafting should undergo AVR at the
time of the revascularization procedure.
◆ Similarly, patients with moderate or more severe AS undergoing surgery on other valves
(e.g., mitral valve repair) or the aortic root should also undergo AVR as part of the surgical
procedure.
Chapter 9 • Aortic Valve Replacement 131
Opening of right
coronary artery
Opening of left
Right cusp, coronary artery
aortic valve
Left cusp,
aortic valve
Ventricular septum
Left bundle branch

Figure 9.1
Indications for Aortic Valve Replacement in Aortic Regurgitation
◆ AVR is recommended for patients with severe regurgitation in the presence of symptoms or
any evidence of pathologic LV remodeling (e.g., impairment of LV function, LV dilation,
significant elevation of LV end-diastolic pressure).
◆ Symptomatic patients with advanced LV dysfunction (ejection fraction < 0.25 or end-systolic
dimension > 60 mm) present difficult management issues. Some patients manifest meaningful
recovery of LV function after operation, but many will have developed irreversible myocardial
changes. The mortality rate associated with valve replacement approaches 10% in these
patients, and the postoperative mortality rate over the subsequent few years is high.
◆ AVR should be considered more strongly for patients with New York Heart Association (NYHA)
functional class II and III symptoms, especially if symptoms and evidence of LV dysfunction are
of recent onset, and intensive short-term therapy with vasodilators, diuretics, or intravenous positive
inotropic agents results in substantial improvement in hemodynamics or systolic function. However,
even in patients with NYHA functional class IV symptoms and an ejection fraction less than 0.25,
the high risks associated with AVR and subsequent medical management of LV dysfunction are
usually a better alternative than the higher risks of long-term medical management alone.8
◆ AVR in asymptomatic patients remains a controversial topic, but it is generally agreed that
valve replacement is indicated for patients with LV systolic dysfunction.8-14 As noted previously,
for the purposes of these guidelines, LV systolic dysfunction is defined as an ejection fraction
below normal at rest.
◆ Valve replacement is also recommended for patients with severe LV dilation (end-diastolic
dimension > 75 mm or end-systolic dimension > 55 mm), even if the ejection fraction is
normal. Most patients with this degree of dilation have already developed systolic dysfunction
because of afterload mismatch and thus are candidates for valve replacement on the basis of
the depressed ejection fraction. The elevated end-systolic dimension in this regard is often a
surrogate for systolic dysfunction. The relatively small number of asymptomatic patients with
preserved systolic function, despite severe increases in end-systolic and end-diastolic chamber
size, should be considered for surgery because they appear to represent a high-risk group
with an increased incidence of sudden death15,16; the results of valve replacement in these
patients have thus far been excellent. In contrast, postoperative mortality is considerable once
patients with severe LV dilation develop symptoms or LV systolic dysfunction.17
◆ Once the cardiac structures have been exposed, the patient is heparinized, and the distal
ascending aorta and right atrial appendage are cannulated. If the aorta is heavily calcified, the
surgeon may consider femoral or axillary cannulation and deep hypothermia with circulatory
arrest without cross-clamping to avoid stroke. Transesophageal or epiaortic echocardiography
can be useful if there is some uncertainty about the state of the aorta.18 A retrograde cardioplegia
cannula is placed into the coronary sinus. Cardiopulmonary bypass is instituted, and a LV vent
is placed through the right superior pulmonary vein. A cannula is placed in the mid ascending
aorta for the delivery of cardioplegia into the aortic root and later de-airing. The aorta is cross-
clamped, and the heart is arrested with antegrade and retrograde cardioplegia. Intermittent
doses of cardioplegia are given throughout the procedure. In patients with significant aortic
insufficiency, antegrade cardioplegia is often not effective, and arrest can be initiated with
retrograde cardioplegia, followed by direct injection of cardioplegia into the coronary ostia.
◆ Access to the aortic valve can be through an oblique or a transverse aortotomy. The aortotomy is
placed at least 1 cm above the sinotubular junction, above the right coronary ostium. This circumvents
compromising or injuring the right coronary artery during closure of the aortotomy. The aortotomy
can be extended to the noncoronary sinus of Valsalva for greater exposure (Fig. 9.2).
Aortotomy
Figure 9.2
◆ Traction sutures can be placed at the sinotubular junction above the commissures. This
provides maximum exposure of the annulus. The instillation of carbon dioxide into the
operative field while the aorta is open may reduce intracardiac air when the cross-clamp is
removed.
◆ With the aortic valve exposed, the leaflets are resected, and the annulus is débrided of calcium.
The surgeon must leave a thin rim of valve tissue and not excise the annulus completely.
Resection of the valve is initiated at the commissure between the right and noncoronary
sinuses. The commissure is excised from the aortic wall, and the right coronary cusp is excised
(Fig. 9.3). The commissure between the left and right coronary cusps is excised, and the left
coronary cusp is removed. Resection is completed with excision of the noncoronary cusp,
performed toward the commissure between the left and noncoronary cusps (Fig. 9.4). When
calcification is encountered, careful débridement is required to avoid detaching the aorta from
the ventricle. A rongeur can be used to crush the calcium into smaller pieces to facilitate
removal. All debris must be accounted for; this will minimize the possibility of stroke and
coronary ostial occlusion of embolization. Extensive and vigorous irrigation must be performed
after valve excision. A small gauze cloth may be placed into the left ventricle to prevent calcified
particulate matter from entering the cavity, especially if the valve is severely calcified. Retrograde
cardioplegia is given during irrigation to prevent debris from entering the coronary ostia.
◆ The annulus is measured, and the appropriate-sized valve is selected for the replacement.
If the annulus is too small, various aortic root enlargement techniques can be used (see
Chapter 11).
◆ Several suturing techniques have been used, but the most common technique uses horizontal
pledgeted sutures with pledgets on the aortic or ventricular aspect of the annulus, depending
on the type of valve being inserted.
◆ We use an interrupted suture technique that affords maximum strength of the prosthetic
attachment and has a low incidence of perivalvular leak. We place sutures from below the
annulus, exiting slightly above it into the aorta. Double-needle, pledgeted 2-0 Dacron sutures
are used, with little space between them. The sutures are alternating green and white to
simplify identification of the suture pairs. The pledgets are placed below the annulus in the
LV outflow tract. This secures the prosthesis by compressing the annulus between the sutures
and prosthesis (Fig. 9.5).
Wall of
aorta
Aortic
Right coronary
valve
cusp excised
Figure 9.3
Completion of
noncoronary
cusp excision
Figure 9.4
Suture
placement
Figure 9.5
◆ Sutures are placed in the right coronary annulus toward the commissure between the right
and noncoronary sinuses. In a similar fashion, the left coronary annulus is sutured toward
the noncoronary sinus. Finally, the noncoronary sutures are placed (Fig. 9.6). Deep sutures
along the posterior annulus, under the left main artery, should be avoided, given that the left
main artery runs for a short distance along the posterior aspect of the aorta. Deep sutures in
the muscle below the right coronary leaflet may damage the conduction system—in particular
the left bundle and bundle of His, and should once again be avoided (see Fig. 9.1).
◆ The sutures are then passed through the sewing ring of the prosthesis, which is tied down
in the supraannular position (Fig. 9.7). Supraannular valves allow for a larger orifice area
and tend to seat well in the annulus. We prefer to tie down the commissure sutures first,
followed by the left, right, and noncoronary sinuses.
◆ The use of sutureless prosthetic heart valves, initially developed in the 1960s, has been
abandoned, due to multiple complications, such as paravalvular leaks and valve-related

thromboembolic events.19 The rapid development of transcatheter technology, however, has
fueled a reemergence of the sutureless strategy in an effort to accelerate the surgical procedure
and potentially reduce adverse outcomes.20 Depending on the manufacturer, these valves may
be contraindicated in bicuspid aortic valves, along with irregular or heavily calcified valves.
◆ The implantation of sutureless valves varies in technique. As with traditional sutured valves,
the leaflets must be excised. The degree to which the annulus is débrided depends on the
particular valve that is chosen. From one to three guiding sutures are used to ensure proper
orientation of the valve relative to the annulus.
◆ Valves are deployed by releasing self-expanding Nitinol stents or balloon inflation of the valve,
once positioned in the native annulus. The inflow portion of the valves are wrapped in cloth
or pericardial tissue to promote adaptation of the prosthesis to the native annulus and prevent
paravalvular leaks.
◆ Once the prosthesis has been secured into place, the aortotomy is closed. Pledgeted, double-
needle polypropylene sutures are placed at the lateral aspects of the aortotomy and tied down.
A horizontal mattress stitch is used from the lateral aortotomy toward the middle. A second
continuous stitch is placed as a second layer for the closure (Fig. 9.8). When a friable or thin
aorta is encountered, consideration should be given to using felt strips for closure.
◆ After release of the cross-clamp, transesophageal echocardiography (TEE) is used to assess
the position of the prosthesis and evaluate for the possibility of perivalvular leak. Intraventricular
air volume can also be determined. If a significant quantity of air remains in the ventricle,
this can be aspirated using a needle in the ventricular apex. Right atrial and right ventricular
pacing wires are placed. After recovery of a suitable heart rhythm, the patient is weaned from
cardiopulmonary bypass, and TEE is used to monitor ventricular function. Cannulae are
removed, heparin is reversed with protamine, and the incision is closed.
Pledget-reinforced
sutures in annulus
of right sinus
Right coronary
artery
Prosthetic
valve
Left coronary
artery
Left sinus repair
Noncoronary sinus
repair
Figure 9.6
Prosthesis
tied down

◆ The postoperative management for a patient having undergone AVR is routine and standard
for most postcardiac surgical patients.
◆ However, several points should be addressed. A patient with AS has a hypertrophied left
ventricle and thus will likely be very sensitive to the preload state. In addition, atrial fibrillation
is often not well tolerated in patients with a stiff, hypertrophic left ventricle. Although a
Swan-Ganz catheter may not always be required, it may help assess the degree of volume
loading and should be considered in complex cases.
◆ Wide fluctuations in blood pressure are not uncommon. Any sudden increase in bleeding
from the chest tubes or mediastinal tubes should alert the surgeon to the possibility of aortotomy
suture line bleeding.
◆ In patients in whom a mechanical valve has been placed, warfarin is started on the first or
second postoperative day. If the international normalized ratio (INR) has not increased by
the fourth day, we recommend intravenous heparin until the patient has achieved a therapeutic
INR. The pacing wires are removed when clinically appropriate and prior to achieving an
INR higher than 2.
◆ Solitary AVR is usually a straightforward procedure. However, attention to several points can
improve the outcome. Because the aortic valve is often calcified, the surgeon should take care
not to lose calcified debris in the ventricle or down the coronary arteries. A gauze pad can
be placed in the ventricle during débridement to prevent embolization, and the ventricle
should be copiously irrigated with cold saline after débridement. In addition, retrograde
cardioplegia should be administered during irrigation.
◆ When implanting any prosthetic valve, the surgeon needs to ensure that the coronary arteries
are not occluded by the sewing ring, pledgets, or sutures. In case of a regional wall motion
abnormality after bypass, it may be necessary to rearrest the heart and inspect the coronary
ostia or to bypass the vessel supplying the dysfunctional region.
◆ In the presence of a small aortic root, it is not advised to force a valve into the root. This
may result in a paravalvular leak or, worse, aortic or ventricular disruption. This is especially
true in older frail patients with a calcified annulus. If the surgeon is concerned with the
possibility of a patient-prosthesis mismatch (predicted aortic valve area index < 0.8 cm2/m2),
he or she should consider enlarging the aortic root annulus (see Chapter 11).
◆ TEE has become a standard part of the procedure. It allows the surgeon and anesthesiologist
to assess the adequacy of replacement in terms of possible paravalvular leak, abnormal leaflet
motion, or regional or global myocardial dysfunction. In our opinion, it should be used in
every case of valve replacement or repair unless contraindicated.
References
1. Connolly HM, Oh JK, Orszulak TA, et al. Aortic valve replacement for aortic stenosis with severe left ventricular dysfunction:
prognostic indicators. Circulation. 1997;95:2395–2400.
2. Smith N, McAnulty JH, Rahimtoola SH. Severe aortic stenosis with impaired left ventricular function and clinical heart failure: results
of valve replacement. Circulation. 1978;58:255–264.
3. Schwartz F, Baumann P, Manthey J, et al. The effect of aortic valve replacement on survival. Circulation. 1982;66:1105–1110.
4. Murphy ES, Lawson RM, Starr A, Rahimtoola SH. Severe aortic stenosis in patients 60 years of age or older: left ventricular function
and 10-year survival after valve replacement. Circulation. 1981;64:II184–II188.
5. Lund O. Preoperative risk evaluation and stratification of long-term survival after valve replacement for aortic stenosis: reasons for
earlier operative intervention. Circulation. 1990;82:124–139.
6. Kouchoukos NT, Davila-Roman VG, Spray TL, et al. Replacement or the aortic root with a pulmonary autograft in children and
young adults with aortic-valve disease. N Engl J Med. 1994;330:1–6.
7. Lund O, Larsen KE. Cardiac pathology after isolated valve replacement for aortic stenosis in relation to preoperative patient status:
early and late autopsy findings. Scand J Thorac Cardiovasc Surg. 1989;23:263–270.
8. Bonow RO, Nikas D, Elefteriades JA. Valve replacement for regurgitant lesions of the aortic or mitral valve in advanced left ventricular
dysfunction. Cardiol Clin. 1995;13:73–83.
9. Ross J Jr. Afterload mismatch in aortic and mitral valve disease: implications for surgical therapy. J Am Coll Cardiol. 1985;5:811–826.
10. Nishimura RA, McGoon MD, Schaff HV, Giuliani ER. Chronic aortic regurgitation: Indications for operation—1988. Mayo Clin Proc.
1988;63:270–280.
11. Bonow RO. Asymptomatic aortic regurgitation: indications for operation. J Card Surg. 1994;9:170–173.
12. Rahimtoola SH. Valve replacement should not be performed in all asymptomatic patients with severe aortic incompetence. J Thorac
13. Carabello BA. The changing unnatural history of valvular regurgitation. Ann Thorac Surg. 1992;53:191–199.
14. Gaasch WH, Sundaram M, Meyer TE. Managing asymptomatic patients with chronic aortic regurgitation. Chest. 1997;111:1702–1709.
15. Turina J, Turina M, Rothlin M, Krayenbuehl HP. Improved late survival in patients with chronic aortic regurgitation by earlier
operation. Circulation. 1984;70:I147–I152.
16. Bonow RO, Lakatos E, Maron BJ, Epstein SE. Serial long-term assessment of the natural history of asymptomatic patients with
chronic aortic regurgitation and normal left ventricular systolic function. Circulation. 1991;84:1625–1635.
17. Klodas E, Enriquez-Sarano M, Tajik AJ, et al. Aortic regurgitation complicated by extreme left ventricular dilation: long-term outcome
after surgical correction. J Am Coll Cardiol. 1996;27:670–677.
18. Byrne JG, Aranki SF, Cohn LH. Aortic valve operations under deep hypothermic circulatory arrest for the porcelain aorta: “no-touch”
technique. Ann Thorac Surg. 1998;65:1313–1315.
19. Magovern GJ, Cromie HW. Sutureless prosthetic heart valves. J Thorac Cardiovasc Surg. 1963;46:726–736.
20. Carrell T, Englberger L, Stalder M. Recent developments for surgical aortic valve replacement: the concept of sutureless valve technology.
http://rossscience.org/ARTICLE/OJCAR-4-1.php. p 2013.
CHAPTER
10
Minimally Invasive,
Mini-Thoracotomy Aortic
Valve Replacement
Joseph Lamelas
Step 1. Introductory Considerations
◆ Minimally invasive valve surgery has numerous benefits compared with a standard median
sternotomy. These benefits include reduced surgical trauma, blood loss, transfusion require-
ments, and reoperations for bleeding. Ventilation times and intensive care unit and hospital
lengths of stay are also reduced. Patients undergoing minimally invasive surgery also experience
a more rapid return to functional capacity and less use of rehabilitative resources, which has
resulted in additional costs savings as well.1-5
◆ The incisions and approaches used in minimally invasive aortic valve surgery have evolved
over time. The concept was first introduced in 1996 by Cosgrove et al.,6 who described a
right parasternal incision approach. This later proved to cause significant chest wall instability
and has since been abandoned. Currently, minimally invasive aortic valve surgery is usually
performed via an upper hemisternotomy approach, either with a T or L transection of the
sternum at the level of the third or fourth intercostal space.7,8 A lower hemisternotomy and
manubrial approach have also been described.9,10 The only true sternal-sparing procedures
are an axillary approach or right minithoracotomy, entering the thoracic cavity via the second
or third intercostal space.11 The focus of this chapter will be on the latter method.
1. Indications and Contraindications
◆ The right minithoracotomy can be used in most subsets of patients requiring an aortic valve
replacement (AVR). Definitive contraindications to a right anterior thoracotomy approach
include patients with a severely calcified aorta (porcelain aorta), evident preoperatively by
cardiac catheterization or computed tomography (CT) scan or intraoperatively by palpation,
patients who cannot be safely cannulated peripherally due to peripheral vascular disease or
140
Chapter 10 • Minimally Invasive, Mini-Thoracotomy Aortic Valve Replacement140.e1
Keywords
minimally invasive
minithoracotomy
aortic valve replacement
Chapter 10 • Minimally Invasive, Mini-Thoracotomy Aortic Valve Replacement 141
centrally due to calcium in the aorta, and patients who require a valve-sparing operation.
The aforementioned groups require greater exposure of the operative field. Patients who
present with previous right thoracic surgery or dense adhesions from an inflammatory reaction
may undergo a minithoracotomy approach. In this particular group, minimal dissection is
performed in the pleural cavity, and the pericardial space is immediately entered and exposed.
◆ The benefits of the minithoracotomy over a standard sternotomy AVR have also been seen
in higher-risk patients, including older patients (> 75 years old),1 obese patients (body mass
index [BMI] > 30 kg/m2),2 patients with chronic obstructive pulmonary disease (COPD),4
and patients with a low ejection fraction (< 35%). Several studies have demonstrated a lower
morbidity and mortality in these higher-risk patients.12 An extended application of this procedure
can be offered to patients who require replacement of the ascending aorta and hemiarch along
with an AVR.13 Most of these procedures are performed under deep hypothermic circulatory
arrest and retrograde cerebral perfusion. In patients requiring a full root replacement due to
aneurysmal disease or a small aortic annulus, an aortic root replacement with reimplantation
of the coronaries can also be performed. In addition, reoperative aortic valve surgery in
patients with prior valve surgery or coronary revascularization via a right minithoracotomy
approach is feasible.14,15 All these procedures are more technically challenging and require
additional experience. Other applications include AVR with aortic root enlargement, AVR
with a septal myectomy, and AVR with a single bypass to the proximal or distal right coronary
artery (RCA). The posterior descending artery is difficult to visualize with this approach. In
patients with coronary artery disease amenable to percutaneous intervention, a hybrid approach
is preferable. A percutaneous intervention can be performed at any time prior to the minimally
invasive valve surgery. A minithoracotomy approach can be offered to patients receiving dual
antiplatelet therapy.16,17
2. Preoperative Preparation: Special Diagnostic or Imaging Tests
◆ The preoperative workup includes routine blood work, chest radiography, cardiac catheteriza-
tion, and echocardiography. A routine CT angiogram is not necessary unless severe peripheral
vascular disease is suspected by history or physical examination, although a CT angiogram
is highly recommended when initiating a minimally invasive program. Stroke rates are low
in patients undergoing femoral cannulation, despite the use of retrograde arterial perfusion, 18,19
and are comparable to rates in patients undergoing a sternotomy valve procedure.
◆ Routine CT scans of the chest are not necessary either, although others have defined inclusion
criteria based on CT scan findings, which may be beneficial initially.5 Chest CT scans may
also potentially diminish the incidence of conversions.
3. Challenging Anatomy
◆ The anatomy of certain patients can pose additional challenges when performing the procedure
via a right minithoracotomy approach. A chest x-ray demonstrating the right border of the
heart adjacent to the right border of the vertebral column may be associated with the heart
being displaced toward the left side of the chest. This is also true for patients with a pectus
excavatum. If the angle of the aorta and ventricle lie at 90 degrees on the ventriculogram
(cardiac catheterization), visualization of the aortic valve may be more challenging. Visualization
of the aortic valve is usually more challenging in patients with a bicuspid aortic valve. Although
challenging, these anatomic variants are not definitive contraindications for the surgery.
4. Ventilation
◆ A single-lumen endotracheal tube is inserted, and double-lung ventilation is used throughout

the operation. If visualization of the heart is impaired by the lungs, the lungs are temporarily
deflated, or cardiopulmonary bypass can be initiated early in the procedure.
◆ Single-lung ventilation with a double-lumen endotracheal tube or bronchial blocker is not
performed unless significant pleural adhesions limit visualization and dissection. Cases of
unilateral reexpansion pulmonary edema secondary to single-lung ventilation have been
reported.20
5. Monitoring Lines
◆ The preoperative preparation includes insertion of a left radial arterial line and right internal
jugular or left subclavian vein Swan-Ganz catheter. A left radial arterial line is always preferred
in case right axillary artery cannulation is required. Patients undergoing reoperative aortic
valve surgery will have a temporary transvenous pacemaker inserted after the induction of
anesthesia.
6. Anesthesia
◆ The patient is induced with a muscle relaxant (fentanyl and midazolam). A volatile agent is
administered throughout the surgery. Remifentanil is started immediately prior to exposing
the artery and vein for cannulation. Heparin (300-400 units/kg) is also given at this time in
preparation for cannulation. The dosage of remifentanil is increased prior to the chest incision.
While on cardiopulmonary bypass, the remifentanil dose is lowered, and midazolam is
administered. After weaning from cardiopulmonary bypass, remifentanil is continued at a
low dose. At completion of the operation, the patient is transported to the intensive care unit
and continued on remifentanil.
7. Transesophageal Echocardiography
◆ Every patient should have a thorough intraoperative two-dimensional (2D) and three-dimensional
(3D) transesophageal echocardiographic assessment. The sizes of the aortic annulus and
ascending aorta are measured. Left ventricular function is assessed. The mitral valve is visualized
and analyzed. If mitral valve pathology requiring repair or replacement is identified, patient
positioning may need to be changed. Assessment of atherosclerotic disease in the ascending
and descending aorta is performed. Evidence of a grade 4 or 5 free-floating atheroma in the
descending aorta would preclude femoral cannulation and retrograde arterial perfusion.
Positioning of the venous cannula in the superior vena cava (SVC) is performed with trans-
esophageal echocardiography (TEE). A bicaval midesophageal view done at 80 to 100 degrees
is used for placement of the venous cannula into the SVC. TEE is also used in reoperative
aortic valve surgery for insertion of a retrograde cardioplegia cannula. A midesophageal,

four-chamber view at 0 degrees is used for guiding placement of a retrograde cannula into
the coronary sinus if necessary.21
◆ Intraoperative fluoroscopy can also be used to aid placement of the venous guidewire and
cannula when the wire cannot be visualized by TEE. Intraoperative iliac and abdominal aortic
angiograms with fluoroscopy are obtained when there is uncertainty after insertion of the
femoral arterial cannula or when calcified plaques are encountered during cannulation.
8. Antibiotics
◆ Patients receive 2 g of a cephalosporin within 1 hour of skin incision and every 8 hours
thereafter for 48 hours. Patients allergic to penicillin receive 1 g of vancomycin within 1 hour
of skin incision and every 12 hours for 48 hours thereafter. Dosing will be altered depending
on renal function. Patients who have been admitted to the hospital for an extended period
of time before their scheduled surgery will receive vancomycin.
1. Preparation and Positioning
◆ Patientsare positioned supine, with the arms at the side. A roll is not placed between or
below the scapula to elevate the chest. Defibrillator pads are placed on the patient’s back.
One pad is placed on the right posterior shoulder and the other on the left lower posterior
thorax. The chest is prepped with chlorhexidine. In addition, the inguinal region and lower
extremities are prepped for peripheral cannulation and for vein harvesting, if required.
◆ A femoral platform is the access site of choice. Left femoral artery and vein cannulation
are preferred because most patients undergo a cardiac catheterization via the right femoral
artery. A CT angiogram is not routinely obtained unless severe peripheral vascular disease
is suspected. Prior to cannulation, the patient is fully heparinized (300-400 units/kg). A
2- to 3-cm longitudinal skin incision is made above the inguinal crease. This approach,
along with limited dissection of the anterior aspect of the vessels, decreases the incidence of
seroma formation. Careful attention is paid to assessing the quality of the artery. Presence of a
posterior horseshoe calcified plaque is not a contraindication for cannulation. Circumferential
calcification would negate cannulation. A 5-0 Prolene purse-string suture is placed on the
anterior aspect of each vessel. A modified Seldinger technique is used for cannulation. A
guidewire is advanced into the proximal descending aorta and verified by TEE. Passage of
the wire should be performed without resistance. Thereafter, an arterial cannula is inserted
into the artery. The size of the cannula chosen will depend on the patient’s body surface area.
Occasionally, when passing the cannula over the guidewire, plaque may be felt as the cannula
is being advanced. The cannula is advanced as long as there is no resistance. If any resistance
is encountered while advancing the cannula, an alternative access site should be chosen. If
any concerns exist, intraoperative angiography is performed, with contrast injected through
the cannula side port.
◆ When the femoral artery is small, circumferential dissection of the vessel is performed, proximal
and distal control of the artery is obtained, and a direct arteriotomy is performed. The
guidewire is back-loaded in the arterial cannula, and the cannula is introduced into the artery.
The guidewire is advanced, and then the cannula is passed over the guidewire (Fig. 10.1). If
an alternative cannulation site is required, the right axillary artery is the next access point of
choice. In this case, a 2-cm skin incision is performed 1 to 2 cm beneath the clavicle, medial
to the deltopectoral groove. Care is taken not to injure the surrounding nerves. The vein is
usually encountered first and is inferior to the artery. The artery is commonly deep, and the
pulse is palpated to guide the dissection. Once exposed, the artery is encircled proximally
and distally with vessel loops. A direct arteriotomy is preferred for passage of the cannula.
Intraoperative fluoroscopy and angiography is always performed. Of note, a Seldinger technique
can be used, although the risk of damaging the vessel is greater. Central cannulation can also
be performed. In these cases, the pericardium is opened, and all the pericardial retraction
sutures are placed. Purse-string sutures are then placed as distally as possible in the ascending
aorta, and a Seldinger technique is also used for cannulation.
3. Venous Cannulation
◆ Once arterial cannulation is completed, femoral venous cannulation is performed using a

Seldinger technique. A 180-cm wire is passed through the femoral vein and into the SVC
under TEE guidance. A 0-degree bicaval view is obtained for placement. Thereafter, a 25 F
venous cannula is advanced deep into the SVC. To obtain adequate venous drainage, the
cannula should be in the SVC and vacuum drainage applied. Vacuum assistance with 35 mm Hg
of negative suction is applied and increased to 65 mm Hg, if necessary. The application of
negative pressure causes an increase in the formation of gaseous microemboli, although this
has not been proven to be harmful. Studies have demonstrated that surpassing 60 mm Hg
of negative pressure does not increase the incidence of neurologic events.22 Additional venous
drainage is required in case of right-sided distention or dislodgment of the venous cannula
into the right atrium. In these cases, a 4-0 purse-string suture is placed on the SVC, and
additional sump suction is inserted into the SVC.
4. Incision
◆ A 5- to 6-cm right minithoracotomy skin incision is performed 1 cm lateral to the sternum
at the level of the second or third intercostal space (Fig. 10.2). Once the skin and subcutaneous
tissues are entered, limited dissection of the pectoralis muscle is performed. Exposure can be
challenging in young muscular patients. The intercostal muscle is then entered. The right
internal mammary artery and vein are identified and transected between two clips. Care is
taken to visualize each vessel clearly. The lower costal cartilage is transected immediately
lateral to the sternum. Alternatively, the cartilage can be left intact and a rib spreader inserted
to gain additional exposure. This option can cause a residual chest wall defect, which could
lead to paradoxic chest wall motion.
Figure 10.1
Figure 10.2
Figure 10.1 Femoral arterial and venous cannulation.
Figure 10.2 External landmarks for right mini thoracotomy incision.

5. Retraction
◆ A soft tissue retractor is inserted into the pleural cavity and provides improved visualization.
An intercostal rib spreader is placed to provide additional exposure. A chest tube incision
(utility port) is then made several interspaces below the chest incision. Intravenous tubing is
placed through the utility port and passed out from the chest incision. This tubing functions
as a guide to pass cannulae and tubes and avoids creating multiple false tracks through the
chest wall. In addition, this will decrease the potential of injuring the intercostal vessels (Fig.
10.3). At this point, cardiopulmonary bypass is instituted, and the lungs are deflated. The
pericardium is opened over the aorta, and the incision extended down toward the inferior
vena cava. Care is taken not to open the pericardium superiorly past the aortopericardial
reflection. A pericardial stay suture is placed at the level of the right superior pulmonary vein
and tacked to the skin to aid exposure. An additional pericardial retraction suture is placed
at the level of the SVC.
6. Left Ventricular Venting
◆ The right atrium is retracted to the left, and the pericardium adjacent to the right superior
pulmonary vein is retracted to the right. A purse-string suture is placed on the right superior
pulmonary vein (Fig. 10.4). A blunt-tipped left ventricular vent is inserted into the left atrium
or left ventricle. This is then exteriorized through the chest tube incision (utility port).
7. Retrograde Cardioplegia (Optional)
◆ A purse-string suture is placed around the lateral aspect of the right atrial appendage, and a
retrograde cardioplegia cannula is inserted into the coronary sinus. The end of the cardioplegia
cannula is bent at a 45-degree angle approximately 1 to 2 cm from its tip. This will usually
facilitate placement into the coronary sinus. If this maneuver is not successful, the cannula
is removed, and the tip is straightened and reinserted. TEE guidance is used to assess entry
into the coronary sinus. On the midesophageal four-chamber view, at a probe depth of 30 to
35 cm with the transducer angle between 0 and 20 degrees, the mitral and tricuspid valves
are visualized. After advancing the probe slightly, the coronary sinus in the long-axis view
can be appreciated just above the attachment of the tricuspid valve septal leaflet to the
interventricular septum.21 Once the cannula is visualized in the coronary sinus, the stylet is
removed, and the cannula is advanced an additional 1 to 2 cm into the coronary sinus. It is
important to advance the cannula further once visualized in the coronary sinus to avoid
dislodgment.
◆ There are four points to confirm proper placement of the retrograde cannula. The first is TEE
visualization of the cannula. The second is dark venous blood return from the cannula
immediately after proper placement. The third is ventricularization of the pressure transduced
from the cannula. The fourth is visualizing active blood return from the coronary ostia after
delivering cardioplegia. The cardioplegia catheter is also exteriorized through the utility port.
Figure 10.3
Figure 10.4
Figure 10.3 Right mini thoracotomy exposure with soft tissue retractor and rib spreader.
Figure 10.4 Left ventricular vent in right superior pulmonary vein.

8. Exposure
◆ Alternatively, and preferentially, retrograde cardioplegia cannulation is omitted, and the right
atrial appendage is retracted with a no. 2 silk loop. This loop is tunneled through the utility
port and pulls the right atrial appendage inferiorly to improve visualization of the aortic root
(Figs. 10.5 and 10.6).
◆ Additional pericardial sutures are placed. It is important not to open the pericardium superiorly
up to its insertion on the aorta (Fig. 10.7). This will limit the ability of the pericardium to
provide the necessary retraction. Each maneuver will help lead to the next step in facilitating
additional exposure. In general, one should not make judgment on the exposure or one’s
ability to perform minimally invasive AVR until the patient has been placed on bypass, and
the heart and lungs are decompressed.
◆ A plane is then established beneath the aorta and above the superior aspect of the right branch
of the pulmonary artery for placement of the aortic cross-clamp. The aorta is not dissected
free from the main pulmonary artery. A retractable, shafted, cygnet cross-clamp is then used
to cross-clamp the ascending aorta. A 6-inch, 14-G angiocatheter is inserted into the aorta
to deliver an induction dose of cardioplegia (Fig. 10.8). Thereafter, retrograde cardioplegia
is delivered at 20-minute intervals or sooner, if required. Additional doses of cardioplegia are
given directly into the coronary ostia if blood return is not visualized from both ostia during
delivery of retrograde cardioplegia or if there is a suspicion that the coronary sinus cannula
was not properly placed. However, note that this aforementioned cardioplegia strategy is no
longer used since the implementation of extended-effect cardioplegia solutions.23 A modified
del Nido solution (four parts blood to one part crystalloid) containing 40 mEq potassium is
delivered either into the aortic root or directly into the coronary ostia. A 2-L induction dose
will allow at least 90 to 100 minutes of safe protection. Of note, no studies to date have
confirmed the degree of protection that this particular cardioplegia method provides in the
adult cardiac surgical patient.
9. Temperature
◆ The patient’s temperature is allowed to fall to 34°C (93.2°F). Active cooling is not performed
unless the ascending aorta and hemiarch are being replaced.13 In these cases, the SVC is
encircled with a vessel loop, a 4-0 Prolene purse-string suture is placed on the SVC, and a
24 F wire-reinforced venous cannula is tunneled through the utility port and into the SVC.
This is used for retrograde cerebral perfusion during the period of deep hypothermic circulatory
arrest. In this case, the patient is cooled to 20°C (68°F).

Figure 10.5 Silk loop placed on tip of right atrial appendage.
Figure 10.6 Right atrial appendage retracted with silk loop.
Figure 10.7 Pericardial incision.
Figure 10.8 Delivery of antegrade cardioplegia.

10. Minimally Invasive Aortic Valve Replacement
◆ An aortotomy is made at the level of the linear fat pad located on the anterior aspect of the
aorta with long-shafted Metzenbaum scissors (Geister Medizintechnik, Tuttlingen, Germany).
Care is taken to stay at least 2 cm from the cross-clamp. A silk suture is then placed on the
upper aspect of the aortotomy to allow retraction of the aorta and exposure of the aortic valve
(Fig. 10.9). When the ventricular fat overlying the RCA impedes visualization, another retraction
suture can be placed on this fat pad and tacked to the pericardium. CO2 is infused into the
operative field at a rate of 2 L/min throughout the entire procedure. Infusing higher amounts
of CO2 will raise the patient’s CO2 levels while on cardiopulmonary bypass and will pose an
arduous task for the perfusionist to sweep off. Long-handled conventional Metzenbaum scissors
or long-shafted Mayo scissors are used to resect the aortic valve. If needed, a rongeur is used
to débride additional calcium. Because the assistant has limited visibility to help suction the
calcium, the rongeur is held in one hand and the suction in the other simultaneously. After
excision of the valve, the root and left ventricle are irrigated to remove any residual debris.
Thereafter, 3-0 Prolene sutures are placed at the level of the commissures to provide a so-called
no-touch technique for exposure of the aortic valve. An aortic valve exposure device (Aortic
Cuff [small, medium, or large], Miami Instruments, Miami, FL) is used to provide further
exposure, if necessary (Fig. 10.10). The valve sutures are then placed on the aortic annulus
in the conventional manner (Fig. 10.11). The valve is sized, and the valve of choice is selected.
After the sutures are placed through the sewing cuff, the valve is delivered onto the annulus.
The valve usually requires manipulation to cross the sinotubular junction. Once seated on
the aortic annulus, each suture is tied down carefully (Fig. 10.12). In certain cases, some
of the sutures can be tied manually, but one must avoid excessive traction on the suture to
avoid tearing the annulus, which will lead to a paravalvular leak. Each knot is inspected prior
to cutting the suture to ensure that an air knot does not exist. If an air knot has occurred,
the knot is teased and unraveled. This same suture is then tied again. Once the valve is
properly seated, the aortotomy is closed in the desired fashion (Fig. 10.13).
11. Pacing Wires
◆ Prior to removal of the cross-clamp, the acute margin of the right ventricle is retracted with
a sponge stick, and the muscular wall of the inferior aspect of the right ventricle is visualized.
A ventricular pacing wire is placed very superficially on the epicardium. It is important to
perform this maneuver with the heart empty prior to removing the cross-clamp (Fig. 10.14).
After the clamp is removed, it is virtually impossible to place a ventricular lead on the inferior
wall of the right ventricle. An atrial pacing wire can be placed, although this is rarely necessary.
The patient is then placed in a Trendelenburg position, the heart is filled, and air is removed
from the aortic root. The cross-clamp is removed and the angiocatheter, which was initially
used to deliver antegrade cardioplegia, is placed back into the aortic root for further removal
of air. The heart is filled and allowed to eject during this time. The left ventricular vent, which
was placed in the right superior pulmonary vein, also aids air removal.

Figure 10.9 Ascending aortotomy 2 cm from cross clamp.
Figure 10.10 Exposure of aortic annulus with exposure device.
Figure 10.11 Sutures placed on ventricular aspect of annulus.
Figure 10.12 Aortic valve seated on annulus.
Figure 10.13 Aortotomy closure.
Figure 10.14 Retraction of acute margin of heart and placement of right ventricular pacing wire.
◆ Instruments are not placed directly through the chest incision to manipulate the heart. Once
there is TEE confirmation of adequate air removal, two purse-string sutures are placed to seal
the antegrade cardioplegia delivery site. The patient is subsequently weaned from cardiopul-
monary bypass. After half of the protamine is administered, the femoral venous cannula is
removed, and the purse-string suture is tied. After complete administration of the protamine,
the arterial cannula is removed, and the purse-sting suture is tied as well.
12. Drains
◆ A Blake chest drain is placed over the main pulmonary artery and advanced into the posterior
pericardial well (Fig. 10.15). An additional Blake drain is placed posteriorly and laterally in
the pleural space. The Blake drains, pacing wire, and pain management catheters are all
exteriorized through the utility port.
13. Closure
◆ Closure of the chest wall needs to be meticulously performed to avoid paradoxic chest wall
motion and maintain chest wall stability. Once hemostasis is obtained, one additional clip is
placed on either side of the transected right internal mammary artery and vein. Care is taken
not to place an excessive number of clips because of the potential of tearing the vessels. The
ON-Q Pain Relief System (Halyard Health, Alpharetta, GA) has two catheters, which are
placed freely in the pleural space and connected to a dispenser that delivers 0.25% bupivacaine
(Marcaine) at 4 mL/hr for 3 days. Alternatively, one catheter can be placed freely in the pleural
space and the other extrapleurally, adjacent to the entered intercostal space. A 1-0 Vicryl
suture is placed through the sternum and then through the transected cartilage. This suture
is tied, and then the same suture is placed in a figure-of-eight fashion from the transected
rib to the upper rib. Thereafter, 0 Vicryl sutures are used to approximate the intercostal muscle
to the periosteum of the rib. The sutures are continued laterally, incorporating as much of
the intercostal muscle as possible. The last suture is locked, and the second layer of the
closure approximates the fat pad that lies underneath the pectoralis muscle. This suture is
continued medially and locked again. The pectoralis muscle is then approximated in a two-layer
fashion. The skin is cosmetically closed in routine fashion11 (Fig. 10.16).
Figure 10.15
Figure 10.16
Figure 10.15 Blake chest tubes placed in pericardial space and pleural space.
Figure 10.16 Skin closure.

Step 3. Postoperative Management
◆ On arrival to the intensive care unit, a rapid ventilator weaning protocol is instituted, depending
on the patient’s condition. The amount of bleeding from the chest tubes is usually insignificant.
Chest tube drainage of more than 75 to 100 mL/hr is not common. If this occurs, reexploration
should be considered unless a coagulopathy is suspected or the patient is on clopidogrel
(Plavix). It is common for patients to have an air leak, which is caused by having two Blake
drains adjacent to each other and exteriorized through one chest tube incision. The drains,
pacing wire, and pain management catheters (ON-Q) are usually removed on the third day.
The drains are usually not removed earlier due to persistent serous drainage. Patients who
do not have coronary artery disease will be placed on nonsteroidal antiinflammatory drugs
for 3 weeks.
Step 4. Summary
◆ A minithoracotomy, minimally invasive aortic valve surgery, is a true sternal-sparing minimally

invasive procedure. Benefits include diminished ventilator time, reduced intensive care unit
and hospital lengths of stay.1-5,19,24 In addition, patients can return to their normal lifestyles
sooner because of less surgical trauma and improved chest wall stability, which allows them
to be more functional sooner compared to standard sternotomy patients. Other benefits
include less transfusions and analgesics and improved cosmesis.19,25 A decrease in the composite
complication rate in higher-risk patients (e.g., obese patients, patients > 75 years, patients
with COPD or low ejection fraction),1,2,4 as well as a decrease in surgical mortality, have been
documented.12,24 A minimally invasive valve program is an essential addition to any cardiac
surgical service and offers patients additional options for the treatment of aortic valve disorders.
In addition, it provides cardiac surgeons with alternative techniques to address concomitant
valvular and aortic pathologies. Considering the rapid development of transcatheter aortic
valve technology with direct access implants as a treatment option, as well as the future
availability of surgical sutureless aortic valves, the minithoracotomy approach is a useful
technique in our armamentarium. Finally, the ability to perform less invasive surgical techniques
such as this one is essential for surgeons who wish to remain relevant.
References
1. Lamelas J, Sarria A, Santana O, Pineda AM, et al. Outcomes of minimally invasive valve surgery versus median sternotomy in patients
75 years or greater. Ann Thorac Surg. 2011;91:79–84.
2. Santana O, Reyna J, Grana R, et al. Outcomes of minimally invasive valve surgery versus standard sternotomy in obese patients
undergoing isolated valve surgery. Ann Thorac Surg. 2011;91:406–410.
3. Schmitto JD, Mokashi SA, Cohn LH. Minimally-invasive valve surgery. J Am Coll Cardiol. 2010;56:455–462.
4. Santana O, Reyna J, Benjo AM, et al. Outcomes of minimally invasive valve surgery in patients with chronic obstructive pulmonary
disease. Eur J Cardiothorac Surg. 2012;42:648–652.
5. Glauber M, Miceli A, Bevilacqua S, Farneti PA. Minimally invasive aortic valve replacement via right anterior minithoracotomy: early
outcomes and midterm follow-up. J Thorac Cardiovasc Surg. 2011;142:1577–1579.
6. Cosgrove DM 3rd, Sabik JF. Minimally invasive approach for aortic valve operations. Ann Thorac Surg. 1996;62:596–597.
7. Johnston DR, Atik FA, Rajeswaran J, et al. Outcomes of less invasive J-incision approach to aortic valve surgery. J Thorac Cardiovasc
Surg. 2012;144:852–858.
8. Tabata M, Umakanthan R, Cohn LH, et al. Early and late outcomes of 1000 minimally invasive aortic valve operations. Eur J
9. Fenton JR, Doty JR. Minimally invasive aortic valve replacement surgery through lower half sternotomy. J Thorac Dis.
2013;5:S658–S661.
10. Burdett CL, Lage IB, Goodwin AT, et al. Manubrium-limited sternotomy decreases blood loss after aortic valve replacement surgery.
Interact Cardiovasc Thorac Surg. 2014;19:605–610.
11. Santana O, Reyna J, Benjo AM, Lamas GA, Lamelas J. Outcomes of minimally invasive valve surgery in patients with chronic
obstructive pulmonary disease. Eur J Cardiothoracic Surg. 2012;42:648–652.
12. Merk DR, Lehmann S, Holzhey DM, et al. Minimal invasive aortic valve replacement surgery is associated with improved survival: a
propensity-matched comparison. Eur J Cardiothorac Surg. 2015;47:11–17.
13. LaPietra A, Santana O, Pineda AM, et al. Outcomes of aortic valve and concomitant ascending aorta replacement performed via a
minimally invasive right thoracotomy approach. Innovations (Phila). 2014;9:339–342.
14. Pineda AM, Santana O, Lamas GA, Lamelas J. Is a minimally invasive approach for re-operative aortic valve replacement superior to a
standard full sternotomy? Interact Cardiovasc Thorac Surg. 2012;15248–15252.
15. Pineda AM, Santana O, Reyna J, et al. Outcomes of reoperative aortic valve replacement via a right mini-thoracotomy versus a median
sterntomy. J Heart Valve Dis. 2013;22:50–55.
16. Santana O, Pineda AM, Cortes-Bergoderi M, et al. Hybrid approach of percutaneous coronary intervention followed by minimally
invasive valve operations. Ann Thorac Surg. 2014;97:2049–2055.
17. Santana O, Funk M, Zamora C, et al. Staged percutaneous coronary intervention and minimally invasive valve surgery: results of a
hybrid approach to concomitant coronary and valvular disease. J Thorac Cardiovasc Surg. 2012;144:634–639.
18. LaPietra A, Santana O, Mihos CG, et al. Incidence of cerebrovascular accidents in patients undergoing minimally invasive valve
surgery. J Thorac Cardiovasc Surg. 2014;148:156–160.
19. Glauber M, Gilmanov D, Farneti PA, et al. Right anterior minithoracotomy for aortic valve replacement: 10-year experience of a single
center. J Thorac Cardiovasc Surg. 2015;150:548–556.
20. Madershahian N, Wippermann J, Sindhu D, Wahlers T. Unilateral re-expansion pulmonary edema: a rare complication following
one-lung ventilation for minimal invasive mitral valve reconstruction. J Card Surg. 2009;24:693–694.
21. Hahn RT, Abraham T, Adams MS, et al. Guidelines for performing a comprehensive transesophageal echocardiographic examination:
recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. J Am Soc
Echocardiogr. 2013;26:921–964.
22. Lou S, Ji B, Liu J, et al. Generation, detection and prevention of gaseous microemboli during cardiopulmonary bypass procedure. Int J
Artif Organs. 2011;34:1039–1051.
23. Matte GS, del Nido PJ. History and use of del Nido cardioplegia solution at Boston Children’s Hospital. J Extra Corpor Technol.
2012;44:98–103.
24. Glower DD, Desai BS, Hughes GC, et al. Aortic valve replacement via right minithoracotomy versus median sternotomy: a propensity
score analysis. Innovations (Phila). 2014;9:75–81.
25. 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.
CHAPTER
11

Aortic Root Enlargement

Techniques
John R. Doty, Sajjad Raza, and Joseph F. Sabik III
Introduction
◆ Aortic valve replacement (AVR) is one of the most commonly performed operations in cardiac
surgery. It is not only effective in alleviating symptoms in patients suffering from aortic valve
disease, but also improves survival. However, in patients with a small aortic annulus, the
benefits of this operation are dependent on the surgeon’s ability to avoid patient-prosthesis
mismatch (PPM). PPM was first described by Rahimtoola in 19781 as: “Mismatch can be
considered to be present when the effective prosthetic valve area, after insertion into the
patient, is less than that of a normal human valve.” Pibarot and Dumesnil2 defined PPM as
a prosthetic valve effective orifice area (EOA) indexed to a body surface area of less than
0.85 cm2/m2. PPM has been shown to be associated with a number of adverse outcomes,
including worse hemodynamic performance, reduced left ventricular mass regression, and
lower survival. If PPM is anticipated with the type of prosthesis that is being planned, the
surgeon can either implant another type of prosthesis with a larger EOA, such as a stentless
bioprosthesis, a new-generation mechanical prosthesis, or an aortic homograft, or he or she
can surgically enlarge the aortic root to accommodate a larger prosthesis of the same type.
◆ The well-known and documented repercussions regarding PPM3 have heightened the desire
of surgeons to master aortic root enlargement techniques. In this chapter, we will discuss the
commonly used aortic root enlargement techniques, including posterior enlarging techniques,
such as the Nicks4 and Manougian5 procedures, and anterior enlarging strategies such as the
Konno-Rastan aortoventriculoplasty and Ross-Konno AVR procedure.6-8 These techniques
increase the diameter of the aorta with a small annulus and allow the implantation of larger
prosthetic valves with better hemodynamic performance. In addition, some other surgical
considerations9-11 in patients with a small aortic root will also be discussed.
◆ It is important to evaluate adult patients for concomitant coronary artery disease with stress
testing and left heart catheterization. The coronary angiogram should be carefully studied for
anomalous origin of either main coronary artery, and the location of the first septal branch
of the left anterior descending artery should be identified if the pulmonary autograft operation
is under consideration.
156
Chapter 11 • Aortic Root Enlargement Techniques156.e1
Abstract
This chapter discusses the commonly used aortic root enlargement techniques that increase the
diameter of the aorta with small annulus and allow the implantation of larger prosthetic valves
with better hemodynamic performance. In addition, some other surgical considerations in patients
with small aortic root will also be discussed.
Chapter 11 • Aortic Root Enlargement Techniques 157
◆ The echocardiogram should be reviewed for evidence of left ventricular hypertrophy and to
assess left ventricular function. Careful preoperative measurement of the aortic annulus can
guide intraoperative valve sizing to avoid PPM and to identify patients in whom aortic root
enlargement is likely. Concomitant subaortic stenosis should be identified because this can
be addressed with myotomy/myectomy if required.
◆ The echocardiogram can also demonstrate concomitant poststenotic dilation of the ascending
aorta or a true ascending aortic aneurysm. If the pulmonary autograft operation is under
consideration, the pulmonary valve should be interrogated for insufficiency or other abnormali-
ties. It is important to note mitral valve structure and degree of insufficiency on the preoperative
echocardiogram because these may be altered with aortic root enlargement.
◆ Adult congenital patients, in particular, who may have a history of associated arch anomalies
may require a computed tomography (CT) or magnetic resonance imaging (MRI) scan to
ensure that these structures and potential anatomic anomalies are well defined.
◆ A resting electrocardiogram should be reviewed to identify any preoperative conduction
abnormalities. Patients should be evaluated for concomitant atrial fibrillation or other rhythm
disturbances that can be addressed during the operation.
◆ The aortic root consists of the aortic annulus, aortic cusps, aortic sinuses, and the sinotubular
junction. The aortic root represents the outflow tract from the left ventricle. It provides
supporting structures for the leaflets of the aortic valve and forms a bridge between the left
ventricle and ascending aorta. All aortic root enlargement procedures are described based on
an anatomic understanding of the coronary artery ostia, coronary sinuses, and commissures.
Special attention should be paid to the relationship of these structures to the conduction
system, the mitral valve and its apparatus, and the interventricular septum. In addition, the
ability to distinguish the membranous portion of the septum is of critical importance.
◆ The left ventricular outflow tract is best appreciated when viewed directly down into the aortic
annulus. The aortic valve and pulmonary valve, although closely related, have different planes.
The infundibular portion of the right ventricle elevates the plane of the pulmonary valve and
trunk above the aortic valve, placing the pulmonary valve higher and more posterior. The
aortic valve shares fibrous continuity with the anterior leaflet of the mitral valve (Fig. 11.1).
◆ The space between the fibrous attachments of the aortic valve leaflets is termed the interleaflet
triangle. These triangles are more flexible than the other segments of the aortic root (Fig.
11.2). The commissure between the right and left coronary cusps is usually located directly
across from the pulmonary artery, with a mirror image configuration of the pulmonary valve
cusps. The commissure between the right coronary cusp and noncoronary cusp is located
anteriorly and is closely related to the interventricular septum and the conduction system.
The commissure between the left coronary cusp and noncoronary cusp is located more
posterior and to the right. This commissure is located opposite the middle portion of the
anterior leaflet of the mitral valve (see Fig. 11.2).
◆ Various portions of the aortic valve are above, at, and below the true aortic annulus. The tops
of the commissures rest above the aortic annulus, well into the sinus portion of the aorta.
The central portions of the leaflets meet below the aortic annulus during diastole, within the
left ventricular outflow tract. The true aortoventricular junction is between these two levels
(Fig. 11.3).
◆ The right coronary artery arises from the right coronary sinus and courses rightward in the
atrioventricular groove. The left main coronary artery is short and branches immediately into
the left circumflex and left anterior descending arteries. The left circumflex artery courses
laterally in the atrioventricular groove, being near the posterior mitral annulus. The left
anterior descending artery lies posterior to the pulmonary artery in its proximal portion before
coursing down the anterior interventricular groove. The first septal branch of the left anterior
descending artery lies directly behind the posterior leaflet of the pulmonary valve (Fig. 11.4).
Left ventricle Right ventricle
Superior
vena cava
Anterior
leaflet of Interleaflet
mitral triangle
valve
Inferior
vena cava
First septal
branch
Ventricular
septum
Interleaflet
triangle
Course of left
coronary artery
1. Left Ventricular Outflow Tract Exposure
◆ Of paramount importance, regardless of any proposed technique, is exposure of the left

ventricular outflow tract. In many cases a complete division of the ascending aorta, approximately
1 cm above the sinotubular junction, provides excellent exposure to the aortic valve and left
ventricular outflow tract. Alternatively, a spiraling-type incision down into the noncoronary
sinus may be used if extensive enlargement is not anticipated.
◆ The aortic valve is excised and the annulus is débrided. A careful determination is made as
to the minimum size of prosthesis that would be acceptable for the patient’s body size. If root
enlargement is indicated to achieve an adequately sized prosthesis, the appropriate technique
is used.
2. Root Enlargement
◆ Posterior enlargement of the aortic root is performed by either the Nicks-Nunez or Rittenhouse-
Manouguian technique (Fig. 11.5). Both approaches are arguably the most commonly accepted
and widely used techniques for aortic root enlargement and will be a large focus of this
chapter. The Nicks-Nunez method is a vertical incision through the commissure between the
left coronary cusp and noncoronary cusp, extending down into the interleaflet triangle. Limiting
the incision to just the interleaflet triangle can enlarge the root sufficiently by 2 to 3 mm. If
greater enlargement is required, the incision can be extended further into the anterior leaflet
of the mitral valve and the roof of the left atrium. The Rittenhouse-Manouguian method is a
vertical incision through the midportion of the noncoronary sinus, through the aortic annulus
and into the anterior leaflet of the mitral valve and roof of the left atrium. The incisions in
the anterior leaflet of the mitral valve can be extended almost to the free edge of the leaflet,
dramatically enlarging the outflow tract.
◆ Anterior enlargement of the aortic root, or aortoventriculoplasty, is performed according to
the technique described by Konno and Rastan (Fig. 11.6). A vertical aortotomy is performed,
and the incision is continued into the right coronary sinus, well leftward of the right coronary
artery. The incision is then extended through the aortic annulus, near the commissure, between
the right and left coronary leaflets. The incision is carried into the interventricular septum
only as far as necessary to achieve the desired enlargement. Deep incisions place the first
septal branch of the left anterior descending artery at risk for injury. A second incision is
made on the right ventricular free wall to enlarge the right ventricular outflow tract.
Nicks-Nunez technique Rittenhouse-Manouguian technique

Figure 11.5
Konno-Rastan technique
Figure 11.6
3. Root Reconstruction
Nicks-Nunez Technique, Patch Reconstruction
◆ After the aortic root has been enlarged sufficiently, a diamond-shaped patch of autologous
pericardium, prosthetic material, or composite of both is fashioned. One end of the patch is
inserted into the distal end of the enlargement at the level of aortic-mitral continuity if the
incision is only into the interleaflet triangle. Interrupted sutures with pledgets are preferred
because the interleaflet triangle lacks fibrous strength. The sutures are then passed through
the sewing ring of the aortic valve prosthesis. The remainder of the valve sutures are placed
through the aortic annulus in standard fashion (Fig. 11.7).
◆ The patch is then tailored for closure of the aortotomy if a spiraled incision has been used,
or it is transected flat at the level of the transverse aortotomy and incorporated as part of the
reanastomosis of the aortic root to the ascending aorta (Fig. 11.8).
Prosthetic
valve
Prosthetic
patch
A B
Three pledgeted sutures
C D
Figure 11.7
Patch
(anterior)
Patch
(posterior)
Close
aortotomy
A B
Figure 11.8
◆ If the incision has been carried farther into the left ventricular outflow tract by crossing into
the anterior leaflet of the mitral valve and left atrium, reconstruction is begun by placing the
patch into the deepest portion of the incision. The defect in the anterior leaflet is repaired
with the patch. Interrupted sutures without pledgets are used for accuracy and strength
(Fig. 11.9).
◆ At the level of the aortic annulus, interrupted sutures with pledgets are placed and passed,
first through the patch and then through the prosthetic valve. The remainder of the valve
sutures are placed through the aortic annulus in standard fashion. If the left atrial wall is
flexible, and the defect is small, the left atrial wall can be approximated directly to the patch.
Otherwise, a second patch is fashioned to reconstruct the left atrial defect (Fig. 11.10).
◆ The patch is then tailored for closure of the aortotomy or incorporated as part of the aortic
reanastomosis, as previously described.
Rittenhouse-Manouguian Technique, Patch Reconstruction
◆ After enlargement of the root by extending the incision across the noncoronary portion of
the aortic annulus into the anterior leaflet of the mitral valve and roof of the left atrium, a
diamond-shaped patch of either autologous pericardium or prosthetic material (e.g., polytet-
rafluoroethylene [PTFE] or Dacron) is fashioned. As with the Nicks-Nunez method, reconstruc-
tion is begun by placing the patch into the deepest portion of the incision. The defect in the
anterior leaflet is repaired with the patch, using interrupted or continuous sutures without
pledgets for accuracy and strength (Fig. 11.11).
Prosthetic
valve
Mitral valve
Left atrium
Prosthetic
patch
PTFE
Dacron patch
A B
Figure 11.11
◆ At the level of the aortic annulus, interrupted sutures with pledgets are placed and passed,
first through the patch and then through the prosthetic valve (Fig. 11.12A). The remainder
of the valve sutures are placed through the aortic annulus in standard fashion (see Fig. 11.12B).
If the left atrial wall is flexible, and the defect is small, it can be approximated directly to the
patch. Otherwise, a second patch is fashioned to reconstruct the left atrial defect (see Fig.
11.12C).
◆ The patch is then tailored for closure of the aortotomy if a spiraled incision has been used,
or it is transected flat at the level of the transverse aortotomy and incorporated as part of the
reanastomosis of the aortic root to the ascending aorta.
Konno-Rastan Aortoventriculoplasty
◆ The aortic root is mobilized by careful dissection anteriorly between the right coronary sinus
and the pulmonary artery. This dissection is performed to the left side of the right coronary
artery and is carried down to the level of the aortic annulus. The aortic root is enlarged with
an incision through the right coronary portion of the aortic annulus, near the commissure,
between the right and left coronary cusps. The incision is deepened into the interventricular
septum, and a matching incision is made on the right ventricular free wall to enlarge the
right ventricular outflow tract (Fig. 11.13).
◆ A diamond-shaped patch of prosthetic material is fashioned and placed deep into the inter-
ventricular septal incision. Continuous sutures are used to attach the patch to the ventricular
muscle, up to the level of the aortic annulus (Fig. 11.14).
Prosthetic
valve
Left atrium
Aortic valve
replaced
A B
C
Figure 11.12
Patch for
Septal incision ventricular septum
Right
ventricle
Septum
Aortic
valve
◆ A second triangular patch is fashioned. Interrupted sutures with pledgets are used to attach
the base of the triangular right ventricular outflow tract patch to the junction of the diamond-
shaped left ventricular outflow tract patch at the level of the aortic annulus. The sutures are
then passed through the sewing ring of the prosthetic valve (Fig. 11.15). The remainder of
the valve sutures are placed through the aortic annulus in standard fashion, and the prosthesis
is secured into position.
◆ The right ventricular outflow tract patch is then folded over the right ventricular free wall
defect, and continuous sutures are used to attach the patch to the ventricular muscle. The
left ventricular outflow tract patch is tailored to close the defect in the aorta using the continuous
suture technique (Fig. 11.16).
Aortic Allograft—Full Root Technique With Anterior Leaflet of the Mitral Valve
◆ The aortic allograft is prepared with the attached, intact, anterior leaflet of the mitral valve.
A small rim of donor left atrial tissue is also usually present and should be retained on the
allograft. The remnants of the chordae are removed from the allograft anterior leaflet. In this
fashion, the allograft can be used to reconstruct very large defects of the aortic root and
enlarge the root substantially.
◆ The aortic valve and sinus tissue are removed. The coronary arteries are mobilized on generous
buttons of sinus tissue. The left ventricular outflow tract is enlarged posteriorly with either
a Nicks-Nunez or Rittenhouse-Manouguian incision extending down into the anterior leaflet
of the mitral valve (Fig. 11.17).
Second patch for

Prosthetic right ventricular
valve outflow tract
Aortic valve Aorta and right ventricular

replacement complete outflow tract enlarged
A B
Figure 11.16
◆ The anterior leaflet of the allograft is inserted into the defect in the patient’s anterior leaflet
and attached using interrupted sutures, without pledgets, for accuracy and strength. Care
and precision are used for this reconstruction to avoid distorting the mitral valve and causing
undue tension (Figs. 11.18 and 11.19).
◆ The allograft is attached to the left ventricular outflow tract using interrupted sutures for
accuracy. This proximal suture line is then reinforced with biologic glue. If the left atrial wall
is flexible, and the defect is small, it can be approximated directly to the rim of the atrial wall
of the allograft. Otherwise, a patch of autologous pericardium or allograft aorta is fashioned
to reconstruct the left atrial defect (Fig. 11.20).
◆ The coronary artery buttons are attached in the appropriate position to the aortic allograft
with continuous sutures. The allograft is attached to the ascending aorta with continuous
sutures, and all suture lines are reinforced with biologic glue.
Ross-Konno Reconstruction
◆ Severe hypoplasia of the left ventricular outflow tract in young patients can be successfully
managed with combined aortoventriculoplasty and pulmonary autograft replacement of the
aortic valve.
◆ Bicaval cannulation and cardiopulmonary bypass are initiated, and a transverse aortotomy is
performed after cardioplegic arrest. The aortic valve is excised, and the annulus is débrided.
The sinus tissue is removed, and the coronary arteries are mobilized on generous buttons of
sinus tissue. The pulmonary artery is carefully dissected off the aorta and top of the right
ventricle until the ventricular muscle fibers are identified, running in a perpendicular orienta-
tion. This portion of the dissection is begun at the commissure between the left and right
coronary cusps and carried underneath the pulmonary artery. The pulmonary artery is transected
near the bifurcation, and the pulmonary valve is carefully inspected.
◆ A small right-angled clamp is passed well below the pulmonary annulus, along the line with
the anterior commissure. The clamp is pushed out through the right ventricular free wall,
and the right ventricle is divided well below the pulmonary annulus, with direct visualization
of the pulmonary valve leaflets. Scissors are used to divide the right ventricular outflow tract
anteriorly, leaving a generous portion of the free wall with the autograft. Sharp dissection of
the ventricular septum with a knife is used to separate the pulmonary trunk from the right
ventricle to protect the first septal branch of the left anterior descending coronary artery.
Mitral valve Mitral valve

remnant
Left atrium
Entire anterior
leaflet of mitral valve
Anterior leaflet of
mitral valve
Intact
noncoronary
sinus
A B
Figure 11.18
Graft aorta

◆ A vertical incision is made through the aortic annulus, near the commissure between the
right and left coronary leaflets. The incision is carried into the interventricular septum to
enlarge the left ventricular outflow tract (Fig. 11.21). The right ventricular muscle portion
of the autograft is inserted deep into the left ventricular outflow tract (Fig. 11.22A), and
interrupted sutures are used to attach it to the defect in the interventricular septum (see Fig.
11.22B). The autograft is then attached to the aortic annulus with interrupted sutures. The
sutures are secured, and the suture line is reinforced with biologic glue.
◆ The coronary arteries are reimplanted onto the autograft in the appropriate position using a
continuous suture technique. The autograft is anastomosed to the ascending aorta with a
continuous suture technique, and the suture lines are reinforced with biologic glue.
◆ The right ventricular outflow tract is measured, and an appropriately sized pulmonary homograft
is selected. The distal end of the pulmonary homograft is attached to the bifurcation of the
patient’s pulmonary artery with continuous sutures. The proximal portion of the pulmonary
homograft is attached to the right ventricular outflow tract using continuous sutures. Part of
the suture line may include the pulmonary autograft. If additional enlargement of the right
ventricular outflow tract is necessary, a patch of autologous pericardium is used to augment
the right ventricular free wall.
Incision into ventricular septum

Figure 11.21
Pulmonary trunk attached

to ventricular septum
A B
Figure 11.22
Step 4. Other Considerations
1. Two-Directional Enlargement
◆ In patients for whom the conventional posterior root enlargement technique is not wide
enough to implant a prosthetic valve of desired size, two-directional enlargement involving
a combination of both posterior and anterior enlargement techniques could be used9 (Fig.
11.23). For this technique, the posterior enlargement is performed first, and then an additional
aortotomy is made anteriorly and extended to the ventricular septum. The aortic annulus
could be enlarged by 68% after this two-directional enlargement technique.
◆ The aortotomy is made obliquely toward the noncoronary sinus. The aortic annulus is measured
with dilators after removal of the aortic valve, and posterior enlargement is performed according
to the Nicks or Manouguian procedure. An additional anterior enlargement is then made just
to the commissure, between the left and the right coronary cusps. Reconstruction of the
annulus and repair of the aortotomy are carried out with a bifurcated Dacron patch.
2. Myectomy or Myotomy
◆ In patients for whom the preoperative evaluation has also revealed subaortic narrowing or
obstruction, a concomitant myotomy or myectomy may be an option, in addition to AVR.
Exposure is obtained by either an aortotomy or a complete transection of the ascending aorta.
The coronary artery ostia are then identified to avoid any iatrogenic injury. In addition, the
valve leaflets, commissures, and area of the presumed conduction system are also well identified
and protected during the process of myectomy or myotomy.
◆ Optimal visualization of the ventricular septum is facilitated by posterior displacement of the
anterior wall of the left ventricle with a sponge or sponge stick. A small suction cannula may
also be placed across the aortic annulus to retract the anterior mitral valve leaflet and papillary
muscles posteriorly and rightward away from the ventricular septum. The myotomy or myectomy
incision is made using a no. 11 blade scalpel, beginning the incision at the midventricular
level and extending upward to within 8 to 10 mm of the nadir of the annulus of the right
coronary cusp (Fig. 11.24). Any incision made at the base of the ventricular septum that is
more rightward than the nadir of the right cusp will injure the membranous septum and
conduction tissue, with concerns for resultant complete heart block. A second longitudinal
incision parallel to the first incision is made to be carried up to within 8 to 10 mm of the
aortic annulus, at the commissure between the right and left coronary cusps. The area to the
left of this incision is the left ventricular free wall. These two incisions are joined superiorly,
and a hook may be used to allow for better traction of the proposed resected muscle, which
can be easily elevated. A deep wedge of septum is then resected, beginning at the base of the
septum and working toward the midventricle.
◆ By carefully understanding preoperative transthoracic echocardiography (TTE) and/or trans-
esophageal echocardiography (TEE) measurements, care can be taken to avoid the iatrogenic
creation of a ventricular septal defect.
Figure 11.23 Otaki M, Oku H, Nakamoto S, et al. Two-directional aortic annular enlargement for aortic valve
replacement in the small aortic annulus. Ann Thorac Surg. 1997;63:261–263.
RCA
Figure 11.24 Messmer BJ. Extended myectomy for hypertrophic obstructive cardiomyopathy.
Ann Thorac Surg. 1994 Aug;58(2):575-7.
3. Bentall-Type Aortic Upsizing Procedures
◆ In patients with a small aortic annulus that needs aortic root replacement, Bentall-type aortic
upsizing procedures can be considered.10,11
◆ Standard postoperative management in the intensive care unit includes ventilator support,
continuous cardiac output monitoring with a pulmonary artery catheter, and other routine
care measures for a cardiac surgical patient. Right and left atrial pressure lines are useful for
direct continuous measurement of atrial pressures.
◆ A judicious balance between fluid resuscitation and inotropic support is required. Many of
these patients have left ventricular hypertrophy, and administration of relatively small amounts
of intravenous fluids will drastically alter filling pressures. In addition, the thick ventricular
myocardium is sensitive to inotropes and may be irritable after intraoperative myocardial
ischemia. The preoperative status of left ventricular hypertrophy and function, in addition to
the appearance of the left ventricle on TEE during completion of the procedure, will allow
for a framework to drive decision making.
◆ Efforts should be made to avoid hypertension because this will place undue strain on the
suture lines of the left ventricular outflow tract reconstruction. Placement of an intraaortic
balloon pump is preferable to high doses of inotropes and aggressive fluid resuscitation.
◆ A high index of suspicion for coronary insufficiency should be held for every patient, whether
a full root replacement or simple AVR was performed. Full root replacement with coronary
reimplantation can result in kinking of a coronary artery. Prosthetic valve replacement can
result in coronary ostial obstruction by a valve stent or sewing ring.
◆ The typical presentation of coronary insufficiency is the inability to wean from cardiopulmonary
bypass. Intraoperative TEE is essential to demonstrate impaired ventricular function, with or

without electrocardiographic evidence of coronary ischemia. If a simple valve replacement
was performed, the prosthesis should be removed and reinserted or a different prosthesis
selected. If a full root replacement was performed, the safest approach is to perform coronary
artery bypass surgery on the affected coronary artery.
◆ Careful and thoughtful preoperative and intraoperative planning will avoid PPM. A value of
less than 0.85 is indicative of PPM and may result in reduced recovery of the left ventricle
early and late after operation. Effort should be made to keep the ratio above 1.0 for all patients.
◆ Root enlargement and root replacement operations are extensive operations, with multiple
suture lines outside the heart exposed to systemic arterial pressure. The application of biologic
glue can help control intraoperative bleeding by sealing the needle holes. Biologic glue does
not seal gaps in an anastomosis, and this feature allows identification of areas that require
additional suture or pledgets to control hemostasis. A thorough survey of all suture lines,
especially those located in the difficult to reach and visualized posterior locations and around
the coronary buttons, should be completed prior to the administration of protamine and
other blood products.
◆ The first septal branch of the left anterior descending artery should be meticulously preserved
during pulmonary autograft harvest and pulmonary homograft implantation. Injury to the
first septal branch can result in significant left ventricular dysfunction, which may not fully
recover over time.
◆ The incisions described in this chapter for root enlargement are placed in areas of the aortic
root that avoid the conduction system. Particular attention should be paid to the area below
the commissure, between the right and noncoronary leaflets, extending leftward under the
right coronary artery ostium, to avoid injury to the conduction system. In addition, attempts
to insert a rigid valve prosthesis tightly into a small aortic annulus can produce excessive
pressure on the conduction system, resulting in dysfunction or heart block.
◆ Due to the significant challenges of future reoperation on the aortic root following any form
of enlargement procedure, great care should be taken to ensure appropriate decision making
regarding prosthesis selection. Surgeons should be well versed in the long-term outcomes of
the various valve prostheses that may be used in the operation.
◆ Surgeons should be prepared to perform extensive reconstruction of the aortic root and
ascending aorta, as indicated during surgery. The best long-term outcomes can be expected
by addressing all associated pathologic processes at the initial operation, rather than leaving
behind conditions that could result in early reoperation.
References
1. Rahimtoola SH. The problem of valve prosthesis—patient mismatch. Circulation. 1978;58:20–24.
2. Pibarot P, Dumesnil JG, Lemieux M, et al. Impact of prosthesis-patient mismatch on hemodynamic and symptomatic status, morbidity
and mortality after aortic valve replacement with a bioprosthetic heart valve. J Heart Valve Dis. 1998;7:211–218.
3. Pibarot P, Dumesnil JG. Prosthesis-patient mismatch: definition, clinical impact, and prevention. Heart. 2006;92(8):1022–1029.
4. Nicks R, Cartmill T, Bernstein L. Hypoplasia of the aortic root: the problem of aortic valve replacement. Thorax. 1970;25:339–346.
5. Manougian S, Seybold-Epting W. Patch enlargement of the aortic valve ring by extending the aortic incision into the anterior mitral
leaflet. J Thorac Cardiovasc Surg. 1979;78:402–412.
6. Konno S, Imai Y, Lida Y, et al. A new method for prosthetic valve replacement in congenital aortic stenosis associated with hypoplasia
of the aortic valve ring. J Thorac Cardiovasc Surg. 1975;70:909–917.
7. Rastan H, Koncz J. Aortoventriculoplasty: a new technique for the treatment of left ventricular outflow tract obstruction. J Thorac
8. Reddy VM, Rajasinghe HA, Teitel DF, et al. Aortoventriculoplasty with the pulmonary autograft: the Ross-Konno procedure. J Thorac
9. Otaki M, Oku H, Nakamoto S, et al. Two-directional aortic annular enlargement for aortic valve replacement in the small aortic
annulus. Ann Thorac Surg. 1997;63:261–263.
10. Usui A, Ueda Y. Biological Bentall procedure with a Valsalva graft for a small aortic root. Eur J Cardiothorac Surg. 2008;34:224–225.
11. Albertini A, Dell’Amore A, Zussa C, Lamarra M. Modified Bentall operation: the double sewing ring technique. Eur J Cardiothorac
Surg. 2007;32:804–806.
CHAPTER
12
Aortic Valve Repair

Maria Lorena Rodriguez, Gebrine El Khoury,
and Munir Boodhwani
Step 1. Introductory Considerations
◆ Aortic valve repair (AVr) has been shown to have a lower rate of valve-related complications
compared to aortic valve replacement (AVR).1-3
◆ It is especially beneficial for those in the younger age group due to a higher rate of bioprosthetic
degeneration in the case of AVR and the cumulative risk of thromboembolism and bleeding
in mechanical aortic valves.3
◆ The aortic valve (AV) is comprised of the functional aortic annulus and cusps.
◆ The functional aortic annulus is comprised of the sinotubular junction (STJ) and ventriculoaortic
junction (VAJ4,5; Fig. 12.1).
◆ The basal ring is the plane that passes through the nadir of the aortic cusps.
◆ At the right noncoronary commissure, the membranous septum is the border of dissection
for the VAJ. At the left-right coronary commissure, the ventricular muscle is the border for
VAJ dissection. These anatomic borders illustrate why the VAJ does not reach the basal ring.
◆ The VAJ level approximates the basal ring level at the noncoronary sinus (NCS), noncoronary
left commissure, and left coronary sinus (LCS).
177
Chapter 12 • Aortic Valve Repair177.e1
Abstract
Aortic valve repair has been shown to yield good outcomes for select patients when performed
by trained surgeons. In this chapter, we will discuss the surgical anatomy of the aortic valve,
the surgical steps to aortic valve repair, as well as the pre-, intra-, and postoperative considerations
that need to be addressed for a successful repair.
Keywords
aortic valve
repair
aortic valve surgery
cardiac surgery
Left coronary
ostium
STJ
VAJ
Noncoronary
cusp
Right coronary
artery
NCC LCC RCC
Ventriculoaortic junction
Basal ring
Membranous Fibrous Ventricular Membranous

B portion portion muscle portion
Figure 12.1 B, From Boodhwani M, El Khoury G: Aortic valve repair. Operative techniques in thoracic and
cardiovascular surgery. 2009.
Figure 12.1 (A) Aortic valve anatomy. (B) Ventriculoatrial junction.

Chapter 12 • Aortic Valve Repair 179
◆ The aortic cusp geometric height is the maximum tissue height. The effective height measures
from the basal ring plane to the level of the central coaptation of the cusps (Fig. 12.2). The
noncoronary cusp (NCC) is higher than the right coronary cusp (RCC) and left coronary
cusp (LCC).4,6
◆ The AV cusp coaptation normally occurs at the midlevel, between the STJ and VAJ.4,7,8 Effective
cusp coaptation length is 2 to 6 mm.4,7

◆ Cusp mobility is a function of the free margin length in relation to the length of annular cusp
insertion.4 These lengths are adjusted appropriately during a repair to reestablish valve
competency while ensuring good mobility.
◆ Alteration in one component of the AV leads to alteration in the others. Each component
should be seen in relation to the others.

◆ A repair-oriented classification of aortic insufficiency (AI) has been developed to guide patient
selection and treatment3 (Fig. 12.3).

◆ Various forms of cusp division and fusion can occur, resulting in unicuspid, bicuspid, and
quadricuspid anomalies, which may be associated with aortopathy and congenital cardiac
diseases.
◆ The most common cause of AI is dilation of the functional aortic annulus. Thus, a focused
history on the presence of hypertension, family aortic and connective tissue disorders, and
the acuity of signs and symptoms will help with management. A history of infective endocarditis,
or rheumatic heart disease or the presence of myxomatous mitral disease may infrequently
be associated.
◆ Preoperative echocardiography (echo) is essential for identifying the cause of the AI and will
help guide the intraoperative evaluation. It should be able to demonstrate the aortic root and
ascending aorta dimensions. The echocardiogram will also be able to show the anatomy of
the cusps and the presence of prolapse, fenestrations, bands, calcifications, and vegetations.
The quality and direction of the AI jet should also be examined.
a Effective height
b Coaptation length
c Geometric height
a b c
Figure 12.2
Type I Type II Type III

Normal cusp motion with FAA dilatation or cusp perforation Cusp Cusp
Al Class Prolapse Restriction
la lb lc ld
Mechanism
Prolapse
Aortic Valve Repair Leaflet
Patch Repair
STJ sparing: Repair
Repair Free Margin
remodeling Reimplantation Plication
Techniques SCA Autologous or
Ascending or Shaving
(Primary) Remodeling bovine Decalcification
Aortic Graft Triangular
with SCA pericardium Patch
Resection
Free Margin
Resuspension
STJ
(Secondary) SCA SCA SCA SCA
Annuloplasty
Figure 12.3 From Boodhwani M, El Khoury G: Aortic valve repair. Oper Tech Thorac Cardiovasc Surg. 2009.
Figure 12.2 The coaptation height and length and geometric height of the AV leaflets.
Figure 12.3 Functional classification of aortic valve insufficiency.

◆ Cusp prolapse occurs when one or more cusps coapt below the normal height of coaptation,
at the midheight of the sinus of Valsalva. The presence of an eccentric jet is a sensitive indicator
of prolapse. The presence of a fibrous band is a very specific sign of cusp prolapse and identifies
the prolapsing cusp8 (Fig. 12.4).
◆ In patients in whom the aortic dimensions are borderline, a preoperative chest computed
tomography (CT) scan will aid in a more definitive measurement of the dimensions.
1. Surgery
Isolated Aortic Insufficiency8
◆ A transverse aortotomy is performed, 1 cm from the STJ, leaving 2 to 3 cm of posterior aorta
intact. The distal aorta is retracted cephalad for a better exposure of the AV; 4-0 polypropylene
sutures are placed at the level of each commissure (Fig. 12.5).
◆ Axial traction (perpendicular to the annular plane) is placed on the commissural retraction
sutures to assess the AV. The AV anatomy is thoroughly examined, including the cusp coaptation,
amount of excess tissue, leaflet mobility, presence of restrictions and calcifications, and bands.
The characteristic of the aortic sinuses are likewise examined for suggestions of aneurysmal
degeneration such as wall thinning and coronary ostia displacement (Video 12.1).
◆ A prolapsing cusp can be identified by the presence of excess free margin length and, occasion-
ally, a transverse fibrous band.

◆ Radial traction (parallel to the annular plane) is then applied to the commissural stitches,
and the center of the cusp free margin is pushed gently to the left ventricle. A nonprolapsing
cusp will remain at the physiologic level, which is halfway between the cusp base and its
maximal height at the commissure. A prolapsing cusp will be able to be pushed lower into
the left ventricle due to excessive amounts of tissue.
◆ Cusp repair is then performed using free margin plication or resuspension or both. Annular
stabilization can be performed with a subcommissural annuloplasty (SCA) or external or

internal ring.
A B
C D
Figure 12.4 From Assessment and repair of aortic valve cusp prolapse: implications for valve-sparing procedure. J Thorac Cardiovasc
Surg 2011;141:917-25.
Figure 12.5
Figure 12.4 Transeosphageal echocardiographic images. (A) Eccentric aortic insufficiency jet. (B) Cusp prolapse and fibrous band (white
arrow). (C) Fibrous band (white arrow). (D) Fibrous band (black arrow).
Figure 12.5 Aortic valve exposure using axial traction.

Cusp Prolapse Repair9-11
◆ A 7-0 polypropylene suture is passed through the center of the two nonprolapsing cusps
which will serve as reference. Gentle axial traction is applied to the reference cusps, and the
prolapsing cusp is pulled parallel to the reference cusp. A 6-0 polypropylene suture is passed
through the prolapsing cusp from the aortic to the ventricular side, where it meets the center
of the reference cusp. The direction of traction is then reversed, and the same suture is passed
from the ventricular to the aortic side at the point where it meets the middle of the reference
cusp. This excess free margin is then plicated by tying the suture with the excess tissue on
the aortic side. Further plication is done until it is 5 to 10 mm onto the body of the aortic
cusp, using interrupted or running locked 6-0 polypropylene sutures. Significant excessive
tissue may be resected before the plication (Fig. 12.6; Video 12.2).
◆ In the case of two prolapsing cusps, a 6-0 suture is passed through the center of the free
margin of the reference nonprolapsing cusp. One prolapsed cusp is then pulled parallel to
the reference cusp, and a 6-0 suture is passed through the free margin at the point where it
meets the center of the reference cusp. Then the suture is passed back through the cusp at
an equivalent distance from that cusp’s center, toward the other side. Plication then proceeds
as above and is repeated for the second prolapsing cusp.
◆ In the case of all three cusps prolapsing, careful surgical art and judgment are applied, with
the goal of plicating the free margins enough so that the cusps coapt at the midpoint level
of the aortic sinuses.
A B
C D
Figure 12.6 From Boodhwani M, El Khoury G: Aortic valve repair. Operative techniques in
thoracic and cardiovascular surgery. 2009.
Figure 12.6 Cusp repair: central margin plication. (A) A polypropylene 7-0 suture is passed through the center of the two nonprolapsing
reference cusps and gental axial traction is applied. The prolapsing cusp is then pulled parallel to the reference cusp and a polypropylene
6-0 suture is passed through the prolapsing cusp, from the aortic to the ventricular side, at the point where it meets the center of the
reference cusp. (B) The direction of the traction is reversed, and the same suture is passed from the ventricular to the aortic side of the
cups where it meets the middle of the reference cusp. (C) The excess free margin which is now delineated is plicated by tying the suture,
leaving the excess tissue on the aortic side. (D) The plication is extended 5-10 mm onto the body of the cusp by additional interrupted or
running locked polypropylene 6-0 sutures.
◆ Resuspension of the free margin allows symmetric shortening and reinforcement, which is
particularly useful if there are cusp stress fenestrations. A 7-0 polytetrafluoroethylene suture
is passed through the free margin, 0.5 to 1 mm from the edge. A second suture is passed 1
to 1.5 mm below the first, going beyond the fenestration if there is one.12 When appropriate
correction has been reached, the two sutures are tied at the opposite ends (Fig. 12.7).
◆ Decalcification is done to optimize leaflet mobility. A no. 11 blade is used to shave off the
calcium through a plane in the leaflet, taking care to avoid perforation. Excessive calcification,
restriction, and fibrosis do not result in a good valve repair and is an indication to proceed
with valve replacement.
◆ Type III lesions with limited calcification and fibrosis may be amenable for repair through
decalcification, resection, and patching. Cusp perforations may also be repaired with a patch.
A pericardial patch is trimmed to resemble the defect in shape, with an additional 2-mm
margin around it. This is secured to the aortic surface of the cusp using a continuous Prolene
5-0 or 6-0 suture. As yet, there is no proven benefit for the use of one type of patch material
or another. Nontreated autologous pericardium is preferred for simple repair and bovine
pericardium for complex repair.13 AV repairs necessitating a patch are at higher risk of failure,
possibly due to the progression of the inherent disease of the leaflet, as well as deterioration
of the patch material (Fig. 12.8).
A B
C D
E F
Figure 12.7 From Boodhwani M, El Khoury G: Operative techniques in thoracic and cardiovascular
surgery. 2009.
Pericardial patch
for cusp restoration
Figure 12.8
Figure 12.7 Cusp repair: resuspension of the free margin. (A) A polypropylene 7-0 suture is passed through the center of the two
nonprolapsing reference cusps and gentle axial traction is applied. (B) A Gore-Tex 7-0 suture is passed twice on the top of the commissures
of the prolapsing cusp. (C) One arm of each of the sutures are then passed using a running technique over and through the length of the
free margin. (D) Using gentle traction on the sutures and an opposite traction on the middle of the free margin, the first half of the free
margin is shortened by wrinkling the tissue until it reaches the same length as the adjacent reference cusp. (E) Wrinkling is then done on
the second half using the same technique, allowing symmetric shortening. (F) The suture ends are passed through the aortic wall and tied.
Figure 12.8 Pericardial patching using autologous or bovine pericardial patch.

Annular Stabilization8,14
◆ Annular stabilization improves the durability of AV repair by stabilizing and reducing the
diameter of the VAJ and STJ, thereby increasing cusp coaptation. The most durable is
the prosthesis-based annuloplasty that is part of a valve-sparing root replacement (see the
following).
◆ SCA is simple and reproducible. It is done using pledgeted braided sutures, with the first
arm passed from the aortic to the ventricular side, into the interleaflet triangle, and coming
out on the other side of the commissure on the same level as the entry point. The second
arm of the suture is passed in a similar fashion, just below the first. The opposite pledget is
placed, and the suture is tied. This is done for all the interleaflet triangles. The annuloplasty
effect is greater if the SCA sutures are placed closer to the VAJ. Typically, SCA sutures are
placed between the upper and middle thirds of the height of the interleaflet triangle (Fig.
12.9; Video 12.3).
◆ The use of basal rings, both external and internal, is still under study. External rings are
flexible circumferential bands implanted around the lowest outer portion of the aortic root,
with the interrupted sutures passed from inside the root, 1 to 2 mm below the cusp. Internal
rings are implanted 1 to 2 mm below the cusps, with the sutures tied externally at the base
of the aortic root.
◆ Although annular stabilization provides durability to the AV repair, care should be taken to
avoid overreduction, which could lead to aortic stenosis but may also cause cusp prolapse
and AI. Internal rings also have a theoretical increased risk for thromboembolic events.
Pledgeted
subcommisural
annuloplasty sutures
NCC LCC RCC
B
Figure 12.9 B, From Boodhwani M, El Khoury G: Operative techniques in thoracic and
Figure 12.9 Subcommisural annuloplasty. (A) Passing the sutures from one sinus to the other. (B) Illustration of the placement of the
pledgeted sutures in relation to the interleaflet triangle.
Aortic Insufficiency Associated With Aortic Root Aneurysm
◆ The aorta is transected 1 cm from the STJ. An initial assessment of the aortic root and valve
cusps are done (as described previously) to assess for the viability of repairing the valve and
of preserving or replacing the root. In the case of borderline clinical indications for aortic
root aneurysm, the presence of thinned-out aortic sinuses and displacement of one or both
coronary ostium guides us to performing a root replacement. If the AV is deemed reparable,
the aortic root replacement is first performed through a reimplantation or remodeling
technique.
◆ Graft sizing is critical to achieve correct alignment of the AV structures. One method is to
apply adequate radial and axial traction on the commissural sutures to re-create the most
competent valve configuration and then measuring the STJ in this position using a Hegar
dilator or Freestyle valve sizer (Medtronic, Minneapolis; Fig. 12.10). Another simple but
effective method is by measuring the height of the interleaflet triangle at the NCC-LCC
commissure. This height would approximate the VAJ diameter, STJ diameter, and graft size
Valve sizer
Figure 12.10
Figure 12.10 Graft sizing using a Freestyle valve sizer.

of a Valsalva graft (Vascutek Ltd, Renfrewshire, Scotland, UK). In case of noncorrespondence

of graft size, one size above is chosen15 (Fig. 12.11A–D). The Valsalva graft is then patterned
according to the height of the two other commissures (see Fig. 12.11E).
◆ After the proximal aortic root anastomosis and implantation of the coronary buttons, cardioplegia
is applied through the graft for myocardial protection as well as to check for hemostasis.
During this time, a limited transesophageal echocardiography (TEE) may be performed to
check the AV function after the root replacement. The cardioplegia fluid is then carefully
suctioned, taking care not to disturb the cusp positions. This postcardioplegia position is the
most physiologic evaluation available for the AV on an arrested heart. The cusps are then
examined for symmetry and coaptation, and repair is done as described previously.
◆ A notable percentage of cusp prolapses are not obvious preoperatively but become evident
after aortic root repair and thus always merit reevaluation.

◆ Root replacement using the remodeling technique often necessitates an annular stabilization
technique.
◆ The distal graft anastomosis is then performed, taking care to avoid distortion of the
commissures.
2. Postrepair Evaluation
◆ The target effective height is 9 mm, which can be measured with a ruler while the aorta is
still open.16
◆ TEE is critical for intraoperative postrepair evaluation. This is done during the weaning off
of cardiopulmonary bypass and confirmed once off-pump on full heart ejection. Factors that
necessitate re-repair are the presence of more than grade I AI, any eccentric AI jet, coaptation
length less than 5 mm, and coaptation level below the aortic annulus.3 Three-dimensional
TEE may aid in the assessment of coaptation surface area, which is a better surrogate for
coaptation reserve.
◆ An algorithm proposed by le Polain de Waroux et al.17 may be followed. Re-repair is warranted
if the coaptation tips are below the annulus. Any residual AI with a leaflet coaptation length
of less than 4 mm also warrants re-repair.
◆ Other notable factors are the AV gradients for induced aortic stenosis and wall motion
abnormalities in cases in which coronary buttons were involved.

A B
C D
New Sinotubular Junction
NC/LC RC/NC
commissure commissure
Height of
external
limitation
Valsalva graft
trimmed off
E
Figure 12.11 Boodhwani M, de Kerchove L, El Khoury G. Aortic root replacement using the reimplantation technique: tips and
tricks. Interact Cardiovasc Thorac Surg. 2009;8:584-586.
Figure 12.11 Graft sizing using the NCC-LCC commissure height as reference. (A) Meauring the NCC-LCC commissure height. (B) This
height corresponds to the height of the sinus portion of the Valsalva graft. (C) This also corresponds to the graft diameter. (D) The implanted
graft, showing the lie of the NCC-LCC commissure. (E) The graft is patterned according to the height of the LCC-RCC and NCC-RCC
commissures for subsequent implantation.
Bicuspid Aortic Valve
◆ Repair of bicuspid aortic valve (BAV) AI has been gaining acceptance during the last decade,
showing a high rate of reparability and a comparable rate of survival of patients to age- and
gender-matched groups.18
◆ BAV is often associated with aortopathy and is thus commonly managed with a root replacement
procedure, especially in younger individuals.19

◆ Type 0 BAVs have two symmetric cusps and two commissures. The mechanism of AI is cusp
prolapse due to excess tissue. The degree of prolapse is assessed based on the nonprolapsed
reference cusp. In case both cusps are prolapsed, the goal is to restore the coaptation level
to the midpoint of the sinuses of Valsalva. Shaving and decalcification can be done as needed20
(Fig. 12.12A).
◆ A type 1 BAV is comprised of one large nonconjoint cusp and two smaller fused cusps, with
a median raphe or pseudocommissure (see Fig. 12.12B and C). The conjoint cusp has a large
base of leaflet implantation. The mechanism of AI may be from a restrictive raphe or prolapse
of the conjoint cusp. If the raphe is only mildly fibrosed, it is shaved off to improve the
mobility of the cusp (Fig. 12.13). If the raphe is restrictive, a conservative resection is done.
If there is an adequate amount of cusp tissue preserved, this may be closed primarily using
A B C
Figure 12.12 From Boodhwani M, El Khoury G: Aortic valve repair. Operative techniques in thoracic and
Noncalcified Raphe removed

median raphe leaving leaflet intact
A B
Figure 12.13
Figure 12.12 Biscupid aortic valve. (A) Type O valve. (B) Type 1 valve with prolapsing conjoint cusp. (C) Type 1 valve with restrictive
raphe.
Figure 12.13 Type 1 bicuspid aortic valve with noncalcified median raphe. (A) Mildly thickened and fibrosed raphe. (B) Shaving of the
raphe with intent of preservation.
locked or interrupted 6-0 polypropylene sutures (Fig. 12.14). If there is no adequate tissue,
pericardial patching is performed as described previously. Refinement of the repair may be
done using plication or resuspension20 (see Fig. 12.8).
◆ In case of an associated root replacement, the leaflet base implantation of the two cusps is
maintained in a symmetric fashion—that is, adjusted to an equal distribution, as in the case

of a type 1 BAV. The pseudocommissure is reimplanted in the graft at its natural height.
Unicuspid Aortic Valve21
◆ A unicuspid aortic valve (UAV) frequently presents as aortic stenosis, but may also present
as AI. It may also be associated with aortopathy, and those patients present even younger
than BAV patients.
◆ The aortic pathology is first addressed. The posterior commissure is usually normal and is
preserved. A tongue of aortic root on the opposing side is also preserved; this will be part of
the neocommissure for a bicuspidization technique. The dysplastic cusp (usually the RCC)
and adjacent raphe are resected. Two patches are tailored to reconstruct the rest of the
remaining two cusps and are joined to form the neocommissure. Plication sutures are placed
with the aim of achieving a target height of 10 mm (Fig. 12.15).
Quadricuspid Aortic Valve22
◆ Most cases of a quadricuspid aortic valve (QAV) are incidentally diagnosed, suggesting that
is it very much compatible with life. It may present as aortic stenosis, AI, or a mix of both.
It may also be associated with aortopathy.
◆ If the cusps are well-preserved and judged reparable, the procedure may be done with
resection, reconstruction, and tricuspidization or bicuspidization. Annular stabilization is

warranted if the root is preserved.
◆ Other congenital defects should be sought, such as an anomalous origin of the coronaries.
◆ Most QAVs are not reparable and are treated with an AVR.
Resection of restrictive,
calcified raphe
A B
Primary re-approximation
C
Figure 12.14 Franciulli M, Aicher D, Readle-hurst T, Takahashi H, Rodionycheva S, Schafers H-J: Root remodeling and
aortic valve repair for unicuspid aortic valve. Ann Thorac Surg 2014;98:823-9.
Pericardial
patch
A B
Figure 12.15
Figure 12.14 Type 1 bicuspid aortic valve repair with calcified median raphe. (A) Resection of restrictive raphe. (B) Assessment of adequacy
of remaining tissue by placing two arms of a polypropylene suture on the margin of the conjoint cusps on either sides of the resected raphe.
(C) If adequate tissue is available, primary reapproximation is done using interrupted or running locked polypropylene 6-0 sutures.
Figure 12.15 Unicuspid aortic valve repair. (A) Dissection of the aortic root, preserving a tongue of aortic tissue opposite that of the
commissure. (B) Using pericardial patches, the cusps are reconstructed to function like a symmetric bicuspid valve.
Step 5. Postoperative Considerations
1. Medical Management
◆ Aspirin is administered routinely. Blood pressure control is ensured to reduce the hemodynamic
stress, help arrest the disease process of aortic dilation, and reduce stress on repaired cusps.
◆ Close follow-up is necessary to optimize the monitoring of the durability of the AV repair.
This is essential, especially for those patients whose aortic roots were preserved and are
expected to dilate potentially over time. We recommend follow-up with postrepair echocar-
diography at 3, 6, and 12 months and annually thereafter.
2. Outcomes
◆ Early mortality rate is low at 0% to 2.0%.1-3,10,11,13,16 Overall survival is 80% to 87% at 9 to

10 years, which is comparable to patients who underwent AVR. Rates of major adverse cardiac
and cerebrovascular events and valve-related complications such as thromboembolic events,
bleeding, and endocarditis are low.1,3,4,8,11,13
◆ Freedom from AV reintervention is 89% to 92% at 10 years.1,2,16 The most common cause of
AV reintervention is recurrent AI. Risk factors for this include the presence of residual AI
postoperatively, short coaptation length, low level of coaptation, and large aortic annulus.16,17
◆ The outcomes for AVr for isolated AI is similar to that of AI associated with aortic dilation,
independent of the surgical technique used.3,8 There is a higher rate of AI recurrence for AVr
performed on type III (restrictive) leaflets, especially if rheumatic.3,17
◆ Re-repair is still a good option in case of initial failure, and freedom from AVR is 92% at 10
years.2
◆ Results are comparable for AVr in BAV and tricuspid aortic valve (TAV).2,13,18 Quantitative
outcomes results for UAV and QAV are still being developed, but recent reports have shown
that AVr in these valves may be considered as a feasible alternative to outright replacement.21,22
Step 6. Pearls
◆ The most commonly involved cusp in a prolapse is the RCC. However, the TEE is not able
to evaluate the NCC and LCC fully. The presence of an eccentric jet and/or a fibrous band
is highly suspicious for prolapse.
◆ There are excellent outcomes for AVr in types I and II AI, especially for patients who have
not yet manifested with heart failure. This could promote consideration for an earlier surgical
intervention.
◆ Type III AI (restrictive) has a less durable result for AVr and should have a lower threshold
for AVR.
◆ AVr should be treated as a specialized field of cardiac surgery, and triage to particular centers
and surgeons is advised.

References
1. De Meester C, Pasquet A, Gerber B, et al. Valve repair improves the outcome of surgery for chronic severe aortic regurgitation: a
propensity score analysis. J Thorac Cardiovasc Surg. 2014;148:1913–1920.
2. Aicher D, Fries R, Rodionycheva S, et al. Aortic valve repair leads to a low incidence of valve-related complications. Eur J Cardiothorac
Surg. 2010;37:127–132.
3. Boodhwani M, de Kerchove L, Glineur D, et al. Repair-oriented classification of aortic insufficiency: impact on surgical techniques
and clinical outcomes. J Thorac Cardiovasc Surg. 2009;137:286–294.
4. El Khoury G, De Kerchove L. Principles of aortic valve repair. J Thorac Cardiovasc Surg. 2013;145:S26–S29.
5. De Kerchove L, Jashari R, Boodhwani M, et al. Surgical anatomy of the aortic root: implication for valve-sparing reimplantation and
aortic valve annuloplasty. J Thorac Cardiovasc Surg. 2015;149:425–433.
6. Schafers HJ, Schmied W, Psych D, et al. Cusp height in aortic valves. J Thorac Cardiovasc Surg. 2013;146:269–274.
7. Venoverschelde JL, Van Dyck M, Gerber B, et al. The role of echocardiography in aortic valve repair. Ann Cardiothorac Surg.
2013;2:65–72.
8. Boodhwani M, De Kerchove L, Watremez C, et al. Assessment and repair of aortic valve cusp prolapse: implications for valve-sparing
procedures. J Thorac Cardiovasc Surg. 2011;141:917–925.
9. Boodhwani M, De Kerchove L, Glineur D, El Khoury G. A simple method for the quantification and correction of aortic cusp
prolapse by means of free margin plication. J Thorac Cardiovasc Surg. 2010;139:1075–1077.
10. De Kerchove L, Glineur D, Poncelet A, et al. Repair of aortic leaflet prolapse: a ten-year experience. Eur J Cardiothorac Surg.
2008;34:785–791.
11. De Kerchove L, Boodhwani M, Glineur D, et al. Cusp prolapse repair in trileaflet aortic valves: free margin plication and free margin
resuspension techniques. Ann Thorac Surg. 2009;88:455–461.
12. David T, Armstrong S. Aortic cusp repair with Gore-Tex sutures during aortic valve-sparing operations. J Thorac Cardiovasc Surg.
2010;139:140–142.
13. Nezhad ZM, De Kerchove L, Hechadi J, et al. Aortic valve repair with patch in non-rheumatic disease: indication, techniques and
durability. Eur J Cardiothorac Surg. 2014;46:997–1005.
14. De Kerchove L, Vismarra R, Mangini A, et al. In vitro comparison of three techniques for ventriculo-aortic junction annuloplasty. Eur
J Cardiothorac Surg. 2012;41:1117–1124.
15. Boodhwani M, El Khoury G, De Kerchove L. Graft sizing for aortic valve sparing surgery. Ann Cardiothorac Surg. 2013;2:140–143.
16. Kunihara T, Aicher D, Rodionycheva S, et al. Preoperative aortic root geometry and postoperative cusp configuration primarily
determine long-term outcome after valve-preserving aortic root repair. J Thorac Cardiovasc Surg. 2012;143:1389–1395.
17. Le Polain de Waroux JB, Pouleur AC, Robert A, et al. Mechanisms of recurrent aortic regurgitation after aortic valve repair. JACC
Cardiovasc Imaging. 2009;2:931–939.
18. Svensson L, Al Kindi A, Vivacqua A, et al. Long-term durability of bicuspid aortic valve repair. Ann Thorac Surg. 2014;97:1539–1548.
19. Navarra E, El Khoury G, Glineur D, et al. Effect of annulus dimension and annuloplasty on bicuspid aortic valve repair. Eur J
20. Boodhwani M, De Kerchove L, Glineur D, et al. Repair of regurgitant bicuspid aortic valves: a systematic approach. J Thorac
21. Franciulli M, Aicher D, Radle-Hurst T, et al. Root remodeling and aortic valve repair for unicuspid aortic valve. Ann Thorac Surg.
2014;98:823–829.
22. Idrees JJ, Roselli E, Arafat A, et al. Outcomes after repair or replacement of dysfunctional quadricuspid aortic valve. J Thorac
CHAPTER
13
Aortic Valve-Sparing
Operations
Tirone E. David
Step 1. Surgical Anatomy of the Aortic Root
◆ The aortic root is the anatomic segment between the left ventricle and ascending aorta. From
the surgical viewpoint, it consists of the aortic annulus (AA), aortic cusps, aortic sinuses, and
sinotubular junction (STJ). Although the term aortic annulus may be anatomically incorrect,
it is often used in surgical anatomy and pathology to describe the aortoventricular junction.
Approximately 45% of the circumference of the AA is attached to muscular interventricular
septum, and 55% is attached to fibrous tissue, as shown in Fig. 13.1. This fibrous tissue is
the membranous interventricular septum and the fibrous body that connects the anterior
leaflet of the mitral valve to the aortic root.
◆ The AA is scalloped and attaches the aortic cusps to the aortic root and left ventricle. The
portion of the AA corresponding to the noncoronary cusp is attached entirely to fibrous tissue,
whereas the portions corresponding to the left and right coronary cusps are partially attached
to fibrous tissue and partially to cardiac muscle. The highest point of the AA, where two
cusps meet, is the commissure. The anatomic arrangement of the AA creates a triangular
space beneath the cusps, termed the subcommissural triangle. There are three commissures
and three subcommissural triangles. The STJ lies immediately above the commissures and
separates the aortic root from the ascending aorta. The arterial wall contained between the
AA and STJ creates the aortic sinuses, or sinuses of Valsalva. The three aortic cusps have a
crescent shape and often are of different sizes, but the length of the base of a cusp is always
1.5 times longer than the length of its free margin (FM), as illustrated in Fig. 13.2. Thus, a
large cusp will have a proportionally longer base (AA), longer FM, longer intercommissural
distance along the STJ, and larger aortic sinus. The noncoronary and right cusps and sinuses
are often larger than the left cusp and left aortic sinus.
◆ The AA is a three-dimensional structure that evolves along three separate planes, as illustrated
in Fig. 13.3A–C. Each aortic cusp is inserted in the annulus along a horizontal plane (see
Fig. 13.3D). For practical purposes, we usually refer to its diameter as the maximal distance
at the level of its nadir.
◆ The relationship of the diameters of the AA at this level and at higher levels until reaching
the commissures (STJ) varies with age. In children and young adults, the diameter of the AA
is 15% to 20% larger than its diameter at the level of the commissures (STJ). As the elastic
fibers of the arterial wall decrease with age, the STJ dilates and tends to become equal to the
diameter of the lower AA in adults. However, the AA of each cusp evolves along a single
horizontal plane (see Fig. 13.3).
199
Chapter 13 • Aortic Valve-Sparing Operations199.e1
Abstract
Aortic valve-sparing operations have become part of the surgical armamentarium to treat aortic
root aneurysm and ascending aorta aneurysm with aortic insufficiency. Both types of procedures,
remodeling of the aortic root and reimplantation of the aortic valve have provided excellent
long term results when the procedure is correctly matched to the aortic root pathology.
Keywords
aortic root aneurysm

aortic insufficiency
Figure 13.1
STJ
FM
AA
Base
Figure 13.2
A B
C D
Figure 13.3
Figure 13.1 Photograph of an aortic root.
Figure 13.2 Geometric relationship among various components of the aortic root.
Figure 13.3 The aortic annulu evolves along a cylinder.

Chapter 13 • Aortic Valve-Sparing Operations 201
◆ Ascending aortic aneurysms can cause aortic dissection or rupture when their transverse
diameter exceeds 55 mm. Aneurysms of the ascending aorta can also cause dilation of the
STJ, with consequent aortic insufficiency due to lack of coaptation of the cusps, as illustrated
in Fig. 13.4. One or more aortic sinuses may also become secondarily dilated, but the AA
often remains normal. Patients with ascending aortic aneurysms and aortic insufficiency are
usually in their sixth or seventh decade of life. If the aortic cusps are normal or minimally
elongated along their FMs, it is possible to replace the ascending aorta with correction of the
diameter of the STJ, replace one or more sinuses if necessary, repair the cusps if there is
prolapse, and reestablish aortic valve competence.
◆ Aortic root aneurysms usually start with dilation of the aortic sinuses and, with time, the
dilation extends proximally into the AA and distally into the STJ. Patients with an aortic root
aneurysm are usually in the second to fourth decade of life when they need surgery, and the
aneurysm is often associated with genetic syndromes, such as Marfan syndrome, Loeys-Dietz
syndrome, and others. The two subcommissural triangles of the noncoronary cusp flatten as
the AA dilates, which decreases the coaptation area of the cusps and may cause aortic insuf-
ficiency (Fig. 13.5). The indication for surgery is usually based on the diameter of the aortic
sinuses and family history of aortic dissection. In most cases, surgery is recommended when
the diameter reaches 50 mm and less if there is a family history of aortic dissection.
◆ This chapter reviews the operative techniques used to preserve the aortic valve in patients
with ascending aortic aneurysm and aortic insufficiency, as well as patients with aortic root
aneurysm, with or without aortic insufficiency. The term aortic valve-sparing operation was
introduced to describe these procedures.
◆ Patients with an ascending aortic aneurysm are usually asymptomatic, even if they have aortic
insufficiency. Although echocardiography often establishes the diagnosis of an ascending aortic
aneurysm and provides information regarding aortic valve function, computed tomography
(CT) or magnetic resonance imaging (MRI) of the aorta is necessary to determine the extent
of the aneurysm. The transverse arch is often involved in older patients with aneurysm of
the ascending aorta and aortic insufficiency.
◆ Most patients with aortic root aneurysm are asymptomatic and have only mild or no aortic
insufficiency. Some patients complain of vague chest pain. Severe chest pain is suggestive of
rapid expansion or an intimal tear with dissection. Echocardiography establishes the diagnosis
and gives information regarding aortic valve function. CT or MRI of the aorta is also diagnostic
and provides useful information on the remaining thoracic aorta, although the transverse arch
is seldom involved.
◆ Transesophageal echocardiography (TEE) is the best diagnostic tool to study the aortic valve
and the mechanism of aortic insufficiency in patients with ascending aortic or aortic root
aneurysm, as well as to measure the diameters of the AA, STJ, and cusp height. Each component
of the aortic root must be carefully interrogated, particularly the aortic cusps. The number
of cusps, their thickness, appearance of their FMs, and excursion of each cusp during the
cardiac cycle must be examined in multiple views. The coaptation lines of the aortic cusps
should be interrogated by color Doppler imaging. The direction and size of the regurgitant
jets should be recorded in many views. Information regarding the morphologic features of
the AA, aortic sinuses, STJ, and ascending aorta should be obtained. Obviously, the aortic
cusps are the most important determinant of aortic valve repair. If the cusps are thin and
mobile and have smooth FMs, the feasibility of aortic valve repair is very high, including
patients with bicuspid aortic valves.
Normal sinotubular junction Dilated sinotubular junction
Figure 13.4
Normal aortic annulus Dilated aortic annulus
Figure 13.5
Figure 13.4 Dilation of the sinotubular junction prevents the cusps from coapting and causes aortic insufficiency.
Figure 13.5 Dilation of the aortic annulus flattens the subcommissural triangles of the noncoronary cusp and pulls the belly of the cusps
apart.
◆ Aortic valve-sparing operations are usually performed through a median sternotomy, but the
procedure can also be done through a limited skin incision (8–10 cm) and a partial or full
median sternotomy.
◆ Cardiopulmonary bypass is established by inserting an arterial cannula into the proximal
aortic arch if only the aortic root and proximal ascending aorta are involved or into the right
axillary or innominate artery if the aortic arch needs replacement. Venous drainage for car-
diopulmonary bypass is usually done with a single double-stage cannula placed in the right
atrium or with bicaval cannulation when the mitral valve also needs repair. The heart is
protected during aortic clamping by giving cold blood cardioplegia directly into the coronary
arteries intermittently. I maintain the systemic temperature at around 34°C (93°F). If the
aortic arch needs replacement, it is done first under moderate systemic hypothermia (22°–25°C;
72°–77°F) and continuous antegrade cerebral perfusion through the right axillary or innominate
artery. A cannula is also inserted into the left carotid artery if the pressure in this artery is
less than 50% of that in the innominate artery. If the mitral valve needs repair, it is done
before the aortic root pathology is addressed.
◆ Intraoperative TEE is indispensable in aortic valve-sparing operations for assessment of aortic
valve function before and after repair of the valve.
1. Ascending Aortic Aneurysms With Aortic Insufficiency
◆ The ascending aorta is transected 5 to 6 mm above the STJ and the aortic cusps are inspected.
Although this inspection is largely to confirm what a preoperative transesophageal echocardiogram
has already shown, stress fenestration close to the commissural areas and minor degrees of
elongation of the FMs are not easily detected preoperatively.
◆ The aortic insufficiency is usually due to dilation of the STJ. Correction of the valve dysfunction
is accomplished by reducing the diameter of the STJ by suturing a graft of appropriate diameter
to it. The simplest method to determine the diameter of the graft is to approximate the three
commissures until the cusps coapt centrally. Valve sizers such as the Medtronic Freestyle
(Medtronic, Minneapolis) are metric and handy for this purpose. When in doubt between
two sizes, it is safer to take the larger one because the STJ can be further reduced under
echocardiographic guidance after completion of the operation by plication of the spaces
between two commissures. In adult patients, small-caliber grafts may increase left ventricular
afterload. Thus, if the estimated diameter of the STJ is 22 mm in a patient with a body surface
area of 2 m2, a larger graft (26 or 28 mm) should be used and reduced to 22 mm at the end
where the graft is going to be used to correct the diameter of the STJ. Fig. 13.6 illustrates
this operative procedure. Before the graft is sutured to the STJ, the graft should be divided
into thirds to correspond to each commissure. If one cusp is larger than the others, the
intercommissural distance should be proportionally larger.
Sinotubular
junction
Figure 13.6
Figure 13.6 Replacement of the ascending aorta with an appropriately sized graft restores valve competency by reducing the sinotubular
junction.
◆ If the noncoronary aortic sinus is excessively dilated or dissected (in cases of aortic dissection),
it should be replaced. The graft is divided into thirds according to the spaces between com-
missures, and a neoaortic sinus is fashioned, as illustrated in Fig. 13.7. The height of the
tailored neoaortic sinus should be approximately the same as the diameter of the graft. Next,
the commissures of the noncoronary cusp are secured to the graft, and the neoaortic sinus
is sutured to the remnant of the arterial wall and AA with continuous 4-0 polypropylene
sutures. The remaining part of the graft is sutured to the STJ along the left and right aortic
sinuses. If the noncoronary and right aortic sinuses are dilated or dissected, they should be
replaced as described previously and illustrated in Fig. 13.8. In this case, the right coronary
artery should be reimplanted into its neoaortic sinus.
B
Figure 13.7
Figure 13.8
Figure 13.7 The noncoronary aortic sinus may be dilated and can be replaced at the same time as replacement of the ascending aorta with
an appropriately tailored tubular Dacron graft.
Figure 13.8 The noncoronary and right aortic sinuses may have to be replaced.
◆ Finally, if all three aortic sinuses are dilated, the sinuses are excised, leaving 5 mm of arterial
wall attached to the AA. The coronary arteries are detached from their sinuses along with
5 mm of arterial wall around their orifices (Fig. 13.9A). The three commissures are suspended
at the same level and positioned in such way as to allow the three cusps to coapt centrally
(see Fig. 13.9B). The diameter of the circle that includes all three commissures can be estimated
with metric aortic valve sizers. As before, when in doubt between two sizes, it is safer to
choose the larger one. Three neoaortic sinuses are tailored in one of the ends of the graft (see
Fig. 13.9C). The width of the neoaortic sinuses is proportional to the size of the cusps and
intercommissural distances. The arterial wall immediately above the commissures is secured
to the graft, and the neoaortic sinuses are sutured to the remnants of the native aortic sinuses
and AA with continuous 4-0 polypropylene sutures (see Fig. 13.9D). The coronary arteries
are reimplanted into their respective sinuses (see Fig. 13.9E). To avoid late aneurysm formation
in the arterial buttons, the diameter of the openings in the neoaortic sinuses should not
exceed twice the diameter of the coronary arteries.
E
Figure 13.9
Figure 13.9 All three aortic sinuses can be replaced with a tailored tubular Dacron graft.
◆ The foregoing operative techniques are known as remodeling of the aortic root. After correction
of the dilated STJ and replacement of one or more aortic sinuses, as described previously, the
cusps should coapt well above the level of the nadir of the AA. If one or more cusps coapt
at a lower level than the others, the FM is elongated and should be shortened by plication
along the nodule of Arantius, as illustrated in Fig. 13.10. This is done with 6-0 or 5-0
polypropylene sutures, depending on the thickness of the cusp.
◆ A cusp with stress fenestration along its commissural edge can be reinforced by weaving a
double layer of fine (6-0 or 7-0) polytetrafluoroethylene sutures along its FM, as illustrated
in Fig. 13.11. After completion of the aortic root remodeling, valve competence is assessed
by injecting cardioplegia into the graft under pressure. If the ventricle does not distend, there
is no aortic insufficiency or only a trace because mild aortic insufficiency causes distention
of the ventricle.
2. Aortic Root Aneurysm
◆ Although the previously described aortic root remodeling procedure, with replacement of all
three aortic sinuses, has been used to treat patients with aortic root aneurysm, I believe that
the AA dilates in some patients late after surgery, particularly in those with an associated
genetic syndrome, limiting the durability of the valve repair. Thus, in young adults with an
aortic root aneurysm, the technique of reimplantation of the aortic valve has been shown to
provide more durable results. This operation is more complicated than remodeling the aortic
root because greater knowledge of the functional anatomy of the aortic valve is needed to
reconstruct the AA, STJ, aortic sinuses, and sometimes the aortic cusps as well.
◆ Reimplantation of the aortic valve starts by freeing the aortic root from surrounding structures
and excising the three aortic sinuses, as described earlier for the remodeling procedure (see
Fig. 13.9A and B). Five to 6 mm of aortic sinus wall is left attached to the AA all around.
Stay sutures are placed immediately above each commissure for traction.
Figure 13.10
Figure 13.11
Figure 13.10 Cusp prolapse can be corrected by plication along the nodule of Arantius.
Figure 13.11 Cusps with large fenestration can be reinforced with a double layer of fine expanded polytetrafluorethylene suture above
and below the defect.
◆ The aortic root is then dissected free from the pulmonary artery and right ventricle, down to
a level immediately below the AA. On the right side of the aortic root, it may be difficult, if
not impossible, to separate the subcommissural triangles of the noncoronary cusp from the
right and left atria because their insertion in the root may be at a higher level than the base
of those triangles. The dissection is extended down to the level of the insertion of the atria
in the aortic root. Next, multiple horizontal mattress sutures of 2-0 or 3-0 polyester are passed
from the inside to the outside of the left ventricular outflow tract, immediately below the
nadir of the AA, through a single horizontal plane along the fibrous portion of the outflow
tract, and along its scalloped shape in the interventricular septum, as illustrated in Fig. 13.12A.
These sutures are passed through the base of the subcommissural triangles of the noncoronary
cusp, along a horizontal plane that corresponds to a level immediately below the nadir of the
AA. Depending on the height of the membranous septum, the sutures may have to be a bit
higher than the nadir of the AA to avoid the bundle of His. These sutures may incorporate
part of the right and left atria if their insertion is higher than that horizontal plane. If the
membranous septum and anterior leaflet of the mitral valve is often thin and soft, Teflon
pledgets should be used in these sutures.
◆ The heights of the cusps are averaged, and a tubular Dacron graft with a diameter equal to
double of that average is selected for reconstruction of the root. Conversely, the diameter of
the graft can be estimated as described for the remodeling technique or by using the height
of the commissure between the left and noncoronary cusps.
◆ Three equidistant marks are placed in one end of the graft to correspond to each commissure.
A triangular segment of 5 mm is cut off along the mark that corresponds to the subcommissural
triangle of the left and right cusps (see Fig. 13.12A). The sutures previously placed in the
left ventricular outflow tract are now passed through the graft. The sutures should be spaced
symmetrically if the AA is not dilated (see Fig. 13.12B). If there is obvious dilation of the
AA, the sutures should be spaced symmetrically along the muscular component of the outflow
tract and closer together beneath the subcommissural triangles of the noncoronary cusp
because that is where dilation occurs in patients with connective tissue disorders. The level
at which these sutures are passed through the graft is also important and should reproduce
what was done when they were passed through the left ventricular outflow tract.
◆ The sutures are tied on the outside of the graft. Care must be exercised not to purse-string
this suture line. The graft is then cut in a length of approximately 5 cm and pulled up gently,
and the three commissures are also pulled vertically and temporarily secured to the graft with
transfixing 4-0 polypropylene sutures, but they are not tied (see Fig. 13.12C). Once the three
commissures are suspended inside the graft, the commissures and cusps are inspected to
make sure that they are all correctly aligned. Next, the sutures are tied on the outside of the
graft and used to secure the AA into the graft. This is accomplished by passing the suture
sequentially from the inside to the outside right at the level of the annulus and from the
outside to the inside at the level of the remnants of the arterial wall. I start at the level of the
commissure and stop at the nadir of the AA, where the sutures are tied together on the outside
of the graft. The coronary arteries are reimplanted into their respective sinuses.
◆ The coaptation level of the aortic cusps is inspected; it should be well above the level of the
nadir of the annulus. If one or two cusps coapt at a lower level, the FM can be shortened,
as illustrated in Figs. 13.10 and 13.12D. If fenestrations are present, the FM can be reinforced
with a double layer of 6-0 or 7-0 polytetrafluoroethylene sutures (see Fig. 13.11). The graft
can be clamped distally, and cardioplegia given into the aortic root to test for valve competence,
as described for remodeling of the aortic root.
◆ Finally, the graft is sutured to the distal ascending aorta, as illustrated in Fig. 13.12E. I believe
that the most durable reimplantation procedure is when a straight tubular Dacron graft is
used. If neoaortic sinuses are desirable, a graft 2 or 4 mm larger than what is needed is
selected and plicated to reduce its diameter in the area corresponding to the nadir of the AA
and in between commissures (see Fig. 13.12E). The average graft size used in reimplantation
of the aortic valve is 28 to 30 mm when a straight graft is used and 30 to 32 mm when
neoaortic sinuses are created.
A D
C
Figure 13.12
Figure 13.12 Reimplantation of the aortic valve.

◆ Reimplantation of the aortic valve is also extremely valuable for patients with an incompetent
bicuspid aortic valve, when the AA is frequently dilated. Patients with acute type A aortic
dissection who have a dilated aortic root are also good candidates for this type of aortic
valve-sparing procedure.
◆ The operative mortality rate for aortic valve-sparing operations is low in elective cases
(< 2%), even in patients who require more extensive operations, including mitral valve repair,
replacement of the aortic arch, and myocardial revascularization. These patients do not require
any procedure-specific care in the intensive care unit or ward. In my experience, patients
with an ascending aortic aneurysm and aortic insufficiency often have a transverse arch
aneurysm and sometimes mega aorta syndrome. These patients require more extensive vascular
surgery than those with aortic root aneurysm, with consequently higher rates of postoperative
complications such as stroke, myocardial infarction, renal failure, and respiratory failure.
However, more than 90% of all patients experience no serious postoperative complications.
◆ Postoperative bleeding is relatively common and, in my experience, approximately 50%
require blood products. New heart block is rare (< 1%). Atrial fibrillation occurs in approximately
20% of these patients and is managed pharmacologically. Patients with an aortic root aneurysm
associated with a genetic syndrome and those with an aortic dissection should receive a beta
blocker, if tolerated. No oral anticoagulation is given unless atrial fibrillation persists for more
than 24 hours or they have had a mitral annuloplasty ring or band, in which case they receive
heparin initially and warfarin for 3 months.
◆ Echocardiographic studies to assess aortic valve function should be performed annually in
all patients. In those with more extensive vascular disease or aortic dissection, periodic CT
scanning or MRI of the aorta is also important during follow-up.
◆ Aortic valve-sparing operations are complex procedures. A sound knowledge of the functional
anatomy and pathology of the aortic root and technical expertise are needed for their performance.
As with any other type of heart valve repair, it should not be performed if the aortic cusps
are grossly abnormal. From the preoperative selection of patients by TEE to the intraoperative
analysis of the aortic cusps and root and what is needed to restore the functional anatomy
of the aortic valve, every step is crucial.
◆ Sizing of the graft is difficult for the surgeon who is learning to perform these operations.
Sizing of the graft is easier for remodeling of the aortic root than for reimplantation of the
aortic valve. The guidelines for sizing the graft for reimplantation of the aortic valve given in
this chapter are based more on clinical experience than on scientific investigation of functional
anatomy. The length of the FMs of the cusps, degree of scalloping of the AA, and diameter
of the STJ can all be altered during reconstruction of the root, but the height of the cusps
cannot. For this reason, I use the average height of the cusps to estimate the appropriate
diameter of the AA at the level of its nadir. By using grafts with a diameter equal to twice the
average height of the cusps, the radius of the reconstructed AA becomes equal to the height
minus the thickness of the aortoventricular junction because it is sutured inside the graft.
This reduction in diameter of the annulus has proven effective in allowing the cusps to coapt
well above the nadir of the annulus, and it provides a good seal of the aortic orifice during
diastole.
◆ The level of coaptation of the aortic cusps has been shown to be important for the durability
of these procedures. If the cusps coapt at the same level as the annulus, the probability of
prolapse of a cusp with consequent aortic insufficiency is greatly increased, compared with
cusps that coapt at least 8 mm above the nadir of the AA. Thus, sizing of the graft and
shortening the length of the cusps’ FMs are extremely important determinants of late valve
function.
◆ As illustrated in Fig. 13.3, the AA evolves along single horizontal planes. The only geometric
shape suitable to stabilize a dilated AA is a cylinder. Thus, a straight tubular Dacron graft is
probably the best shape for reimplantation of the aortic valve. Newer grafts with neoaortic
sinuses are spherical and probably deform the AA once the valve is secured inside them.
Thus, I do not recommend these grafts for reimplantation.
◆ Aortic valve-sparing operations are extensive, and hemostatic anastomoses between the various
components are of utmost importance. Coagulopathy at the end of a long cardiopulmonary

bypass is common, and every measure must be taken to avoid mechanical bleeding.
Bibliography
Aicher D, Kunihara T, Issa OA, et al. Valve configuration determines long-term results after repair of the bicuspid aortic valve. Circulation.
2011;123:178–185.
David TE. Aortic valve sparing in different aortic valve and aortic root conditions. J Am Coll Cardiol. 2016;68:654–664.
David TE, David CM, Feindel CM, Manlhiot C. Reimplantation of the aortic valve at 20 years. J Thorac Cardiovasc Surg.
2017;153:232–238.
David TE, David CD, Manlhiot C, et al. Outcomes of aortic valve-sparing operations in Marfan syndrome. J Am Coll Cardiol.
2015;66:1445–1453.
David TE, Feindel CM, David CM, Manlhiot C. A quarter of a century of experience with aortic valve-sparing operations. J Thorac
de Kerchove L, Boodhwani M, Glineur D, et al. Valve sparing-root replacement with the reimplantation technique to increase the
durability of bicuspid aortic valve repair. J Thorac Cardiovasc Surg. 2011;142:1430–1438.
Kunihara T, Aicher D, Rodionycheva S, et al. Preoperative aortic root geometry and postoperative cusp configuration primarily determine
long-term outcome after valve-preserving aortic root repair. J Thorac Cardiovasc Surg. 2012;143:1389–1395.
CHAPTER
14
Bentall Procedure
Richard Jay Shemin
◆ In 1968, Bentall and De Bono1 described a technique for composite aortic valve and root
replacement with reimplantation of the coronary arteries. The coronary arteries were sewn
to the graft as a side-to-side anastomosis, and the aneurysm wall was wrapped around the
graft.
◆ During the ensuing years, this technique underwent various modifications, primarily because
of pseudoaneurysm formation at the side-to-side anastomosis of the coronary button to the

graft.
◆ The Bentall operation currently uses a technique for treating combined disease of the aortic
valve and aortic root with an end-to-side coronary button technique, a modification of the
original technique described by Kouchoukos et al. in 1991.2
◆ All procedures are performed by creating an open distal anastomosis when there is an inadequate
cuff of normal aorta below the cross-clamp or by replacing the entire arch or hemiarch during
a period of moderate or deep hypothermic circulatory arrest with antegrade cerebral perfusion
or total circulatory arrest with or without retrograde venous perfusion.
◆ The modified Bentall procedure is the procedure of choice when treating the aortic valve,
aortic sinuses, and ascending aorta.
◆ The pertinent anatomy consists of the aortic valve and related pathology, sinuses of Valsalva,
coronary ostia, ascending aorta, and aortic arch. Specific pathologic processes present different
challenges in a Bentall procedure. The more common situations are bicuspid aortic valve
stenosis (AS) or aortic regurgitation (AR) with a dilated ascending aorta, AR and ascending
aortic aneurysm (e.g., Marfan syndrome), and acute or chronic aortic dissection.
215
Chapter 14 • Bentall Procedure215.e1
Abstract
The Bentall procedure technique has evolved to become a standardized, reliable procedure that
can be performed for a variety of aortic vavle and aortic root pathology. The technique described
in this chapter describes the details of the author’s technique and variations for specific pathology.
Myocardial protection and cerebral protection is discussed.
Keywords
bentall
aortic replacement
valve replacement
composite aortic valve
aortic replacement
◆ The planning of the procedure requires preoperative echocardiography and cardiac catheteriza-
tion with coronary angiography and optional aortic root angiography with panning into the
aortic arch. A carotid artery Doppler examination may be useful. The use of a contrast magnetic
resonance imaging (MRI) or computed tomography (CT) scan with three-dimensional recon-
struction is standard to help measure the extent and size of the aneurysm.
◆ The choice of valve should be determined in consultation with the patient. If there is no
associated coronary disease, the procedure can be performed through a ministernotomy. In

this case, peripheral venous cannulation is often necessary because of limited access to the
right atrial appendage.
◆ The need for circulatory arrest and possible electroencephalographic monitoring should be
determined if the arch is involved or if the aneurysm extends distally to the level of the
innominate artery, requiring circulatory arrest to perform an open anastomosis. When circulatory
arrest is required, decisions about cerebral protection need to be made with regard to technique,
cardiopulmonary bypass (CPB) setup, temperature, and antegrade perfusion.
◆ A plan for cardioplegia administration is essential, especially if a ministernotomy is to be
used. I prefer antegrade and retrograde del Nido blood cardioplegia readministered every 60
to 90 minutes.
◆ Special consideration is given to the treatment of postprocedure coagulopathy. Administration
platelets, coagulation factors, and possible factor VII may be necessary. I use heparin-coated
CPB circuits. In addition, a Rotem device (Tem International, Basel, Switzerland) is used to
guide component therapy for postoperative coagulation.
◆ The Bentall procedure can be performed through a median sternotomy or ministernotomy,

with a 4-cm vertical skin incision over the upper sternum and the midsternal split extending
from the sternal notch to the right fourth interspace (J-shaped sternotomy).
◆ Cannulation sites can be into the ascending aorta, transverse arch, femoral artery or, preferably,
into a 6- or 8-mm Dacron graft anastomosed end to side to the right axillary artery. Axillary
perfusion provides antegrade flow, facilitates antegrade cerebral perfusion if the innominate
artery is clamped, and is especially useful in cases of aortic dissection.
◆ The site chosen for cannulation depends on the anatomy, extent of pathology, and indications
for the operation. For example, the axillary artery is preferred for all cases in which circulatory
arrest is to be used. The upper ascending aorta or arch is a safe and convenient site in
aneurysmal disease. If the replacement extends into the aortic arch, the arterial perfusion
cannula will be removed during the circulatory arrest period, with subsequent direct cannulation
of the graft or through a side limb.
◆ Venous cannulation is through the right atrial appendage, with a triple-stage cannula or long
femoral venous cannula, inserted by cutdown through a purse-string suture or percutaneously

with a Seldinger technique. The position of the cannula in the right atrium is confirmed with
transesophageal echocardiography (TEE).
◆ To protect the heart, a cold blood cardioplegia solution or del Nido solution is infused
antegrade directly into the aorta (if there is no aortic insufficiency [AI]), via the coronary
ostia, and retrograde through the coronary sinus. A topical cold saline solution augments
myocardial cooling. A del Nido solution provides excellent myocardial protection and should
be readministered every 60 to 90 minutes. It also does not require a reperfusion strategy.
Chapter 14 • Bentall Procedure 217
◆ Systemic cooling to a temperature of 34°C (93.2°F) is sufficient for routine replacement of

the aortic root, but a temperature of 12°–18°C (53.6°–64.4°F) is necessary if a total circulatory
arrest technique is used. An isoelectric tracing on the electroencephalographic monitor can
be a biologic guide to circulatory arrest. An antegrade cerebral perfusion (18°C; 64.4°F)
technique can be used with moderate systemic hypothermia at 25°C (77°F).
◆ An optional left ventricular (LV) vent inserted into the right superior pulmonary vein or
pulmonary artery vent facilitates decompression of the LV. With severe AI, the heart will
distend in spite of venting the left ventricle, especially during fibrillation induced during the
cooling period.
◆ Cardiac distention during cooling will require cross-clamping the aorta and the initiation of
cardioplegic arrest. As cooling continues, the proximal portion of the procedure can be
performed—valve replacement and coronary button reimplantation. As soon as the goal
systemic temperature is achieved in circulatory arrest cases, the proximal portion of the
procedure is stopped and the arch replacement performed. Antegrade cerebral perfusion can
extend the safe circulatory arrest time. Retrograde superior vena cava (SVC) perfusion is most
effective in preventing the embolization of debris and air in very atherosclerotic aneurysms.
In addition, monitoring bilateral near-infrared oxygen saturation over the forehead helps
guide the possible need (e.g., a reduction in left-sided oxygen saturation) for direct perfusion
of the left carotid in addition to the right carotid perfusion by clamping the innominate artery.
◆ After the arch replacement is completed, the graft can be cannulated. If the axillary artery
has been used, antegrade perfusion and de-airing of the arch are initiated. The graft is clamped,
and rewarming is begun. The proximal portion of the procedure is completed. Finally, the
graft to graft anastomosis is completed.
1. Proximal Portion of the Procedure
◆ The aorta is transected below the cross-clamp, leaving a cuff of aorta for the distal anasto-
mosis. The proximal aorta is opened with a longitudinal incision. The incision is extended
toward the noncoronary sinus to avoid the right coronary artery ostia, which may have migrated
high due to the aneurysm. Sinus aneurysm tissue is excised, leaving a 2–3 mm rim. Buttons
of aortic tissue around the ostia of the coronary arteries are created and mobilized (Fig. 14.1).
◆ The right coronary artery must be adequately mobilized to prevent torsion after reanastomosis
to the graft (Fig. 14.2).

◆ The aortic valve is excised and the annulus is débrided of all calcium. After sizing of the
aortic annulus, a series of pledgeted mattress sutures is placed (Fig. 14.3).

◆ If a bioprosthetic valve is to be used, the suture needle is passed from the ventricular to the
aortic aspect of the annulus for fixation of the valve in a supraannular position.
◆ For a mechanical prosthetic valve, the sutures are placed from the aortic to the ventricular
aspect of the annulus to effect intraannular fixation of the valve (Fig. 14.4). If the annulus is
smaller than 23 mm, a supraannular suture technique is an option.
◆ Fig. 14.4 shows details of the intraannular everting technique for valve implantation. The
everting technique is preferred for mechanical valve conduits. Visualization of this anastomosis
for hemostasis will not be possible until the heart is ejecting, and inspection of the annular
areas beneath the coronary buttons will be almost impossible. These sutures must be placed
close together and tied tightly to create a hemostatic seal. In addition, a running 3-0 prolene
from the remaining aortic wall to the sewing cuff of the valve conduit enhances hemostasis.
◆ If the annulus is small and a larger valve is desired, a mechanical valve can be placed in a
supraannular position using the infraannular suture technique needed for the bioprosthetic
valve.
A B
Figure 14.3
A B
Figure 14.4
◆ A composite graft consisting of a St. Jude valve and a Hemashield or Gelweave graft is used
in patients for whom a mechanical valve is indicated (Fig. 14.5).
◆ In patients for whom a biologic valve is chosen, a homemade composite, consisting of a
stented pericardial valve and Gelweave graft, is used. The size of the graft should equal the
outer diameter of the valve sewing cuff. Running 4-0 polypropylene sutures are used to attach
the graft to the sewing cuff of the valve.
◆ A homograft or autograft (Ross procedure) is an alternative composite biologic conduit.
◆ After the valve sutures are secured, 3-0 Prolene sutures are run from the aortic wall to the
valve sewing cuff to aid in hemostasis. Then buttons of the coronary ostia are anastomosed.
Minimal mobilization of the left coronary artery is necessary. The first centimeter of the right
coronary artery is mobilized. The buttons are implanted in an end-to-side fashion with running
5-0 or 6-0 Prolene sutures, incorporating a Teflon felt strip to reinforce the suture line
(Fig. 14.6).
◆ After attachment of the left coronary artery is completed, the length of the graft is determined
by clamping the distal end of the graft and stretching the graft by distending it with antegrade
cardioplegia. The left main suture line is tested for leaks during this maneuver. Excess graft
material is removed with the ophthalmic cautery to prevent fraying of the Dacron material.
The distal graft to the aorta or graft to graft anastomosis (if an arch replacement was performed)
is completed with 4-0 polypropylene sutures and a Teflon strip to reinforce the suture line.
◆ Cardioplegia is readministered antegrade into the graft. With the graft distended, the correct
position to anastomose the right coronary button can be accurately determined to avoid
tension and torsion (Fig. 14.7). The right coronary artery is sewn (5-0 or 6-0 polypropylene
sutures) to the graft. Warm cardioplegia is administered antegrade into the graft, allowing a
final check of the suture lines for bleeding, before completing the air maneuvers and removal
of the cross-clamp.
Figure 14.5
A B
Figure 14.6
Figure 14.7
◆ Rarely, the coronary arteries cannot be mobilized to reach the prosthetic aortic graft. Dacron
graft extensions are a possible option (Fig. 14.8).
◆ The Cabrol technique, using a simple Dacron graft (8 mm), is illustrated in Fig. 14.9. The
ends of the tubular graft are sewn end to end to the coronary arteries. The length and orientation
of the graft should be carefully planned. The body of the graft is sewn side to side to the
aortic graft, providing inflow and distribution to the coronary arteries.
2. Bentall With Arch Replacement
◆ To allow an open distal anastomosis or total aortic arch reconstruction, the patient’s head is
placed downward, CPB is discontinued, and antegrade cerebral perfusion with 18°C (64.4°F)
blood is begun. The aorta is excised appropriately. The anastomosis between the trimmed
Dacron graft and aorta is performed with 4-0 polypropylene running sutures, reinforced by
an outer Teflon felt strip. Before CPB is resumed, the head vessels are carefully inspected for
air and particulate debris. Selective cerebral perfusion is discontinued and, in cases with an
especially high risk of embolization, a brief period of retrograde perfusion through the SVC
at a pressure of 20 mm Hg, can be useful to flush out air and debris further.
◆ After reestablishing CPB, the arch graft is clamped and warming begun. If the Bentall portion
of the procedure needs to be complete, this is done at this time. Finally, the graft (arch) to
graft (ascending aorta) anastomosis is completed.
◆ Air from the graft and cardiac chambers is removed after releasing the cross-clamp. The aortic
root vent is maintained on suction.

◆ The heart is reperfused and allowed to resume sinus rhythm. Defibrillation is used if necessary.
Atrial and ventricular bipolar pacing wires are placed. Adequacy of air removal from the
cardiac chambers is monitored with TEE.
◆ CPB is discontinued when a bladder temperature of 37°C (98.6°F) is reached. Hemostasis
often requires transfusion of clotting factors and platelets. Appropriate drainage tubes are
placed in the mediastinum.
◆ A variety of biologic glues is available. It is often helpful to seal the suture lines with glue
when they are dry. When used, the glue should be applied sparingly. Overapplication of glue
may prevent observation of important surgical leaks that require suture repair. In most cases,
I do not use glue. Only when the aorta is very friable, thin, or dissected do I apply biologic
glue.
◆ The basic principles of hemodynamic monitoring of the cardiac surgical patient after aortic
valve replacement apply. Specific considerations relate to the extent of root and arch replace-
ment. Neurologic assessment is important. Close monitoring for excessive bleeding or tamponade
is essential and may prompt an urgent return to the operating room for exploration and
evacuation of hematoma. Monitoring for myocardial ischemia or right ventricular dysfunction
can indicate a problem with the coronary buttons, most commonly the right button.
◆ If a mechanical composite conduit was implanted, anticoagulation with warfarin can be started
on the first postoperative day. I do not use heparin unless the international normalized ratio
(INR) has not responded by the third postoperative day. The target INR is 2.5. If a bioprosthetic
composite valve has been used, I do not prescribe warfarin, only aspirin.
Top view
Side view
A B
Figure 14.8
Figure 14.9
◆ The recent introduction of home testing of coagulation status offers an opportunity for improved
follow-up of patients who are undergoing mechanical valve replacement. Studies have suggested
that the ability to monitor the INR weekly at home results in improved maintenance of in-range
values compared with a laboratory-based testing regimen3 and translates into a lower frequency
of bleeding and thrombotic complications.4 Furthermore, Schmidtke et al.5 have demonstrated
that self-management of anticoagulation leads to a superior quality of life after mechanical
valve replacement compared with conventional physician-monitored anticoagulation.
◆ If a bioprosthetic composite valve was used, I do not prescribe warfarin, only aspirin.
◆ An echocardiogram before discharge is helpful to ensure normal valve and myocardial function
and to evaluate residual pericardial hematoma. As in any group of patients with an aneurysm
or dissection, a significant number of patients may require subsequent operations for aneurysms
elsewhere in the aorta. This reinforces previous observations indicating that conscientious
postoperative follow-up of these patients is necessary.
◆ The practice of monitoring patients with an annual CT scan or MRI is necessary when an
aneurysm has been resected, especially for the first 2 years. Subsequently, every other year
is sufficient.
◆ Bentall failures are rare during long-term follow-up. The Bentall technique is safe and durable,
with a low incidence of postoperative complications in a population with disease of the

ascending aorta and aortic valve.
◆ The lower frequency of reoperation is a major advantage compared with the results of valve-
sparing approaches, in which significant AI develops in a variable proportion of patients.

◆ Because the Bentall operation is associated with excellent short- and long-term results, aggressive
use of this procedure is appropriate if aortic valve surgery is necessary in a patient with even
mild (4.5 cm) ascending aortic dilation.
◆ The Bentall operation is considered the standard procedure against which to measure the
outcomes of newer valve-sparing approaches to aortic root disease.
◆ “Cut well and sew well and the patient will do well.”
◆ “The right operation, for the right indication, that is well executed helps ensure clinical
success.”
◆ Preoperative planning is very important. Understanding the extent of the pathologic process
involving the valve, aorta, and coronary arteries is essential. Three-dimensional reconstructions
of the aortic contrast-enhanced CT scan or MRI provide very helpful information.
◆ Proper creation and mobilization of the coronary buttons will prevent kinking and twisting.
If the coronary arteries are adequately mobilized, especially the right coronary artery, and the
ostia do not reach the graft, the Cabrol technique is useful, especially in redo operations.
Endocarditis and other inflammatory diseases involving the base of the aortic root are situations
in which adequate mobilization of the arteries may not be possible.
◆ Secure suturing of the valve to the annulus is essential. This anastomosis cannot be tested.
Any leaks under the left or right coronary arteries are impossible to visualize if a repair suture
is necessary. This is why I use 3-0 running Prolene sutures from the residual aorta to the
valve sewing cuff after tying the valve-interrupted sutures.
◆ The graft should be distended with cardioplegia to test the left coronary anastomosis after it
is performed, because this is a location that will be difficult to visualize later. With the graft
distended, the length to the distal aorta can be determined. I perform the distal end-to-end
anastomosis and redistend the graft with cardioplegia to determine the exact location for the
right coronary anastomosis accurately. This technique, along with proper mobilization of the
right coronary, prevents technical errors that could lead to inadequate flow through the coronary
artery.
◆ Do not leave the operating room without achieving good hemostasis.
References
1. Bentall H, De Bono A. A technique for complete replacement of the ascending aorta. Thorax. 1968;23:338–339.
2. Kouchoukos NT, Wareing TH, Murphy SF, Perrillo JB. Sixteen-year experience with aortic root replacement: results of 172 operations.
Ann Surg. 1991;214:308–320.
3. Rosengart TK. Anticoagulation self-testing after heart valve replacement. J Heart Valve Dis. 2002;11(suppl 1):S61–S65.
4. Kortke H, Korfer R. International normalized ratio self-management after mechanical heart valve replacement: is an early start
advantageous? Ann Thorac Surg. 2001;72:44–48.
5. Schmidtke C, Huppe M, Berndt S, et al. Quality of life after aortic valve replacement: self-management or conventional anticoagulation
therapy after mechanical valve replacement plus pulmonary autograft. Z Kardiol. 2001;90:860–866.
Bibliography
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Ehrlich MP, Ergin MA, McCullough JN, et al. Favorable outcome after composite valve-graft replacement in patients older than 65 years.
Ann Thorac Surg. 2000;71:1454–1459.
Ergin MA, Griepp EB, Lansman SL, et al. Hypothermic circulatory arrest and other methods of cerebral protection during operations on
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2000;70:542–546.
Yacoub MH, Gehle P, Chandrasekaran V, et al. Late results of a valve-preserving operation in patients with aneurysms of the ascending
aorta and root. J Thorac Cardiovasc Surg. 1998;115:1080–1190.
Yotsumoto G, Moriyama Y, Toyohira H, et al. Congenital bicuspid aortic valve: analysis of 63 surgical cases. J Heart Valve Dis.
1998;7:500–503.
Zehr KJ, Thubrikar MJ, Gong GG, et al. Clinical introduction of a novel prosthesis for valve-preserving aortic root reconstruction for
annuloaortic ectasia. J Thorac Cardiovasc Surg. 2000;120:692–698.
CHAPTER
15
Surgery of the
Left Heart Valve
Infective Endocarditis
Gösta B. Pettersson and Syed Tarique Hussain
Step 1. Pathogenesis, Pathology, and Microbiology of Left-Sided Infective Endocarditis1-6
◆ Infective endocarditis (IE) is the most severe and devastating complication of heart valve
disease, whether it is native valve endocarditis (NVE), prosthetic valve endocarditis (PVE),
or infection on another cardiac device. Despite advances in surgical technique, operations for
IE remain associated with the highest mortality of any valve disease.
◆ IE patients require a multispecialty team approach, which includes an infectious disease
specialist, cardiologist, and cardiac surgeon, with input from other specialties, such as neurology
and nephrology, when needed. This is because the clinical scenarios presented by patients
with IE are often very complex and require prompt diagnosis for the early institution of
antibiotic treatment and decision making related to complications, including the risk of
embolism and need for and timing of high-risk surgery.
◆ The microbiology of IE depends on whether the valve is native or prosthetic and whether
the infection is community or hospital acquired. Staphylococci, streptococci, and enterococci

are responsible for about 85% of all cases of IE.
◆ The infecting organisms produce and release virulence factors, including toxins, and enzymes.
The enzymes produced are organism-specific regarding tissue specificity and efficiency. The
severity of invasion and destruction, involvement of the valve annulus and beyond, occurs
in stages—cellulitis, abscess, abscess cavity, and finally pseudoaneurysm—and are a function
of virulence and time, with Staphylococcus aureus being the most aggressive and destructive.6
◆ The capacity of biofilm production, which protects bacteria from host immune defenses and
impedes antimicrobial efficacy, thus significantly reducing the ability of medical therapy alone
to eradicate the infection, is a hallmark of microorganisms commonly causing IE.5
225
Chapter 15 • Surgery of the Left Heart Valve Infective Endocarditis 225.e1
Keywords
infective endocarditis
native valve endocarditis
prosthetic valve endocarditis
Step 2. Diagnosis of Infective Endocarditis1-5,7
◆ A high index of suspicion and low threshold to perform the examination and studies necessary
to exclude IE are essential to diagnosis and early treatment. The diagnosis of IE is based on
clinical symptoms, physical findings, microbiology results, echocardiograms, and other results.
Echocardiography and blood cultures are the cornerstones of diagnosing IE. Whenever possible,
blood cultures should be obtained before starting antibiotics.
◆ Transthoracic echocardiography (TTE) must be supplemented with transesophageal echocar-
diography (TEE) in most cases of suspected PVE. TEE is more sensitive than TTE and remains
the present gold standard diagnostic modality for documenting IE. The role and added value
of cardiac computed tomography (CT), magnetic resonance imaging (MRI), and other comple-
mentary imaging technologies are still unclear.
◆ Duke criteria or modified Duke criteria are used to confirm the certainty of the diagnosis.
However, clinical judgment is very important on an individual basis, such as PVE and negative
blood cultures, and so on (Table 15.1).7
Step 3. Special Considerations Related to Surgery for Infective Endocarditis1-5,8-33
◆ Surgical treatment should be considered for patients with signs of heart failure, severe valve
dysfunction, PVE, invasion with paravalvular abscess or cardiac fistulas, recurrent systemic
embolization, large mobile vegetations, and persistent sepsis despite adequate antibiotic therapy
for more than 5 to 7 days. Most patients with PVE will require surgery. See the next section
for indications for surgery.
◆ Early surgery is recommended. Once a surgical indication is present, surgery should not be
delayed. Early surgery is defined as being carried out “during initial hospitalization independently
of completion of a full therapeutic course of antibiotics.”1,3,5
Table 15.1 Modified duke criteria for the diagnosis of infective endocarditis
MAJOR CRITERIA
Blood culture positive for infective endocarditis
• Typical microorganisms consistent with infective endocarditis from two separate blood cultures: Streptococcus viridans, S. bovis HACEK group, S. aureus,
or community-acquired enterococci, in the absence of a primary focus, or
• Microorganisms consistent with infective endocarditis from a persistently positive blood culture, defined as follows:
• At least two positive cultures of blood drawn >12 hours apart, or
• All of three or a majority of >four separate cultures of blood (with the first and last samples drawn at least 1 hour apart)
• Single positive blood culture for Coxiella burnetii or phase I IgG antibody titer to C. burnetii> 1:800
• Evidence of endocardial involvement:
• Echocardiogram positive for infective endocarditis: TEE recommended in patients with prosthetic valves, rated at least as “possible endocarditis” by
clinical criteria, or complicated endocarditis, such as endocarditis with paravalvular abscess; TTE as the first test in other patients as follows:
• Oscillating intracardiac mass on valve or supporting structures, in the path of regurgitant jets, or on implanted material in the absence of an
alternative anatomic explanation;
• Abscess:
• New partial dehiscence of prosthetic valve
• New valvular regurgitation (worsening or changing of preexisting murmur not sufficient)
MINOR CRITERIA
• Predisposition, predisposing heart condition, or injection drug use
• Fever
• Vascular phenomena: major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, and
Janeway lesions
• Immunologic phenomena: glomerulonephritis, Osler nodes, Roth spots, and rheumatoid factor
• Microbiologic evidence: positive blood culture but does not meet a major criterion as noted above, or serologic evidence of active infection with an
organism consistent with infective endocarditis
• Echocardiographic minor criteria eliminated
Definite endocarditis, two major criteria, or one major + three minor criteria, or five minor criteria; HACEK group, Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, and Kingella;
IE, infective endocarditis; possible endocarditis, one major + one minor, or three minor criteria; TEE, transesophageal echocardiography; TTEm transthoracic echocardiography.
Used with permission from Li JS, Sexton DJ, Mick N, et al: Proposed modifications to the Duke Criteria for the diagnosis of infective endocarditis. Clin Infect Dis 2000; 30:633.
Chapter 15 • Surgery of the Left Heart Valve Infective Endocarditis 227
◆ All patients with IE who require surgery but have neurologic symptoms should have a neurologic
evaluation and brain imaging by CT or MRI before the planned operation. Imaging may need
to be repeated in case of new or worsening symptoms.
◆ In general, surgery should be delayed for 1 to 2 weeks for patients with nonhemorrhagic
strokes and 3 to 4 weeks for patients with hemorrhagic strokes. For those with nonhemorrhagic
embolic strokes, earlier intervention may be justified. The risk of the worsening of stroke
symptoms must be weighed against the indications for surgery and risk of additional emboli
during the waiting period, in consultation with a neurologist.1-5,16,19-31
◆ The need for preoperative coronary angiography should be guided by normal criteria. CT
angiography is an alternative to assess coronary anatomy in patients with large aortic valve
vegetations.1-5
Step 4. Indications for Surgery in Left-Sided Infective Endocarditis1-5
1. Heart Failure
◆ Aortic or mitral IE or PVE with severe acute regurgitation or valve obstruction causing refractory
pulmonary edema or cardiogenic shock.
◆ Aortic or mitral IE with severe acute regurgitation or valve obstruction and persisting heart
failure or echocardiographic signs of poor hemodynamic tolerance (early mitral closure of

pulmonary hypertension).
◆ Aortic or mitral IE or severe prosthetic dehiscence with severe regurgitation and no heart
failure.
2. Uncontrolled Infection
◆ Locally uncontrolled infection (e.g., abscess, pseudoaneurysm, fistula, enlarging vegetation).

◆ Persisting fever and positive blood cultures more than 7 to 10 days not related to an extracardiac
cause.
◆ Infection caused by fungi or multiresistant organisms.
◆ PVE caused by staphylococci or gram-negative bacteria (most cases of early PVE).
3. Prevention of Embolism
◆ Aortic or mitral IE or PVE with large vegetations (> 10 mm) following one or more embolic
episodes despite appropriate antibiotic therapy.
◆ Aortic or mitral IE or PVE with large vegetations (> 10 mm) and other predictors of complicated
course (e.g., heart failure, persistent infection, abscess).

◆ Aortic or mitral or PVE with isolated very large vegetations (> 15 mm).
Step 5. Principles of Surgery for Infective Endocarditis1-5,9,12,18,32
◆ Objectives of IE surgery are to prevent additional embolic events, débride and remove all
infected and necrotic tissue and foreign material, and restore functional valve and cardiac
integrity.
◆ Adequate surgical débridement requires good surgical exposure. A median sternotomy is
required for most IE operations. Ministernotomy and right thoracotomy approaches are likely
to provide insufficient exposure if unexpected or more advanced and invasive disease is
encountered; these procedures are not recommended for IE surgery.
◆ Chest CT is recommended to assess the risk of sternal reentry in patients with previous cardiac
surgery.32 When an arterial structure such as an ascending aorta, pseudoaneurysm, or important

graft is in direct contact with the sternum, consideration should be given to peripheral
cannulation and the institution of cardiopulmonary bypass before sternotomy.5,32,34 Intraoperative
TEE is mandatory.
◆ Perfect myocardial protection is critical because the procedure is often long and complex.
This is achieved with initial induction with antegrade and retrograde blood cardioplegia and
repeat retrograde cardioplegia every 15 to 20 minutes. Open insertion of the retrograde coronary
sinus cannula secures perfect cardioplegia delivery.
◆ For those infections limited to the native valve cusps or leaflets (so-called simple IE), valve
repair or replacement with a biologic or mechanical valve prosthesis according to similar

principles as for patients with noninfected valves should be done. For very sick patients and
those with neurologic complications, a biologic valve is recommended to avoid added
anticoagulation-related complexity in postoperative management.
◆ For infection beyond the cusp or leaflets (advanced pathologies), radical débridement and
reconstruction may be required. Radical débridement means complete removal of foreign

material, necrotic tissue, and vegetations; it does not mean excision with wide margins, which
may cause additional damage, jeopardize valve repair, and make reconstruction more
difficult.
◆ All infected areas must be opened, unroofed, and cleaned out. In patients with PVE, débride-
ment should include removal of the old prosthesis and suture material.
◆ Dirty noncardiotomy suction should be used for the initial débridement and irrigation. The
use of cardiotomy suction is avoided when the field is grossly contaminated to minimize
blood contamination. Débridement is followed by generous irrigation. Surgical instruments
and gloves should be exchanged after the completion of débridement and irrigation.
◆ The excised valve specimens should be handled properly and divided between pathology and
microbiology. Molecular testing of the excised cardiac valves with a polymerase chain reaction
(PCR) assay should be considered when there is uncertainty regarding the causative
microorganism.
Step 6. Surgical Procedures
1. Native Aortic Valve Endocarditisa
◆ For limited localized infection and preserved cusp contour, repair may occasionally be possible.
The resulting cusp defect after the removal of vegetation is repaired with an autologous
pericardial patch. In most cases, cusp preservation is not possible, and valve replacement is
required. The choice is based on the usual criteria, as mentioned earlier.
a
References 1-6, 9, 12, 18, 33, 35, and 36.
◆ For infection limited to the native aortic valve cusps, complete removal of the native valve
cusps and replacement with a valve prosthesis should suffice. Extraaortic invasion of native
valve endocarditis is usually localized, and subcommisural invasion is most common. Often,
the site of annulus penetration is small, which hides a widely spread extraaortic infection
that requires unroofing of the entire infected area for adequate débridement.6
◆ For invasive pathology—infection beyond the valve cusps involving the annulus—radical
resection of all infected tissue and foreign material is necessary. Adequate débridement is
followed by reconstruction (Fig. 15.1).
◆ We recommend caution so as not to lose track of anatomy, cause injury to coronary arteries,
or sacrifice live left ventricular outflow tract (LVOT) muscle and surrounding structures to
make reconstruction more difficult and risky.
◆ When additional material is required for reconstruction, autologous pericardium is our prefer-
ence, but bovine pericardium or other materials can be used. Even in patients with invasive
disease, the tissue destruction usually leaves the LVOT intact, and no additional material is
required for the reconstruction in most cases.6,9
◆ For invasive disease requiring aortic root reconstruction, an aortic allograft is our preferred
choice. The more extensive and destructive the infection, the stronger is the argument in
favor of an allograft over alternative conduits with prosthetic valves.5,12
◆ Bioroots (bioprosthetic valve inside a graft), mechanical valve conduits, porcine aortic roots,
and bovine pericardial root reconstruction may also work if the allografts are unavailable. This
is also true for aortic PVE. The use of an allograft is no substitute for the radical débridement
of all infected tissue!
Step 7. Prosthetic Aortic Valve Endocarditis
◆ See Fig. 15.1.a

◆ A prosthetic aortic valve usually involves the sewing ring and, in contrast to native valve
endocarditis, the invasion is often circumferential. Although the deeper invasion and tissue
destruction can be anywhere around the annulus circumference, large root abscesses develop
preferentially posteriorly and to the left, under the pulmonary trunk.
◆ Bacterial invasion from the aortic root works its way from posterior aortic root invasion into
the right atrium and triangle of Koch; destroying the atrioventricular node and upper end of
the bundle of His is the most common cause of heart block in IE. If a patient has heart block
of any degree, the right atrium must be opened for inspection.6
◆ Occasionally. the sewing ring is infected, but the infection has not yet penetrated deeper into
the annulus. In these cases, it is sometimes feasible to perform adequate débridement and
implant another prosthetic valve of choice without the need for root replacement.
◆ More commonly, the infection in PVE needs more extensive débridement and root reconstruc-
tion. This is done in a similar fashion as that discussed earlier, in the aortic NVE section
(see Fig. 15.1).
a
References 1-6, 8-15, 17, 18, 33, and 35-37.
Figure 15.1 Pettersson GB, Hussain ST, Shrestha NK, et al. Infective endocarditis: an atlas of disease progression for describing, staging,
coding, and understanding the pathology. J Thorac Cardiovasc Surg 2014;147:1142–9.
Figure 15.1 Prosthetic valve endocarditis with sepsis and heart block. (A) Infected mechanical prosthesis with vegetations on sewing ring
(arrow). (B) Same patient with perforation visible in right atrium (RA; arrow). (C) After debridement, destruction in location of atrioventricular
node is seen. This infection has worked its way around the aorta counterclockwise over an extended period, displaying a pseudoaneurysm
stage anteriorly and an active cellulitis stage posteriorly and into right atrium. Left ventricular outflow tract (LVOT) is intact and ready for
reconstruction. (D) After complete debridement of all infected tissue, RA is reconstructed with autologous pericardium (arrow). (E) Aortic
allograft is sutured to LVOT with running monofilament suture. (F) Allograft is tied down and well seated, allowing debrided infected areas
to communicate and drain to pericardium. CFB, central fibrous body; CS, coronary sinus; LCA, left coronary artery; RCA, right coronary
artery; TV, tricuspid valve.
1. Allograft Root Replacement Technique (Fig. 15.1.)6,18,34
◆ The LVOT is almost always preserved after extensive débridement to allow direct anastomosis
to the allograft.6
◆ The main landmarks for guiding the reconstruction and indicating the level of the proximal
suture line are the intervalvular fibrosa (IVF) corresponding to the base of the anterior mitral
leaflets and the two trigones on either side. Both coronary buttons should be adequately
mobilized and large enough for any future reoperation.
◆ The LVOT is sized with Hegar dilators, and an allograft with an internal diameter 2 to 3 mm
less than the diameter of the annulus is chosen. Correct sizing is important.
◆ If a smaller allograft is unavailable, the annulus size is reduced by placing two 2-0 Gore-Tex
sutures around the annulus and tying them down over a Hegar dilator. We avoid the use of
felt or additional support material for the suture line. The allograft is implanted in an anatomic
orientation.
◆ The proximal suture line (between the allograft and LVOT) is performed with running 3-0
or 4-0 monofilament sutures, allowing seating of the allograft deep inside the annulus. A
running technique instead of an interrupted technique allows the distribution of tension
equally to all suture loops.
◆ The allograft is lowered into the LVOT with gentle traction on the sutures, and perfect seating
is ensured. The coronary buttons are reimplanted on the allograft in anatomic positions using
running 4-0 or 5-0 monofilament sutures.
◆ The distal anastomosis (allograft to aorta) is performed with running 4-0 monofilament
sutures. The length of the allograft should be generous to allow for tension-free anastomosis
on either end.
◆ Reconstruction of a destroyed IVF in advanced aortic root destruction is discussed separately.
2. Mitral Valve Endocarditis1-5,9,12-15,18,38-45
◆ Mitral valve endocarditis has some specific features related to its anatomy and degenerative
pathologic features. This makes radical débridement more difficult to accomplish in mitral
cases with atrioventricular groove invasion, necrosis, and abscess formation. This often means
sealing off the infected and débrided cavity, with a resulting increased risk of recurrent
infection.
◆ Mitral annular calcium is frequently the starting site of both infection and invasion. Invasive
disease is less common with mitral than with aortic valve endocarditis and, when invasion
occurs, it is often shallow. Invasion of the anterior annulus leads to destruction of the subaortic
curtain; invasion into the posterior annulus leads to entry into the atrioventricular groove
and separation of the atrium from the ventricle.
◆ The mitral valve is exposed via a left atriotomy through the interatrial groove (Sondergaard’s
groove) or transseptally through the right atrium, which we prefer. If the left atrium is small,
an extended transseptal dome approach can be used for increased exposure.
◆ Dual exposure via an aortotomy is helpful in some cases for débridement and suture placement
and to avoid aortic valve injury.

3. Native Mitral Valve Endocarditis1-5,18,38-45
◆ All grossly infected tissue is removed and the unaffected leaflet, chordae, and papillary muscles
are preserved to support the posterior annulus. Mitral valve repair is preferred and can be
performed safely as long as sufficient tissue remains to allow reconstruction (Figs. 15.2 and
15.3). Standard mitral valve repair techniques are used.
◆ A prosthetic mitral annuloplasty ring or band has a very low added risk of recurrent infection
and can be safely used to provide durable repair. If repair is not possible, the valve needs to
be replaced. The choice of prosthesis follows the normal principles of valve surgery.
◆ In case of invasive disease requiring reconstruction of the mitral annulus, the patches (usually
autologous or bovine pericardium) must be generous to minimize stress on the suture lines.
Relatively small lesions on the anterior leaflet (so-called kissing lesions, typically in association
with aortic valve IE) require débridement and repair with autologous pericardium using
running polypropylene sutures.
◆ In patients with extensive disease involving destruction of the aortic valve and mitral valve
along the base of the anterior mitral leaflet, an aortic allograft with an attached anterior leaflet
of mitral valve provides additional benefit. It can be used to repair the defect in the anterior
mitral leaflet and reconstruct the aortomitral curtain.
◆ Localized defects after débridement of the posterior leaflet can be treated by triangular or
quadrangular resection. A sliding repair can be added, if required.

A B
Figure 15.2 A, Pettersson GB, Hussain ST, Shrestha NK, et al. Infective endocarditis: an atlas of disease
progression for describing, staging, coding, and understanding the pathology. J Thorac Cardiovasc Surg
2014:147;1142–9.
A B
Figure 15.3
Figure 15.2 Mitral valve endocarditis with large vegetation on posterior mitral valve leaflet, with leaflet perforation. Patient had a preoperative
embolic stroke. Valve was repaired after excising the vegetation.
Figure 15.3 (A) Mitral valve endocarditis involving the medial trigone. (B) After resection and repair with a pericardial patch and an
anuloplasty ring.
4. Prosthetic Mitral Valve Endocarditis1-5,11,38-46
◆ Unlike prosthetic aortic valve endocarditis, the exposure for débridement and removal of the
old prosthesis and suture material is worse for prosthetic mitral valve endocarditis. A dual
approach via the left atrium and aorta, as described earlier, is very helpful.
◆ Use a generous patch (to minimize tension on the suture line) if annulus reconstruction is
required. Anchorage to the ventricular muscle to prevent communication and entry into the
paravalvular cavities beneath the valve is very important (Fig. 15.4).
◆ David’s technique uses a semicircular pericardial patch for annular reconstruction, with one
side of the patch secured to the endocardium of the left ventricle and the other side secured
to the left atrium. The new prosthesis is then affixed to the reconstructed annulus.
◆ In case the atrioventricular separation is shallow and narrow, the suture closure technique
can be used.46 Valve sutures are then placed with pledgets on the ventricular side.
B
Figure 15.4
Figure 15.4 Reconstruction of mitral anulus. (A) Prosthetic valve endocarditis with posterior paravalvular abscess. The valve has been
removed and the abscess debrided. A generous pericardial patch sewn to the ventricle and atrium excludes the abscess cavity and reconstructs
the anulus. (B) Valve sutures are placed with the pledgets on the ventricular side. (C) A new prosthesis is affixed to the pericardial patch
and anulus.
5. Double-Valve Endocarditis34,46-48
◆ Most cases of endocarditis involving both the aortic and mitral valves can be managed in a
manner similar to what has been discussed for each of these valves separately. Destruction of
the IVF or aortomitral curtain requires reconstruction, which is technically demanding and
is a high-risk surgery (Fig. 15.5). IVF destruction usually occurs in the setting of PVE affecting
both the aortic and mitral valves, but can occur in any combination or can be extensive
disease of the aortic or mitral valve, with extension into the IVF.
◆ Excellent exposure is required. This can be accomplished by using an extended transseptal
approach or by dividing the superior vena cava and extending the left atriotomy toward the
dome of the left atrium. This therefore allows excellent exposure for débridement of the aortic
and mitral valves, as well as the IVF. Often, however, an incision in the dome and IVF is
enough.
◆ Débridement is followed by generous irrigation of the operative field. The mitral prosthesis
is sized. The IVF corresponds to one-third of the circumference, and the posterior annulus
from trigone to trigone corresponds to two-thirds of the circumference.
◆ The mitral valve prosthesis is implanted first. Valve sutures are placed posteriorly from trigone
to trigone, with pledgets on the ventricular side. Two-thirds of the mitral valve prosthesis is
secured posteriorly at this time.
◆ The IVF is reconstructed using any available tissue or patch material—autologous or bovine
pericardium, synthetic material—or by direct implantation of an aortic allograft by suturing

the allograft mitral valve directly to the mitral valve prosthesis. If using a patch material, a
generous double-layered patch is sewn to the mitral prosthesis’ sewing ring and anchored to
both the trigones. It is critical to secure tension-free closure of the corner where the mitral
annulus, left ventricular wall, and aortic annulus meet.
◆ The lower sheet of the patch is used to close the dome of the left atrium, and the upper sheet
is used for reconstruction of the aortic root. The aortic prosthesis is implanted by securing
it to the native aortic annulus and to the patch.
◆ As discussed earlier, when an aortic allograft is used, the allograft mitral valve is directly sewn
to the mitral prosthesis. A separate patch to close the left atrial dome may still be required.
The most critical area for bleeding is from the lateral trigone and requires tension-free
reconstruction.
A B
C D
Figure 15.5 From Pettersson GB, Hussain ST, Ramankutty RM, et al. Reconstruction of fibrous skeleton: technique, pitfall,
results. Multimed Man Cardiothorac Surg. 2014.
Figure 15.5 Reconstruction of the fibrous trigones. (A) Infection involves the mitral and aortic valves. After removing both the aortic and
mitral prostheses, the divided intervalvular fibrosa converts the aortic and mitral orifices into a single large opening into the left ventricle.
Notice that the planes of the mitral and aortic anuli are at right angles to each other. (B) Mitral prosthesis in place, with two-thirds of the
sewing ring placed along the posterior mitral anulus and a residual defect toward the aorta anteriorly. (C) A triangular autologous pericardial
patch is used to reconstruct the intervalvular fibrosa and close the roof of the left atrium. The base of the patch is sewn to the anterior third
of the mitral prosthesis. (D) Implantation of an aortic allograft. The base of the allograft mitral valve is sewn to the mitral valve prosthesis
and patch. It is important to pay attention to the corners by the central fibrous body and the lateral trigone in order to ensure that the
corners are sealed and no sutures are under tension to avoid tears and leaks.
Step 8. Postoperative Complications and Management1-5,9,12,34
◆ Postoperative complications in patients undergoing surgery for active endocarditis are common.
Postoperative sepsis is very common in these patients. They commonly present with vasoplegia
and hypotension. A combination of sepsis, prolonged cardiopulmonary bypass times, and
extensive débridement and major reconstruction may cause severe coagulopathy and excessive
bleeding in the postoperative period.
◆ Our recommended way of dealing with postoperative coagulopathy in the operating room is
as follows: controlling any surgical bleeders before giving protamine, packing and avoiding
suctioning for 20 to 30 minutes after protamine to allow for clotting before attempting
additional surgical hemostasis, and use of blood products as required.
◆ All patients with active endocarditis receive postoperative antibiotics; the standard duration
is 6 weeks when the infection is active at the time of surgery. The duration of therapy may
be modified by specific clinical scenarios or organisms; thus, antibiotic treatment and its
duration should be carried out in consultation with an infectious disease specialist. In patients
with fungal endocarditis, we recommend a lifelong oral antifungal for suppression because
we have seen numerous recurrences after the antifungal has been stopped.
◆ Postoperatively, patients should be reviewed for probable sources of bacteremia, depending
on the specific causative microorganism. Apart from teeth and mouth, patients with Streptococcus
gallolyticus often have colon polyps or colon cancer and should undergo a colonoscopy.
◆ All patients should have an echocardiogram before discharge to verify the surgical repair and
establish a baseline echocardiogram for follow-up.
Step 9. Clinical Outcomes1-5,9-16,38-45
◆ Despite significant improvement in surgical results, in-hospital mortality for a patient undergoing
IE surgery remains higher than for any other valve surgery. Even with appropriate antibiotics
and surgical intervention, reported in-hospital mortality is 15–20%, and 1-year mortality has
approached 40%.1-5 Traditional factors predicting worse outcomes in endocarditis surgery
have been PVE, invasive stage, which includes abscesses, and S. aureus.
◆ High-volume centers with extensive experience treating endocarditis have more recently
reported lower hospital mortality for surgically treated left-sided endocarditis (8% 30-day
mortality). These centers have also demonstrated similar improved survival for NVE as well
as PVE.5,9,12
◆ Surgically treated left-sided invasive IE has a worse hospital mortality rate than noninvasive
cases (11% vs. 4.4%), mainly because of invasive mitral valve disease. The outcomes after
surgery for aortic valve IE were similar whether or not the disease was invasive (Fig. 15.6).9
◆ For mitral valve IE, event-free survival, hospital mortality, and long-term survival are all
superior after mitral valve repair compared to replacement.38-45

100
100
90
90
80
Aortic 80
70
70
Mitral
Survival (%)
60
Survival (%)
60
50
50
40
Aortic + Mitral 40
30 30
20 20
10 10
0 0
0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7
A Years B Years
100
90
80
70
Survival (%)
60
50
40
30
20
10
0
0 1 2 3 4 5 6 7
C Years
Figure 15.6 Adapted with permission from Hussain ST, Shrestha NK, Gordeon SM, et al. Residual patient, anatomic, and surgical obstacles
in treating active left-sided infective endocarditis. J Thorac Cardiovasc Surg 2014;148:981–8.
Figure 15.6 Survival after surgery for aortic valve endocarditis. (A) Survival after surgery for left-sided infective endocarditis (IE), stratified
by the involved valve. Each symbol represents a death, and vertical bars represent the 68% confidence limits, equivalent to ±1 standard error
in each figure. Filled circles indicate aortic valve IE alone; open circles, mitral valve IE alone; and triangles, aortic and mitral valve IE. Survival
was significantly lower in the mitral and combined groups than in the isolated aortic patients (P<.0001). (B) Survival after surgery for native
(solid blue lines) or prosthetic (dashed red lines) aortic valve IE. (C) Survival after surgery for invasive (red lines) versus noninvasive (blue
lines) aortic valve IE.
Step 10. Key Pearls for Infective Endocarditis Surgery
◆ The objectives of endocarditis surgery are to débride and remove all infected and necrotic
tissue and foreign material and restore functional valves and cardiac integrity.
◆ Other key surgical principles are generous irrigation after débridement, the use of an allograft
for invasive aortic valve endocarditis, and avoiding the use of additional foreign material and
an adhesive (e.g., BioGlue).
◆ In the end, however, the choice of prosthesis is less crucial for the surgical outcome than the
need for complete débridement.

◆ The optimal management of patients with an embolic stroke or cerebral hemorrhage remains
a difficult challenge with regard to optimal timing of surgery.

◆ Surgery for endocarditis is indicated as soon as a surgical indication is present. Earlier surgery
prevents an additional embolism and avoids further destruction and invasion.
References
1. Baddour LM, Wilson WR, Bayer AS, et al. Infective endocarditis in adults: diagnosis, antimicrobial therapy, and management of
complications: a scientific statement for healthcare professionals from the American Heart Association. Circulation.
2015;132:1435–1486.
2. Habib G, Lancellotti P, Antunes MJ, et al. 2015 ESC guidelines for the management of infective endocarditis: The Task Force for the
Management of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by: European Association for
Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM). Eur Heart J. 2015;36:3075–3128.
3. Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease:
executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
Circulation. 2014;129:2440–2492.
4. Byrne JG, Rezai K, Sanchez JA, et al. Surgical management of endocarditis: the Society of Thoracic Surgeons clinical practice
guideline. Ann Thorac Surg. 2011;91:2012–2019.
5. Pettersson GB, Coselli JS, Hussain JT, et al. 2016 The American Association for Thoracic Surgery (AATS) consensus guidelines:
surgical treatment of infective endocarditis: executive summary. J Thorac Cardiovasc Surg. 2017;153:1241–1258.
6. Pettersson GB, Hussain ST, Shrestha NK, et al. Infective endocarditis: an atlas of disease progression for describing, staging, coding
and understanding the pathology. J Thorac Cardiovasc Surg. 2014;147:1142–1149.
7. Li JS, Sexton DJ, Mick N, et al. Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis. Clin Infect Dis.
2000;30:633–638.
8. Cahill TJ, Baddour LM, Habib G, et al. Challenges in infective endocarditis. J Am Coll Cardiol. 2017;69:325–344.
9. Hussain ST, Shrestha NK, Gordon SM, et al. Residual patient, anatomic, and surgical obstacles in treating active left-sided infective
endocarditis. J Thorac Cardiovasc Surg. 2014;148:981–988.
10. Gaca JG, Sheng S, Daneshmand MA, et al. Outcomes for endocarditis surgery in North America: a simplified risk scoring system. J
Thorac Cardiovasc Surg. 2011;141:98–106, e1-2.
11. David TE, Gavra G, Feindel CM, et al. Surgical treatment of active infective endocarditis: a continued challenge. J Thorac Cardiovasc
Surg. 2007;133:144–149.
12. Manne MB, Shrestha NK, Lytle BW, et al. Outcomes after surgical treatment of native and prosthetic valve infective endocarditis. Ann
Thorac Surg. 2012;93:489–493.
13. Thuny F, Grisoli D, Collart F, et al. Management of infective endocarditis: challenges and perspectives. Lancet. 2012;379:965–975.
14. Prendergast BD, Tornos P. Surgery for infective endocarditis: who and when? Circulation. 2010;121:1141–1152.
15. Thuny F, Beurtheret S, Mancini J, et al. The timing of surgery influences mortality and morbidity in adults with severe complicated
infective endocarditis: a propensity analysis. Eur Heart J. 2011;32:2027–2033.
16. Kang DH, Kim YJ, Kim SH, et al. Early surgery versus conventional treatment for infective endocarditis. N Engl J Med.
2012;366:2466–2473.
17. Savage EB, Saha-Chaudhuri P, Asher CR, et al. Outcomes and prosthesis choice for active aortic valve infective endocarditis: analysis
of the Society of Thoracic Surgeons Adult Cardiac Surgery Database. Ann Thorac Surg. 2014;98:806–814.
18. Bedeir K, Reardon M, Ramlawi B. Infective endocarditis: perioperative management and surgical principles. J Thorac Cardiovasc Surg.
2014;147:1133–1141.
19. Funakoshi S, Kaji S, Yamamuro A, et al. Impact of early surgery in the active phase on long-term outcomes in left-sided native valve
infective endocarditis. J Thorac Cardiovasc Surg. 2011;142:836–842, e1.
20. Chu VH, Park LP, Athan E, Delahaye F, et al. Association between surgical indications, operative risk, and clinical outcome in infective
endocarditis: a prospective study from the International Collaboration on Endocarditis. Circulation. 2015;131:131–140.
21. Hodges KE, Hussain ST, Stewart WJ, Pettersson GB. Surgical management of infective endocarditis complicated by ischemic stroke. J
Card Surg. 2017;32:9–13.
22. Yanagawa B, Pettersson GB, Habib G, et al. Surgical management of infective endocarditis complicated by embolic stroke: practical
recommendations for clinicians. Circulation. 2016;134:1280–1292.
23. Hess A, Klein I, Iung B, et al. Brain MRI findings in neurologically asymptomatic patients with infective endocarditis. AJNR Am J
Neuroradiol. 2013;34:1579–1584.
24. Duval X, Iung B, Klein I, et al. Effect of early cerebral magnetic resonance imaging on clinical decisions in infective endocarditis: a
prospective study. Ann Intern Med. 2010;152:497–504.
25. Barsic B, Dickerman S, Krajinovic V, et al. Influence of the timing of cardiac surgery on the outcome of patients with infective
endocarditis and stroke. Clin Infect Dis. 2013;56:209–217.
26. Garcia-Cabrera E, Fernandez-Hidalgo N, Almirante B, et al. Neurological complications of infective endocarditis: risk factors,
outcome, and impact of cardiac surgery: a multicenter observational study. Circulation. 2013;127:2272–2284.
27. Sorabella RA, Han SM, Grbic M, et al. Early operation for endocarditis complicated by preoperative cerebral emboli is not associated
with worsened outcomes. Ann Thorac Surg. 2015;100:501–508.
28. Okita Y, Minakata K, Yasuno S, et al. Optimal timing of surgery for active infective endocarditis with cerebral complications: a
Japanese multicentre study. Eur J Cardiothorac Surg. 2016;50:374–382.
29. Yoshioka D, Toda K, Sakaguchi T, et al. Valve surgery in active endocarditis patients complicated by intracranial haemorrhage: the
influence of the timing of surgery on neurological outcomes. Eur J Cardiothorac Surg. 2014;45:1082–1088.
30. Yoshioka D, Sakaguchi T, Yamauchi T, et al. Impact of early surgical treatment on postoperative neurologic outcome for active
infective endocarditis complicated by cerebral infarction. Ann Thorac Surg. 2012;94:489–495.
31. Misfeld M, Girrbach F, Etz CD, et al. Surgery for infective endocarditis complicated by cerebral embolism: a consecutive series of 375
patients. J Thorac Cardiovasc Surg. 2014;147:1837–1844.
32. Roselli EE, Pettersson GB, Blackstone EH, et al. Adverse events during reoperative cardiac surgery: frequency, characterization, and
rescue. J Thorac Cardiovasc Surg. 2008;135:316–323.
33. Jassar AS, Bavaria JE, Szeto WY, et al. Graft selection for aortic root replacement in complex active endocarditis: does it matter? Ann
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Cardiothorac Surg. 2014;2014:Jun 18.
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involving the aortic valve? J Thorac Cardiovasc Surg. 2016;151:1239–1246.
36. Leontyev S, Borger MA, Modi P, et al. Surgical management of aortic root abscess: a 13-year experience in 172 patients with 100%
follow-up. J Thorac Cardiovasc Surg. 2012;143:332–337.
37. Sabik JF, Lytle BW, Blackstone EH, et al. Aortic root replacement with cryopreserved allograft for prosthetic valve endocarditis. Ann
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38. Shimikawa T, Kasegawa H, Matsuyama S, et al. Long-term outcomes of mitral valve repair for infective endocarditis. Ann Thorac Surg.
2009;88:733–739.
39. Evans CF, Gammie JS. Surgical management of mitral valve infective endocarditis. Semin Thorac Cardiovasc Surg. 2011;23:232–240.
40. Doukas G, Oc M, Alexiou C, et al. Mitral valve repair for active culture-positive infective endocarditis. Heart. 2006;92:361–363.
41. Feringa HH, Shaw LJ, Poldermans D, et al. Mitral valve repair and replacement in endocarditis: a systematic review of literature. Ann
Thorac Surg. 2007;83:564–570.
42. Ruttmann E, Legit C, Poelzl G, et al. Mitral valve repair provides improved outcome over replacement in active infective endocarditis.
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2005;111:2532–2536.
44. Feringa HH, Bax JJ, Klein P, et al. Outcome after mitral valve repair for acute and healed infective endocarditis. Eur J Cardiothorac
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body: an analysis of clinical outcomes. J Thorac Cardiovasc Surg. 2005;129:286–290.
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48. de Kerchove L, Vanoverschelde JL, Poncelet A, et al. Reconstructive surgery in active mitral valve endocarditis: feasibility, safety and
durability. Eur J Cardiothorac Surg. 2007;31:592–599.
CHAPTER
16
Transcatheter Aortic
Valve Replacement
Mani Arsalan, Won-Keun Kim, and Thomas Walther
◆ Transcatheter aortic valve replacement (TAVR) is a relatively new technique that has been
clinically applied mostly in higher risk older patients in the past 10 years. Major differences
in comparison to conventional aortic valve replacement (AVR) are as follows:
◆ Indirect visualization of the target by means of fluoroscopy, transesophageal echocardiography
(TEE), and computed tomography (CT)

◆ Implantation of a specific transcatheter prosthesis consisting of biologic valve leaflets and
usually a metal stent, which can be crimped and thus inserted through a small delivery
sheath
◆ Implantation via remote access on the beating heart, usually without any heart-lung machine
support. Due to these major differences in the technical approach, additional preoperative
considerations are required for TAVR.
◆ Compared to surgical aortic valve replacement (SAVR), some additional anatomic structures
need to be taken into account for TAVR. Although in SAVR the calcification amount and
pattern, presence of a bicuspid valve, and coronary distance are of minor interest, they are
important for preoperative TAVR planning.
◆ The coronary distance (distance between the aortic annulus and left main coronary artery)
is of importance. A distance less than 10 mm, as well as a previous plaque in the coronary
artery, heavily calcified aortic leaflet, narrow aortic annulus, and superficial sinus of Valsalva
are risk factors for coronary obstruction after TAVR.
◆ Calcifications cannot be removed during TAVR. Thus, aortic valve calcification, depending
on its quantity and asymmetry, is associated with paravalvular leaks, whereas left ventricular
outflow tract (LVOT) calcification increases the risk for annular rupture.
◆ Bicuspid aortic valves often have larger annular dimensions. More calcified, irregular, and
bulky leaflets further complicate precise positioning and full apposition of the device with
the annulus, thus increasing the risk for paravalvular leaks.
◆ A horizontal aorta (in the absence of a standardized definition, according to clinical judgment,
this can be considered to be an aorta with an angle ≤ 30 degrees from horizontal) complicates
valve crossing, positioning, and aligning of the prosthesis in relation to the annulus.
◆ Other anatomic structures that need to be considered depend on the TAVR access route—
retrograde transfemoral (TF), transsubclavian (TSc), transaortic (TAo), or antegrade transapical

(TA) approach.
242
Chapter 16 • Transcatheter Aortic Valve Replacement242.e1
Keywords
Transcatheter aortic valve replacement

Chapter 16 • Transcatheter Aortic Valve Replacement 243
◆ Because the boundaries between cardiac surgery and interventional cardiology blur in TAVR,
a heart team is essential for preprocedure decision making, procedure performance, and
postprocedure care. Thus, the heart team has emerged as a class of recommendation I (COR
I) indication in both the European and US guidelines for TAVR.1,2
1. Indications for Aortic Valve Replacement for Aortic Stenosis
◆ TAVR is recommended for patients with severe symptomatic aortic stenosis (AS) who are not
suitable to undergo conventional AVR as assessed by a heart team, who are likely to gain
improvement in their quality of life, and who have a life expectancy of more than 1 year after
consideration of their comorbidities.
◆ Transcatheter aortic valve implantation (TAVI) should also be considered for high-risk patients
with severe symptomatic AS who are suitable for surgery, but for whom TAVI is favored by
a heart team as a COR IIa, level of evidence (LOE) B recommendation.
◆ Various risk scores have been used to aid in decision making by the heart team. Among these,
the logistic EuroScore (ES) is known to overestimate the effective mortality; a logistic ES of
20% or more has been suggested as an indication for TAVI. Its successor, the ES II, has been
shown to correlate better between the anticipated and observed survival. Currently the most
reliable score is the Society of Thoracic Surgeons (STS) predicted risk of mortality (STS-PROM)
score, with a value of more than 8% to 10% indicating high risk.3 However, none of these
risk scores were designed for TAVR. The STS/American College of Cardiology (ACC) TAVR
In-Hospital Mortality Risk score was recently published and combines easy calculation and
good correlation with the real in-hospital mortality.
◆ Regardless of risk scores, other factors include status post–coronary artery bypass grafting
with a patent graft, porcelain aorta, severe chronic obstructive pulmonary disease (COPD),
status postradiation therapy, renal failure, low ejection fraction, and significant frailty, among
others. These may be clear indicators leading to a heart team decision in favor of performing
TAVR.
◆ Thus, TAVR is already widely performed in intermediate-risk patients. The transcatheter valve
therapy registry (TVT registry) has reported a median STS risk score of approximately 7% in
patients treated with TAVI from November 2011 to March 2013.4 During the same period,
the median STS score in the German aortic valve registry (GARY) was 5.0, indicating an
intermediate-risk profile.5 The trend to expand the indications for TAVR to intermediate-risk
and eventually low-risk patients has been gaining momentum after recent studies demonstrated
the noninferiority of TAVR compared to SAVR in intermediate-risk patients.6,7
◆ Despite this trend, it has to be considered that comprehensive long-term follow-up for TAVR
prostheses is not available yet. However, long-term durability will be a prerequisite for further
expansion of the procedure, especially to younger patients.
2. Indications for Transcatheter Aortic Valve Replacement in Aortic Regurgitation
◆ Aortic regurgitation (AR) causes about 11% of all native valve disease.8 However, because
calcification is usually absent in isolated AR, anchoring of a TAVR valve is more challenging
and thus a relative contraindication for TAVR. Various devices have been used off-label for
successful implantation in patients with AR, but only small series have been reported.
◆ Up to now, the Jenavalve prosthesis (Jenavalve Technology, Munich), which clips on to the
aortic valve leaflets, was the first CE mark–approved device for the treatment of isolated AR
and has shown a high success rate in a multicenter study.9 (CE marking is a certification mark
indicating conformity with health, safety, and environmental protection standards for products
sold within the European Economic Area.)
◆ However, despite proven feasibility, neither European nor US guidelines recommend TAVR
for pure AR.
3. Preoperative Planning
◆ Because TAVR is performed without direct vision of the operating field, preoperative planning
and imaging are essential.
◆ After assessment of the perioperative risk and the heart team’s decision that TAVR might be
a treatment option, some anatomic characteristics have to be determined to evaluate if TAVR

is feasible and to estimate the technical risk of the procedure.
◆ With the currently available devices, TAVR can only be performed in patients with an aortic
annulus between 18 and 29 mm (Table 16.1). This, however, applies to more than 95% of
potential patients.
◆ The distance between the annulus and coronary ostia should be more than 10 mm, and/or
the aortic sinus needs to be sufficiently large to prevent occlusion of the coronary ostia by
calcifications or by native valve leaflets.
◆ Ideally, annulus measurements are performed by TEE in two-dimensional and three-dimensional
views, as well as by CT. In recent years, specific CT software tools have been developed that
allow for precise and automated measurement of the aortic root, including the effective aortic
annulus, based on its area and/or perimeter (e.g., 3mensio Structural Heart, Pie Medical
Imaging, Maastricht, The Netherlands).
◆ The improved preoperative planning and imaging techniques have been an important contributing
factor to decrease the incidence of severe paravalvular regurgitation and annulus rupture after
TAVR. Thus, careful screening cannot just stratify the risk more precisely than a risk score,
but is required for assessment of the feasibility of TAVR and for selection of the most appropriate
access and valve.
Table 16.1 Sizing chart for the most commonly used transcatheter aortic valve replacement (TAVR) devices
ANNULUS SIZE
TAVR VALVE 18 19 20 21 22 23 24 25 26 27 28 29
SAPIEN 3 23 23 23 23/26 26 26 26/29 29 29 29
SAPIEN XT 20 20 20/23 23 23 23/26 26 26 26/29 29 29 29
CoreValve Evolut R 23 23 23/26 26 26 26/29 29 29 29
Symetis Acurate TA S S S S, M M M, L L L
Portico 23 23 23/25 25 25/27 27 27/29 29 29
Direct Flow 23 23 23/25 23/25 25 25/27 27 27/29 29 29
Lotus 23 23 23 23/25 25 25/27 27 27
4. Valve Choice
◆ Current devices for performing TAVR are mostly second- or third-generation valves that have
shown improved patient outcomes and enhanced safety compared to the first-generation
devices. These include specific features to minimize paravalvular leakage, reduction in delivery
system and sheath diameter to allow TF access, despite smaller access vessels, options to
retrieve the device partly or completely after implantation (if possible, after it is already fully
functional), and the possibility of commissural orientation with exact anatomic positioning.
◆ TAVR devices consist of a specifically designed valve and application system, which is usually
inserted over a guidewire by means of a sheath or in a sheathless manner. The valve consists
of a thin stent, which is balloon-expandable (stainless steel or cobalt-chromium) or self-
expanding (usually nitinol). Valve leaflets consist of bovine pericardium, porcine pericardium,
or porcine leaflets. Some of these valves have an additional anticalcification treatment similar
to that of conventional surgical xenografts to protect against tissue degeneration and thus
achieve optimal valve durability.
◆ An overview of the most common prostheses is shown in Fig. 16.1.
◆ The balloon-expandable Edwards SAPIEN valve (Edwards Lifesciences, Irvine, CA) is available
for retrograde (TF, TAo, TS) and antegrade (TA) access and is currently available in its third
generation, the SAPIEN 3. It is a rather short device designed for subcoronary implantation,
with the leaflets located in an intraannular position.
◆ The self-expanding Medtronic CoreValve (Medtronic, Minneapolis) is available for retrograde
implantation only. The device stent is longer and thus requires an implantation that surpasses
the coronary ostia while obtaining additional aortic stabilization. The leaflets are attached in
a supraannular position.
◆ In addition to these two most frequently implanted prostheses, several other devices have
been developed:
◆ The Acurate neo system (Symetis, Dusseldorf, Germany) has gained the largest clinical
following after the previously mentioned valves and is available for TF-TAVR and TA-TAVR.
The Acurate valve has a self-expanding nitinol stent that can be placed in an anatomically
correct position, matching the commissures to the native ones quite easily (with the TA
approach), and that allows for partial repositioning.
◆ The Portico device (St. Jude Medical, St. Paul, MN) consists of a nitinol stent that extends
from the aortic annulus to the ascending aorta. It allows for retrieval after up to 80% of
deployment, for which valve functionality can be assessed.
◆ The Lotus valve (Boston Scientific, Marlborough, MA) consists of a nitinol mesh, which is
quite long in the crimped position and foreshortens during deployment. Complete retrieval
of the device is possible, allowing for complete assessment of valve function before final
detachment of the delivery system.
◆ The Direct Flow valve (Direct Flow Medical, Santa Rosa, CA) is unique in design. It consists of
two nonmetallic, inflatable, double-ring structures that are interconnected by a tubular bridging
system. Initially, the valve is filled with a radiopaque exchange solution that is replaced with
a polymer once the correct position in the native aortic annulus has been achieved.
◆ The Jenavalve TA system (Jenavalve Technology, Munich) is a unique self-expandable stent
with additional feelers to guide positioning at the annular level together with commissural
alignment and safe anchoring. It is the only device approved for the treatment of AR (CE
mark–approved device).
◆ The Venus A-Valve (Venus MedTech, Hangzhou, China) is the only TAVR device meeting
China Food and Drug Administration clinical requirements. It is a self-expanding nitinol

stent frame that carries porcine pericardial leaflets and can be delivered via TF, TA, TSc,
and TAo approaches.
◆ The Braile Inovare prosthesis (Braile Biomédica, São José do Rio Preto, Brazil) is a balloon-
expandable device with a cobalt-chromium frame and a single sheet of bovine pericardium
comprising the leaflets. It is already commercially available in Brazil, but currently only
suitable for TA access.
◆ Other devices are in clinical trials or are currently still under development.
A B
Edwards Edwards Medtronic Medtronic Symetis

SAPIEN® XT SAPIEN® 3 CoreValve® CoreValve® Evolut Acurate neoTH
C D E
St. Jude Medical Symetis Jena Valve™* Boston Scientific

Portico™ Acurate TA™ Lotus™ Valve system
Figure 16.1 From Arsalan M, Walther T: Durability of prostheses for transcatheter aortic valve implantation. Nat Rev Cardiol.
2016;13(6):360-7. B3, ACURATE neo™ Aortic Valve. Image provided courtesy of Boston Scientific. © 2017 Boston Scientific
Corporation or its affiliates. All rights reserved. C1, Portico™ valve. Reproduced with permission of St. Jude Medical, © 2017.
All rights reserved. D1, ACURATE TA™ Valve. Image provided courtesy of Boston Scientific. © 2017 Boston Scientific
Corporation or its affiliates. All rights reserved. D2, *This product is no longer available in the market and Jena Valve now
develops a transfemoral pericardial TAVR Valve (JenaValve Everdur). Used with the permission of Jena Valve. All rights reserved.
E2, LOTUS™ Valve. Image provided courtesy of Boston Scientific. © 2017 Boston Scientific Corporation or its affiliates. All
rights reserved.
Figure 16.1 Overview of the most common TAVR prostheses. (A) Balloon expandable bovine pericardial tissue transcatheter bioprosthesis.
(B) Self-expanding porcine pericardial tissue transcatheter bioprosthesis. (C) Self-expanding bovine pericardial tissue transcatheter bioprosthesis.
(D) Self-expanding native porcine leaflets transcatheter bioprosthesis. (E) Alternative expansion design bovine pericardial tissue transcatheter
bioprosthesis.
5. Space Requirements: Hybrid Operating Suite
◆ TAVR procedures will usually be performed in a hybrid operating suite. Because intraoperative
imaging plays a major role in TAVR, a high-quality angiography system is favored over a
mobile, C arm–based system.
◆ Furthermore, in case general anesthesia is needed, TEE should be used for periprocedural
guidance and assessment. Because a fast connection to a heart-lung machine might be needed
in case of hemodynamic instability, an already primed heart-lung machine should therefore
be available.
◆ Furthermore, conversion to conventional surgery via sternotomy should be possible in a
timely manner. All these features, including adequate hygienic standards, can best be realized
in a hybrid operating suite. A well-equipped cardiac catheterization laboratory may be the
next best alternative. Positioning of the patient, together with hardware setup and operator
and assistant positioning, are shown in Fig. 16.2.
◆ The TF approach has become the routine access approach for TAVR. This is especially true
in patients with wide and straight access vessels. In patients unsuitable for TF-TAVR, TA
access is the most frequently used alternative. We therefore describe the operative steps for
these two procedures.
1. Patient Preparation
◆ TF-TAVR can be performed under conscious sedation, whereas TA-TAVR requires general
anesthesia. Invasive blood pressure monitoring is required independently of the access used.
◆ External defibrillator electrode pads should be attached before supine patient positioning.
Sterile preparation and covering should be performed in a manner similar to that for a
conventional cardiac surgery operation. The sternum should be uncovered in case of a necessary
conversion to a median sternotomy.
◆ A temporal pacemaker can be inserted transvenously through the jugular or femoral vein. In
case of TA access, an epimyocardial pacemaker can be placed directly within the purse-string
sutures after a thoracotomy.
2. Safety Net
◆ After puncture of a femoral artery (in case of TF-TAVR, on the contralateral side), a 5 F pigtail
catheter is placed through a 6 F sheath into the noncoronary sinus as a marker for valve
positioning and to allow for angiographic visualization during implantation.
◆ An additional 5 F sheath is placed in the femoral vein as a safety net (Fig. 16.3).
HLM on
standby
C-arm
Monitor Crimping
table
Assistant
OR table with patient
Anesthetist
Scrub
nurse
Cardiologist/
Surgeon
TEE Instruments
Figure 16.2
Sinotubular
junction
Left cusp
Right cusp
Annular
plane Noncoronary
cusp
Figure 16.3
Figure 16.2 Example of a hybrid operative theater setup.
Figure 16.3 Safety net: femoral arterial and venous sheath in place.
3. Access
Transfemoral-Transcatheter Aortic Valve Replacement Access
◆ It is important that the common femoral artery be punctured above the bifurcation because
puncture of the superficial or profunda femoris artery is associated with a higher risk of
vascular complications, obstruction, and failure of closure (Fig. 16.4).
◆ Several techniques exist to guide correct puncture. It can be done from the contralateral side
using a crossover technique or with a small sheath inserted distally on the ipsilateral side in
the femoral artery. A contrast agent can be administered to identify the puncture target (see
Fig. 16.4B).
◆ A 6 F sheath and soft-tipped J-wire are inserted. Next, the artery is prepared with a closure
device (e.g., two ProGlide sutures, Abbott Laboratories, Abbott Park, IL).
◆ Heparin can now be administered (100 IE/kg body weight). The aim is to achieve an activated
clotting time of about 300 seconds.

◆ The aortic valve is crossed retrograde using an Amplatz left catheter (AL1; Boston Scientific)
and a hydrophilic straight wire with a soft tip.

◆ The AL1 catheter is exchanged with a pigtail catheter and a very stiff Amplatz wire or preshaped
Safari wire (Boston Scientific) is positioned in the left ventricle.
Transapical-Transcatheter Aortic Valve Replacement Access
◆ After a lateral minithoracotomy through an approximately 5-cm-long skin incision in the

sixth intercostal cavity, the apex should be identified (Fig. 16.5). If the apex cannot be easily
accessed through the intercostal cavity, the same skin incision should be used to switch to a
higher or lower intercostal cavity. The preoperative CT scan may indicate the relationship of
the apex to the chest wall. Furthermore, preoperative transthoracic echocardiography can be
used to localize the apex and mark the exact position for the incision.
◆ A soft tissue retractor is then inserted. By usage of a small rib spreader, exposition of the apex
can be further improved but is associated with increased postoperative pain and the risk of
rib fractures (Fig. 16.6).
◆ After longitudinal opening of the pericardium, pericardial retraction sutures are placed, and
the left anterior descending (LAD) artery is identified (Fig. 16.7). In case of prior heart surgery
and pericardial adhesions, a small incision in the pericardium without retraction sutures may
be sufficient.
◆ Either U-shaped or O-shaped purse-string sutures are placed lateral to the LAD. This can be
performed with 2-0 Prolene sutures with a large needle and Teflon felt pledgets. The stitches
should be deep (about 4–6 mm) but not transmural, and secured with a snare. Attention
should be given to avoid any tearing of the myocardium (Fig. 16.8). In reoperations, these
sutures can be easily placed through the pericardium.
C
D
F
Figure 16.6

Figure 16.4 Puncture site for transfemoral TAVR. Yellow dot shows optimal needle entry into the common femoral artery.
Figure 16.5 Access site for transapical TAVR.
Figure 16.6 Transapical access without and with metal rib spreader.
Figure 16.7 Transapical access showing the apex after placing pericardial retraction sutures.
Figure 16.8 Apical access after placement of two O-shaped purse-string sutures.
◆ Now heparin can be administered (100 IE/kg body weight), with a goal-activated clotting
time of about 300 seconds.
◆ After puncturing the apex within the purse-string sutures, a soft-tipped wire is advanced
antegrade through the aortic valve (Fig. 16.9).

◆ TEE should be used to prevent the wire from being caught in the chordae of the mitral valve.
Over the soft-tipped wire, a right Judkins catheter is advanced, and the soft-tipped is wire
switched to a super-stiff wire, which is placed in the descending aorta (Fig. 16.10).
Direct Aortic-Transcatheter Aortic Valve Replacement Access
◆ After an upper partial sternotomy or right anterior minithoracotomy, the ascending aorta is
accessed. The preoperative CT scan may provide information regarding the position of the
aorta with regard to the midline. A midline aorta is best for an upper partial sternotomy,
whereas a right-sided aorta is better for a right minithoracotomy. Care should be taken to
ensure that the ascending aorta has minimal calcific disease.
◆ After longitudinal opening of the pericardium, retraction sutures are placed. Two pledgeted
Ethibond sutures are placed in the distal ascending aorta. A minimum of 6 to 7 cm of the
length of the ascending aorta are recommended to use this approach.
◆ Heparin is administered, with a goal-activated clotting time of about 300 seconds.
◆ After puncturing the aorta with an 18-G needle within the purse-string sutures, a soft-tipped
wire is advanced antegrade through the aortic valve. A counterincision may be made through
the skin to aid in delivery of the sheath
◆ The needle is exchanged for a 7 F sheath, and a multipurpose catheter with a straight soft
wire is used to cross the valve. An Amplatz extra-stiff guidewire (Cook Medical, Bloomington,
IN) with a bend on its end is placed. A large sheath is advanced 2 to 4 cm and secured in
preparation for deployment of the valve. Balloon aortic valvuloplasty is performed under
conditions of pacing at 180 to 200 beats/min. The balloon catheter is replaced with the
deployment device, and the TAVR valve is deployed under rapid pacing conditions. After
completion of deployment, the sheath is removed, the purse strings are tied, and the chest
is closed after placement of a single mediastinal tube.
4. Valvuloplasty
◆ If valvuloplasty is required, it can be performed using a 14 F sheath and under rapid pacing
(about 180–200/min). This will lead to temporary cessation of cardiac output (Fig. 16.11).
Figure 16.11
Figure 16.9 Soft tip wire antegradely crosses the aortic valve.
Figure 16.10 Super stiff wire in place.
Figure 16.11 Balloon valvuloplasty.

5. Implantation
◆ Although there are similarities between devices, there are differences in detail regarding
positioning and valve release. Therefore, we briefly describe here the implantation of the two
most commonly implanted TAVR devices.
Medtronic CoreValve
◆ The CoreValve Evolut R System (Medtronic, Minneapolis, MN) is currently the most commonly
used self-expanding TF-TAVR device.
◆ After valvuloplasty, which is optional with the CoreValve Evolut R, the system is advanced
over the stiff wire through the annulus. The distal part of the valve should be placed just
below the annulus and the distal horizontal marker at the level of the pigtail (annulus). The
position can be controlled by contrast agent administration through the pigtail catheter (Fig.
16.12).
◆ The valve is slowly deployed by counterclockwise rotation of the catheter handle. During the
first phase of deployment, the valve tends to dive into the ventricle. This has to be manually
corrected.
◆ A drop in blood pressure occurs once the valve touches the aortic annulus. At this point,
deployment of the valve should be performed faster. The valve can be recaptured and repositioned
until it is released to almost 80%. This allows for control of valve function and AR.
◆ Further rotation of the device handle fully releases the valve.
◆ The delivery system is slowly pulled back into the descending aorta, reassembled, and removed.
A 14 F sheath is inserted, and a pigtail catheter is used to remove the stiff wire.
Figure 16.12
Figure 16.12 Valve position CoreValve.

Edwards SAPIEN
◆ The Edwards SAPIEN valve (Edwards Lifesciences, Irvine, CA) is the only US Food and Drug
Administration (FDA)–approved device for TF, direct aortic, and for TA-TAVR, and is the
most commonly used device for TA-TAVR.
◆ After valvuloplasty, which is optional with the SAPIEN valve, the system’s own introducer
sheath is advanced over the wire, beneath the annulus and into the left ventricle. In the vast
majority of patients, in the past 2 years as of this writing, valvuloplasty has been avoided
with this approach.
◆ Then the already crimped valve is connected to the sheath, and the system is de-aired. The
valve is advanced to the annular position, and the pusher is retrieved (not required for SAPIEN
3). The valve is positioned under fluoroscopic control. About 30% to 50% of the valve should
be positioned supraannularly (Fig. 16.13).
◆ The valve should be oriented in a perpendicular position toward the annulus. This can be
achieved by changing the tension of the super-stiff wire by pulling or giving slack to the wire.
◆ In the optimal position, the valve can be released by inflation of the balloon under angiographic
control with administration of contrast agent over the pigtail in the noncoronary sinus, rapid
pacing, and apnea. In a first step, the balloon should be inflated up to 50%, enabling minor
positional corrections followed by complete inflation for approximately 3 seconds (Fig. 16.14).
◆ After valve implantation, termination of rapid pacing, and apnea, the mean pressure should
recover immediately.
6. Access Closure
◆ Prior to access closure, angiography and/or echocardiography is performed for final evaluation
of valve function. After confirmation of proper valve function, all wires and sheaths can be
removed. The already positioned vascular closure devices can be used to close the femoral
artery access. In case of TA-TAVR, the purse-string sutures can be tied. Before closure of the
pericardium, a hemostat based on collagen (e.g., Surgicel Absorbable Hemostat—Tabotamp,
Johnson & Johnson, New Brunswick, NJ) can be applied to the apex. A thoracic drain should
be advanced into the pleural space, followed by standard wound closure. For both access
routes, the femoral sheaths can be retrieved and the femoral artery access closed by compression
or a vascular closure device.
Figure 16.13
Figure 16.14
Figure 16.13 Valve positioning SAPIEN.
Figure 16.14 SAPIEN implantation.

◆ In SAVR, oral anticoagulation is recommended for 3 months after bioprosthesis implantation.

However, there is no recommendation for a TAVR-specific anticoagulation regimen. New
findings using four-dimensional CT imaging and TEE have shown that leaflet immobility
and, occasionally, valve thrombosis occur in up to 40% of TAVR patients.10 We recommend
dual-antiplatelet therapy with aspirin and clopidogrel for 3 months, followed by lifelong aspirin.
If oral anticoagulation with warfarin is indicated, we recommend warfarin and clopidogrel
administration for 3 months, followed by warfarin (as long as indicated) and aspirin (lifelong).
◆ Pain management is of importance for TA-TAVR patients to allow for the early start of specific
respiratory therapy and avoid any pulmonary complications. Intraoperatively, long-lasting

local anesthesia can be administered intercostally to reduce the necessity of postoperative oral
pain medication.
1. Procedure-Related Issues
◆ Circulatory problems may occur throughout the entire procedure. Especially rapid pacing for
valvuloplasty and/or valve implantation itself can be critical. If, during this, circulation cannot
be fully improved after the peripheral administration of inotropes, direct injection of 1 to
2 mL adrenaline 1 : 100 (1 mg/100 mL saline) through a pigtail catheter in the aortic root
can be helpful. In case of persisting hemodynamic suppression, the heart-lung machine should
be connected using the femoral venous safety net wire to place a venous return cannula and
a femoral arterial cannula in TF-TAVR, usually through the valve delivery access site. This
safety net should always be placed at the beginning of the operation because circulation
problems can already occur in the early stage of the procedure.
◆ Strokes occur due to embolization of native aortic valve calcifications or thromboembolic
events. Embolic protection devices aim to address this issue. However, studies have focused
on surrogate markers of the clinical disease, primarily on silent central nervous system lesions.
Because no study has confirmed the reduction of cerebral embolism and stroke after TAVR,
the use of these devices has not yet become established in everyday clinical routine.
2. Valve-Related Issues
◆ Paravalvular leakage usually results from incomplete prosthesis apposition to the native annulus
due to morphologic patterns or extent of calcification, undersizing of the device, or malpo-
sitioning of the valve. Several studies have identified AR of 2 or more to be an independent
predictor of short- and long-term mortality.11 Due to increasing experience and novel device
technology, AR rates could be lowered. However, in case of at least moderate AR, different
strategies, depending on the underlying cause, can be used to minimize AR.
◆ With good valve position and size, postdilation should be performed. Therefore, a balloon
size corresponding to the diameter of the annulus is generally used. Undue postdilation,
however, could lead to central regurgitation or rupture of the aortic root and therefore should
be avoided.
◆ If the valve was undersized after unsuccessful postdilation rescue, valve-in-valve implantation
should be considered.
◆ In case of inappropriate positioning, repositioning using a snare may be attempted; otherwise
rescue valve-in-valve implantation or conversion to SAVR is mandatory.

◆ Coronary obstruction can occur due to a valve malposition or, eventually, to severe native
valve calcifications coming to rest in front of the ostia. This situation can be resolved by
coronary intervention but, in the event of failure, conversion to a coronary bypass operation
should be performed. Coronary guidewires, however, are not placed routinely before valve
implantation.
◆ Embolization of the prosthesis occurs mostly in case of incorrect valve size, insufficient rapid
pacing during valve deployment, or implantation that is too low. In case of embolization into
the ventricle, conversion with harvesting of the prosthesis and AVR is indicated. If the valve
is still crimped, harvesting through the apex with a catching loop can be possible in TA-TAVR,
but is associated with a high risk of apical injury. In case of distal embolization, the prosthesis
can be anchored in the ascending or descending aorta by overdilation, followed by intraannular
implantation of a second valve.
◆ Annulus rupture and type A dissection can occur intraoperatively or delayed due to incorrect
sizing, excessive oversizing, or postdilation in a heavily calcified annulus. Extravasation of

contrast medium during intraoperative control angiography is often the first indicator of a
rupture. Fortunately, this complication has become rare with optimized perioperative patient
assessment, mostly by means of CT aortic root analysis. Heavy bleeding after apex closure
without any visible bleeding site is another hint. Immediate conversion to conventional
surgery, using patch closure of the defect and conventional AVR, is necessary.
3. Access-Related Issues
◆ Apical bleeding can usually be stopped with additional felt-reinforced sutures. The mean
arterial pressure should be 100 mm Hg or lower; some temporary fast pacing can lead to
more stable conditions for suturing. In case of heavy apical bleeding, temporary connection
to the heart-lung machine might be useful to stop the bleeding under controlled conditions.
◆ Vascular access complications are more likely in TF-TAVR, but have been declining due to
better preoperative patient assessment and imaging and technical improvements, especially
smaller sheath sizes and the use of techniques such as an expandable sheath (Table 16.2).
Local dissections can be treated by implantation of a stent or surgery. In case of surgery, a
peripheral vascular balloon can be used in a contralateral crossover technique or via ipsilateral
antegrade access to occlude the external iliac artery.
Table 16.2 Imaging methods for assessment of anatomic suitability for transcatheter aortic valve
replacement (TAVR)
PARAMETER TTE, TEE ANGIOGRAPHY CT
Aortic valve
AS severity ++ + +
AV annulus diameter ++ + ++
AV anatomy (tricuspid, bicuspid) ++ – +
AV calcification ++ + ++
Aortic root measurements ++ + ++
AV annulus—coronary artery distance – + ++
Heart
LV function ++ + +
Concomitant valvular disease ++ – +
Coronary artery disease – ++ +
Access
Peripheral artery anatomy – + ++
Peripheral artery calcification – + ++
Peripheral artery kinking – + ++
AS, Aortic stenosis; AV, aortic valve; CT, computed tomography; LV, left ventricular; TEE, transesophageal echocardiography; TTE, transthoracic echocardiography; ++, most suitable;
+, suitable; –, unsuitable.
References
1. Vahanian A, Alfieri O, Andreotti F, ESC Committee for Practice Guidelines (CPG), et al. Guidelines on the management of valvular
heart disease (version 2012): the joint task force on the management of valvular heart disease of the European society of cardiology
(ESC) and the European association for cardio-thoracic surgery (EACTS). Eur J Cardiothorac Surg. 2012;42:S1–S44.
2. Nishimura RA, Otto CM, Bonow RO, American College of Cardiology, et al. 2014 AHA/ACC guideline for the management of patients
with valvular heart disease: a report of the American college of cardiology/American heart association task force on practice
guidelines. Circulation. 2014;129:e521–e643.
3. Dewey TM, Brown D, Ryan WH, et al. Reliability of risk algorithms in predicting early and late operative outcomes in high-risk
patients undergoing aortic valve replacement. J Thorac Cardiovasc Surg. 2008;135:180–187.
4. Mack MJ, Brennan JM, Brindis R, STS/ACC TVT Registry, et al. Outcomes following transcatheter aortic valve replacement in the
United States. JAMA. 2013;310:2069–2077.
5. Walther T, Hamm CW, Schuler G, et al. Perioperative results and complications in 15,964 transcatheter aortic valve replacements:
prospective data from the GARY Registry. J Am Coll Cardiol. 2015;65:2173–2180.
6. Leon MB, Smith CR, Mack MJ, et al. Transcatheter or surgical aortic-valve replacement in intermediate-risk patients. N Engl J Med.
2016;374:1609–1620.
7. Thourani VH, Kodali S, Makkar RR, et al. Transcatheter aortic valve replacement versus surgical valve replacement in
intermediate-risk patients: a propensity score analysis. Lancet. 2016;387:2218–2225.
8. Iung B, Baron G, Butchart EG, et al. A prospective survey of patients with valvular heart disease in Europe: the Euro heart survey on
valvular heart disease. Eur Heart J. 2003;24:1231–1243.
9. Seiffert M, Bader R, Kappert U, et al. Initial German experience with transapical implantation of a second-generation transcatheter
heart valve for the treatment of aortic regurgitation. JACC Cardiovasc Interv. 2014;7:1168–1174.
10. Makkar RR, Fontana G, Jilaihawi H, et al. Possible subclinical leaflet thrombosis in bioprosthetic aortic valves. N Engl J Med.
2015;373:2015–2024.
11. Abdel-Wahab M, Zahn R, Horack M, German Transcatheter Aortic Valve Interventions Registry Investigators, et al. Aortic regurgitation
after transcatheter aortic valve implantation: incidence and early outcome. Results from the German Transcatheter Aortic Valve
Interventions Registry. Heart. 2011;97:899–906.
CHAPTER
17
Ross Procedure
Craig J. Baker, S. Ram Kumar, and Vaughn A. Starnes
◆ The Ross procedure replaces the diseased aortic valve with a viable pulmonary autograft and
uses an appropriate conduit (e.g., a cryopreserved pulmonary homograft) to reconstruct the
right ventricular outflow tract (RVOT).
◆ As initially described, the autograft was placed as a scalloped subcoronary implant. The
complexity of the operation and concerns regarding autograft insufficiency have limited
widespread adoption of the procedure. The subsequent use of the full root technique, in
addition to the increasing availability of homografts, has increased interest in the operation.
◆ More recent concerns regarding autograft dilation and neoaortic insufficiency have led to
further refinements.
◆ Relevant surgical anatomy centers on proper enucleation of the pulmonary root and undistorted
implantation into the left ventricular outflow tract (LVOT). In adults, we currently place the
pulmonary autograft within an appropriately sized Dacron conduit to prevent pulmonary
autograft root dilation and subsequent neoaortic insufficiency. This technique also stabilizes
the sinotubular junction.
◆ A thorough understanding of the anatomic relationships between the pulmonary and aortic
valves is critical (Fig. 17.1).
◆ The growth potential of the autograft, favorable hemodynamics, and avoidance of anticoagula-
tion have made Ross procedure the operation of choice for infants, children, and adolescents
with aortic valve disease requiring aortic valve replacement. It should also be considered for
young adults who wish to avoid anticoagulation or who have endocarditis requiring valve
replacement.
◆ We have had excellent results using the Ross procedure in adults with bicuspid aortic valves
requiring replacement. Recent evidence has suggested a low rate of RVOT stenosis in older
patients, which may extend the popularity of the operation for patients up to the sixth decade.
260
Chapter 17 • Ross Procedure260.e1
Abstract
The Ross procedure uses the pulmonary autograft to replace the diseased aortic valve and root.
With appropriate patient selection and technical modifications, the durability of the autograft
can be significantly improved. The Ross procedure continues to be a safe, effective and coumadin-
free alternative for aortic valve replacement across all age groups.
Keywords
autograft
aortic root
pulmonary root
inclusion technique
aortic valve replacement
Chapter 17 • Ross Procedure 261
Sternum
Pulmonary Right coronary artery

valve
Med.
Anterior Lat.
descending
artery Dense connective
Post. tissue
Damage area
Aortic valve
Circumflex
artery
Left main
A coronary artery PULMONARY AUTOGRAFT
Pulmonary autograft
Aorta
Anterior
descending
artery
1st septal artery
Bundle
B PULMONARY AUTOGRAFT
Figure 17.1
◆ It is important to inform patients about the possibility of autograft failure. Avoiding the Ross
operation when a significant geometric discrepancy between the pulmonary and aortic annuli
is detected preoperatively should minimize this complication. If a moderate-sized discrepancy
exists between the aortic and pulmonary roots, a number of techniques to minimize mismatch
have been developed; the surgeon should be familiar with them before performing the
procedure.
◆ Patients with an abnormal pulmonary valve, a complex connective tissue disease, or an
immune complex–mediated disease with known valvular sequelae should be excluded.
◆ A standard median sternotomy is performed. The pericardium is incised, and pericardial stay
sutures are placed. Bicaval cannulation is used, which facilitates exposure and avoids venous
air entrapment following autograft enucleation. Antegrade and retrograde cardioplegia cannulae
are placed, except when aortic sufficiency is present, in which case handheld cannulae may
be used. The patient is placed on cardiopulmonary bypass and cooled to 32°C (89.6°F). A
vent is placed through the right superior pulmonary vein (Fig. 17.2).
◆ The aorta is divided at the sinotubular junction, and the aortic valve is inspected. If no repair
option is available, generous coronary buttons are harvested, and the aortic valve and
root are excised. The pulmonary artery is transected below the branch pulmonary artery
(Fig. 17.3).
◆ After visual inspection of the pulmonary valve leaflets, the pulmonary root with the valve
leaflets is excised from the RVOT. The incision is initiated in the RVOT across the infundibulum,
approximately 4 mm below the pulmonary valve leaflets. A right-angled clamp can be placed
through the pulmonary valve to identify the proper site to begin the ventriculotomy. The
pulmonary root should be excised with a 3- to 4-mm rim of myocardium (Figs. 17.4 and
17.5).
Figure 17.4
Figure 17.5
◆ Aberrant coronary arteries coursing across the RVOT should be identified. The dissection
extends along the septal myocardium, avoiding the first septal perforator and left anterior
descending artery. The dissection continues along the course of the left anterior descending
artery posteriorly, avoiding injury to the left main coronary artery (Figs. 17.6 and 17.7).
◆ After the autograft is harvested, excessive myocardium is excised from the explanted pulmonary
root to avoid LVOT obstruction after implantation (Fig. 17.8).

◆ A Hegar dilator is gently passed through the pulmonary valve to select an appropriately sized
Dacron tube. We usually pick a tube graft 2 mm larger than the measured size of the autograft
to avoid distortion and narrowing. The autograft is secured within the tube graft using running
4-0 polypropylene sutures passed through the myocardium, just below the valve leaflet
(Fig. 17.9).
◆ After the pulmonary root is secured, the graft is cut at the top of the commissures, and the
distal autograft is sutured to the Dacron graft using 4-0 polypropylene (Fig. 17.10). Once
the autograft is completely implanted within the graft, a saline test can confirm leaflet competency
(Fig. 17.11).

◆ The tubularized autograft is sutured to the LVOT using running 3-0 polypropylene (Figs.
17.12 and 17.13). After the proximal anastomosis is complete, the coronary buttons are
reimplanted. A portion of the Dacron conduit and the corresponding internal autograft sinus
are excised after determining the proper location for coronary reimplantation (Fig. 17.14).
The left and right coronary button anastomoses are performed with 5-0 polypropylene sutures.
The coronary buttons create structural support to the right and left sinuses of the autograft
by stabilizing them to the tube graft. Because of concerns regarding the nonsupported non-
coronary sinus, we suture a piece of homograft inside the noncoronary sinus to the corresponding
wall of the Dacron conduit (Fig. 17.15).
◆ An appropriately sized pulmonary homograft is used to reconstruct the RVOT. The distal
anastomosis is performed below the bifurcation. The proximal suture line is completed with
4-0 polypropylene (Fig. 17.16).
◆ The distal suture of the tubularized autograft is completed (Fig. 17.17).

◆ Good postoperative care mandates ensuring excellent hemostasis before leaving the operating
room. Any bleeding, especially from the LVOT suture line or coronary buttons, should be
repaired, if necessary, on cardiopulmonary bypass using cardioplegic arrest.
◆ Placement of blind sutures at the proximal suture line should be avoided because autograft
leaflets may be injured.

◆ Transesophageal echocardiography should confirm good valve function and lack of an LVOT
gradient.
◆ Avoidance of hypertension should be emphasized in the intensive care unit. Generally, myocardial
function is good, and inotropic support is not necessary.
◆ Meticulous technique is imperative to avoid bleeding.

◆ When enucleating the autograft, a definite tissue plane can be identified between the pulmonary
root and surrounding structures. This is most easily identified by initiating the enucleation
on the right (aortic) side of the autograft.
◆ Proper alignment of the autograft in the LVOT is mandatory for a successful outcome.
Bibliography
Bansal N, Kumar SR, Baker CJ, et al. Age-related outcomes of the Ross procedure over 20 years. Ann Thorac Surg. 2015;99:2077–2083.
Chambers JC, Somerville J, Stone S, Ross DN. Pulmonary autograft procedure for aortic valve disease: Long-term results of the pioneer
series. Circulation. 1997;96:2206–2214.
Elkins RC, Knott-Craig CJ, Ward KE, Lane MM. The Ross operation in children: 10-year experience. Ann Thorac Surg. 1998;65:496–502.
Hampton CR, Chong AJ, Verrier ED. Stentless aortic valve replacement: homograft/autograft. In: Cohn LH, Edmunds LH Jr, eds. Cardiac
Surgery in the Adult. 2nd ed. New York: McGraw-Hill; 2003:867–888.
Luciani GB, Favaro A, Casali G, et al. Ross operation in the young. Ann Thorac Surg. 2005;80:2271–2277.
Ross DN. Replacement of the aortic and mitral valves with pulmonary autograft. Lancet. 1967;2:956–958.
CHAPTER
18
Repairing Degenerative
Mitral Valve Disease
Michael J. Paulsen, Andrew B. Goldstone, and Y. Joseph Woo
Introduction
◆ Degenerative mitral valve disease, also called mitral valve prolapse or floppy mitral valve syndrome,
is caused by myxomatous degeneration of the mitral valve tissue, whereby elastin and collagen
bundles are disrupted, and proteoglycan deposition in the spongiosa results in leaflet thickening
and redundancy.1 This, in turn, can cause impaired leaflet coaptation, chordal elongation or
rupture, and annular dilation, resulting in mitral regurgitation.
◆ In the United States and other western countries, degenerative mitral valve disease is the
most common cause of mitral regurgitation, with between 2% and 3% of adults suffering
from at least moderate mitral regurgitation.2–6 Of these, approximately 10% develop significant
mitral regurgitation requiring surgical intervention.7–10
◆ Mitral valve repair is the recommended treatment for degenerative mitral valve disease.11
Mitral valve repair, when compared to replacement, reproducibly improves survival, left
ventricular function, and freedom from reoperation.12–21
◆ Despite the superiority of mitral valve repair over replacement, a large proportion of patients
with degenerative mitral valve disease still undergo replacement.22,23 With experience, nearly
any myxomatous mitral valve can be repaired, importantly with near 0% mortality rates. 13,24–30
◆ In this chapter, various techniques for repairing degenerative mitral valve disease are presented.
The goal is to provide surgeons with an expanded armamentarium for repairing the mitral
valve.
◆ The mitral valve, or left atrioventricular valve, is a dynamic and complex anatomic structure
with a three-dimensional saddle shape that changes throughout the cardiac cycle. To perform
mitral valve repair successfully, a comprehensive understanding of mitral valvular spatial
geometry is compulsory. The mitral valve and its functional components make up the mitral
valve apparatus, consisting of the atriovalvular junction and underlying annulus, the anterior
(aortic) and posterior (mural) leaflets, and the subvalvular apparatus (Fig. 18.1A). The subvalvular
apparatus consists of the chordae tendineae, along with their corresponding papillary muscles
and underlying left ventricular wall.
269
Chapter 18 • Repairing Degenerative Mitral Valve Disease269.e1
Abstract
Degenerative mitral valve disease is a common cause of mitral regurgitation and results in
significant morbidity and mortality. Mitral valve repair is preferred over valve replacement given
improvements in survival, left ventricular function, and freedom from reoperation. The purpose
of this chapter is to provide surgeons with a comprehensive overview of various strategies
available to successfully repair degenerative mitral valve disease. A brief overview of pertinent
surgical anatomy is followed by a discussion on operative strategy and approach, with emphasis
on minimally invasive techniques. Techniques to repair posterior, anterior, and bileaflet prolapse
are discussed, along with some special scenarios. The chapter concludes with an overview on
evaluating the repair, postoperative care, and pearls and pitfalls.
Keywords
Mitral valve repair

myxomatous mitral valve disease
degenerative mitral valve disease
Noncoronary Aortomitral Anterior Left atrium Atriovalvular

sinus curtain leaflet junction
Left coronary Posteromedial Aortomitral
sinus trigone Annulus
curtain
Bundle Atrioventricular
Anterolateral Aorta
of His junction
trigone
Circumflex
Posterior
Left leaflet
ventricular
outflow Left
tract ventriole
Septum
Papillary
muscles
Right ventricle
Coronary
sinus
Left atrium
A B
Posteromedial
commissure
A3
Anterolateral A1
commissure A2
P1 P3
P2
C
Figure 18.1
Figure 18.1 (A) Short axis view of the mitral valve (MV) from the atrium. (B) Horizontal long axis cross section of the MV and left
ventricle. (C) Mitral valve leaflet nomenclature.
Chapter 18 • Repairing Degenerative Mitral Valve Disease 271
◆ The atriovalvular junction (not to be confused with the atrioventricular junction) is the hinge
connecting the atrium to the mitral leaflets; it can be easily identified by looking for the
demarcation between the pink atrial myocardium and pale leaflets. Approximately 1 to 2 mm
deep and external to the hinge is the mitral annulus, which is an ovoid ring of connective
tissue anchoring the mitral leaflets to the fibrous skeleton of the heart. It also forms the
atrioventricular junction between the left atrium and left ventricle (see Fig. 18.1B). It is
important to note that only the hinge is visible to the surgeon; the deeper annulus cannot
be seen. This relationship must be taken into consideration when placing annuloplasty sutures
so as not to disrupt the hinge, which may impair leaflet motion.
◆ The annulus is often thought of as fixed, homogenous, and continuous; however, its consistency
varies around the circumference of the mitral orifice, and its shape changes throughout the
cardiac cycle. Overall, the annulus has a hyperbolic paraboloid (saddle) shape, with the
midanterior and midposterior annular segments highest (farthest) from the apex and the
anterolateral and posteromedial commissures (PC) at the lowest points.31
◆ The mitral valve annulus is connected to the aortic valve annulus at an angle of 120 degrees
via the aortomitral curtain. The aortomitral curtain is flanked by the anterolateral (left) fibrous
trigone and posteromedial (right) fibrous trigone, which along with the aortomitral curtain
make up a particularly dense portion of the annulus where the anterior leaflet of the mitral
valve attaches. This constitutes approximately 40% of the circumference of the annulus. The
remaining 60% of the annulus suspends the posterior leaflet; this portion of the annulus is
discontinuous and thinner, making it more prone to dilation.
◆ The mitral valve is naturally bicuspid, with a larger, semicircular anterior (aortic) leaflet and
a smaller, quadrangular posterior (mural) leaflet (see Fig. 18.1C).

◆ The anterior leaflet delineates the left ventricular inflow tract from the outflow tract. The
anterior leaflet free edge is convex and without scallops.

◆ The posterior leaflet usually contains three distinct scallops—the anterolateral scallop (P1),
the middle scallop (P2), and the posteromedial scallop (P3). The opposing portions of the
anterior leaflet are termed the anterior segment (A1), the middle segment (A2), and the
posterior segment (A3). The areas joining the anterior and posterior leaflets are the anterolateral
commissure (AC) and the PC. This nomenclature facilitates descriptive noninvasive and
surgical valve analysis.
◆ The atrial surface of each leaflet is separated by two visible zones, the more proximal atrial
zone, which is smooth and somewhat transparent, and the distal rough zone (also known
as the zone of coaptation). The rough zone is the point at which the leaflets meet during
systole. Most chordae tendineae insertion sites are located in the rough zone, giving this
region a coarse and irregular appearance (hence, its namesake).
◆ The subvalvular apparatus consists of the chordae tendineae, the anterolateral papillary muscle,
the posteromedial papillary muscle, and the free wall of the left ventricle. The subvalvular
apparatus helps maintain valve function and integrity throughout the cardiac cycle. During
diastole, as blood enters and the left ventricle distends, the papillary muscles and chordae
pull the mitral leaflets open, allowing for maximal valve opening and efficient filling. During
systole, the papillary muscles contract and shorten, maintaining optimal leaflet height and
thereby ensuring a proper zone of coaptation at the level of the annulus to prevent leaflet
prolapse.
◆ Chordae tendineae connect the papillary muscle heads (or, in some cases, the ventricular
wall) to the leaflets; they are divided into three groups—primary, secondary, and tertiary.
Primary (marginal) chordae tendineae attach the papillary muscle heads to the leaflet
margin; they are the thinnest of the chordae and serve to prevent leaflet prolapse. Secondary
(intermediary) chordae attach the papillary muscle heads to the midsection of the ventricular
surface of the leaflets; they are thicker than primary chordae and provide support to the
leaflet tissue. Tertiary (basal) chordae are the thickest of the chordae types and connect the
base of the leaflet or annulus to the papillary muscle head or ventricular wall; they are
typically only found on the posterior and commissural leaflets.
◆ Arising between the middle and apical thirds of the left ventricle, two papillary muscles
support the mitral valve, the anterolateral papillary muscle, and the posteromedial papillary
muscle. Each papillary muscle supplies chordae to both anterior and posterior leaflets. The
papillary muscles and their supporting left ventricular myocardium are critically important
in maintaining optimal valvular function, as described previously. The anterolateral papillary
muscle is typically solitary and receives blood from the left anterior descending artery and
often a branch of the circumflex artery. The posteromedial papillary muscle usually has
multiple heads and typically has a solitary blood source from either the circumflex artery
or right coronary artery. Because of these anatomic differences, the posteromedial papillary
muscle is more sensitive to ischemia and can rupture following a posterior myocardial
infarction, leading to acute mitral regurgitation.
◆ Degenerative mitral valve disease represents a spectrum ranging from fibroelastic deficiency,
with limited elongated or ruptured chordae, to the Barlow syndrome, with extensive change,
including redundant and billowing leaflets. The clinical presentation of patients with fibroelastic
deficiency and Barlow syndrome is often unique. Patients with fibroelastic deficiency are often
older and tend to have a relatively recent diagnosis of mitral disease without a history of a
murmur.32 The leaflets are thin, and typically only one segment is prolapsed secondary to
ruptured chords. On the other hand, patients with Barlow syndrome tend to be younger and
have a long history of a murmur; these patients may have a family history of mitral valve
disease, as well as marfanoid features.32 The leaflets are thickened and billowing, often with
several prolapsing segments; calcification can be extensive, and atrialization of leaflets may
be noted. Mitral regurgitation is also classified as acute or chronic and further subclassified
into chronic and compensated or chronic and decompensated. Consideration of cause and
chronicity are important preoperative considerations that affect operative planning and risk
stratification.
◆ Echocardiography is essential prior to any planned mitral valve surgery because it provides
important information about valve anatomy, disease lesions, and underlying cause. Three-
dimensional echocardiography can also be a helpful adjunct in planning the repair prior to
surgery. Additionally, echocardiography helps interrogate the other heart valves, biventricular
function, atrial size, and estimates pulmonary artery systolic pressure.
Step 3. Operative Conduct
1. Surgical Approach
◆ The mitral valve is conventionally accessed through a median sternotomy (Fig. 18.2A). The
median sternotomy provides excellent exposure to all structures of the heart and is favored
for patients in whom multiple valves or concomitant surgeries (e.g., coronary bypass, aortic
valve replacement) are planned with mitral valve repair. In this approach, standard central
aortic and bicaval cannulation are preferred. Exposure of the mitral valve can be accomplished
through several alternative approaches, as discussed in detail in the following.
A
B
C D
E
Figure 18.2 E from Goldstone AB, Woo YJ. Minimally invasive surgical treatment of valvular heart disease. Semin Thorac Cardiovasc Surg. 2014;
26:37.
Figure 18.2 (A) Median sternotomy. (B) Partial upper sternotomy. (C) Partial lower sternotomy. (D) Right anterolateral minithoracotomy.
(E) Intraoperative photograph of minimally invasive approach via right anterolateral minithoracotomy; note the use of smaller skin incisions
for the placement of an endoscope, suction ports, cross-clamp, and retraction sutures.
◆ A partial upper or lower sternotomy, or hemisternotomy, also permits access to the mitral
valve (Fig. 18.2B, C). Whereas the lower hemisternotomy reduces the size of the skin incision
and extent of sternal separation, the xiphisternal fascia must still be incised and is the area
most prone to wound infection.
◆ Our preferred minimally invasive approach is via a right anterolateral minithoracotomy (see
Fig. 18.2D, E).33,34 This approach provides an excellent en face view of the mitral valve and
spares dissection of the xiphisternal fascia. In patients who have undergone prior cardiac
surgery, particularly aortic valve replacement, this minimally invasive approach can be particularly
useful in not only avoiding a redo sternotomy, but also in visualizing the mitral valve when
a previously placed aortic valve prosthesis prevents excessive manipulation of tissue.
◆ The patient is placed supine on the operating table, with an inflatable cushion placed under
the right shoulder to elevate the right chest and rotate the patient slightly to the left. A 3- to
4-cm skin incision is made just above the nipple in male patients and in the inframammary
crease in females. The thoracic cavity is entered through the third or fourth interspace.
Additional small incisions facilitate placement of an endoscope, suction ports, working arm
ports (for robotic surgery), and aortic cross-clamp. Retraction sutures can also be passed
through tiny skin incisions using a suture passer, which creates a low-profile and clutter-free
operative field.
◆ When using a right anterolateral minithoracotomy, we typically cannulate peripherally. The
femoral artery and vein are cannulated via a small groin incision; the internal jugular vein is
cannulated percutaneously with a 16 F cannula. Venous cannulae are positioned within the
superior vena cava and inferior vena cava under echocardiographic guidance.
◆ We routinely use a transthoracic Chitwood clamp to cross-clamp the ascending aorta. An
endoaortic occlusion balloon can also be used, although a significant learning curve exists
during which the risk for aortic dissection and stroke are elevated. Finally, fibrillatory arrest
strategies may be used in certain situations.35,36
2. Initiating Cardiopulmonary Bypass
◆ Once the patient has been cannulated, initiation of cardiopulmonary bypass can commence.
Myocardial protection is extremely important, and our institution favors cold blood, high-
potassium cardioplegia delivered in an intermittent antegrade or combined antegrade-retrograde
fashion. Moderate systemic hypothermia and local topical hypothermia with topical slush are
also applied.
◆ Alternative myocardial protection strategies exist and may be considered for certain patients.
For example, a beating heart approach can be considered for patients with severe left ventricular
dysfunction. For patients with severe atherosclerosis of the ascending aorta, ventricular fibril-
latory arrest can also be used if cross-clamping the aorta is objectionable.
◆ It is important to consider the sequence of mitral valve surgery in the context of concomitant
procedures. If concomitant coronary artery bypass is performed, distal anastomoses should

be completed prior to mitral valve surgery; lifting the heart following mitral valve prosthesis
implantation increases the risk of posterior ventricular rupture and possible atrioventricular
groove disruption. If aortic valve replacement is required, the native aortic valve leaflets should
be excised and the annulus débrided prior to mitral valve repair to avoid inadvertently cutting
mitral annuloplasty or repair sutures. In addition, mitral valve repair should be completed
prior to the replacement of the aortic valve as a prosthetic aortic valve can distort the mitral
annulus and may complicate mitral valve repair. Tricuspid valve repair, if needed, should
follow left-sided valve procedures and may be completed after aortic cross-clamp removal.
3. Exposing and Examining the Mitral Valve
◆ Optimally exposing the mitral valve is critical to facilitate a successful repair. This can be
achieved through several techniques, as described in the following.
◆ The most common approach to the mitral valve is the interatrial approach through Sondergaard’s
groove, also known as rolling the groove (Fig. 18.3A). In this approach, the right and left atrial
surfaces are carefully separated by dissecting through the fatty tissue anterior to the right
superior and inferior pulmonary veins. It is important to start this incision on the left atrial
body to avoid accidental injury to the pulmonary venous ostia. Carrying this incision too
medially may result in an inadvertent right atriotomy. If encountered, caval tapes or vacuum-
assisted venous return can help manage this issue.
◆ The right atrial transseptal approach is another common method to expose the mitral valve
(see Fig. 18.3B). Bicaval cannulation with caval snaring helps obtain a bloodless field. A right
atriotomy is made and extended posteriorly toward the left atrium. Atrial retractors or silk
stay sutures can facilitate exposure of the septum. The fossa ovalis is identified, and an incision
is made posteriorly to the patient’s right, being careful to leave enough septal tissue to close
the incision at the conclusion of the case. This incision is carried inferiorly to the end of the
fossa ovalis and superiorly to the muscular tissue, near the superior vena cava inlet. The
interatrial septum is then retracted anteriorly to provide optimal visualization of the mitral
valve. This approach is useful in patients who have previously undergone aortic valve replace-
ment because exposure of the AC can otherwise be challenging. It also minimizes external
suture lines and speeds de-airing when concomitant tricuspid valve interventions are planned.
◆ Several less conventional approaches to exposing the mitral valve exist, although these are
used uncommonly and typically only in specific clinical scenarios. The left atrial dome approach,
wherein the roof of the left atrium between the aorta and superior vena cava is incised,
provides an excellent direct view of the mitral valve; however, the incision itself is quite small
and leaves limited working room (see Fig. 18.3C). Additionally, extreme care must be taken
in closing this incision because controlling bleeding in this area is quite challenging after the
patient has been weaned from cardiopulmonary bypass. This approach can be combined with
the transseptal approach in an expanded transseptal/left atrial dome approach to maximize
mitral valve exposure if necessary. In the case of a left ventricular aneurysm repair, the mitral
valve can be approached in a transventricular manner; an off-pump coronary stabilizer is
helpful in adequately exposing the mitral valve in this situation (see Fig. 18.3D).37,38 A transaortic
approach can also be used in cases of aortomitral endocarditis (see Fig. 18.3D).38,39
◆ Once the mitral valve has been exposed, the next step to a successful repair is careful analysis
of the valve to determine the specific mechanism of mitral regurgitation.

A B
Figure 18.3
Figure 18.3 (A) Exposure through Sondergaard’s groove. (B) Transseptal approach for mitral valve exposure. (C) Exposure of the mitral
valve through the dome of the left atrium. (D) Transaortic approach in the case of infective endocarditis.
C
Figure 18.3, cont’d Continued
D
4. Remodeling Ring Annuloplasty
◆ Nearly all patients with chronic mitral regurgitation develop some degree of annular dilation
and, as such, nearly all patients undergoing repair for chronic mitral regurgitation derive
benefit from ring annuloplasty. It is our practice to perform a ring annuloplasty in all patients
undergoing mitral valve repair.
◆ Ring annuloplasty also improves the durability of mitral valve repair because it prevents
further annular dilation and late mitral regurgitation.

◆ The posterior annulus is typically the annular segment that dilates in chronic mitral regurgita-
tion, and thus some surgeons prefer incomplete annuloplasty rings or posterior annuloplasty
bands. Although this approach can effectively prevent late annular dilation, care must be
taken to anchor the band to the fibrous trigones adequately. We prefer complete annuloplasty
rings that are contoured to the physiologic saddle shape of the native, healthy mitral valve
annulus, which more reliably prevents adverse annular remodeling following repair.
◆ Our general approach is first to place annuloplasty sutures because this helps retract the
mitral valve and improves visualization. Following annuloplasty suture placement, obvious
valvular defects are repaired, followed by annuloplasty ring placement. If regurgitation remains,
additional repair techniques can be carried out.
◆ Annuloplasty sutures are placed circumferentially around the annulus. The needle should
enter and exit the tissue just outside the atriovalvular junction, passing through the annulus.
The curve of the needle should be followed, which will generate appropriately sized bites of
approximately 10 mm (Fig. 18.4A). The space between separate sutures should be approximately
2 mm. Care must be taken not to injure surrounding tissue inadvertently. When placing
annuloplasty sutures in the anterior annulus, one must be careful to avoid catching the
noncoronary cusp of the aortic valve. The circumflex coronary artery can be injured if sutures
are placed too deeply near the AC and toward the posterior annulus (see Fig. 18.4B).
◆ Properly sizing the mitral annulus is important to prevent adverse consequences. Overly
restrictive annuloplasty rings can result in systolic anterior motion (SAM) of the mitral valve
or iatrogenic functional mitral stenosis.
◆ Ring sizing is based on intercommissural distance and the surface area of the anterior mitral
leaflet (see Fig. 18.4C). With this in mind, if the free edge of the anterior leaflet extends 2
to 4 mm beyond the inferior aspect of the annuloplasty ring sizer, the surgeon should choose
a ring that is one size larger to prevent the risk of SAM of the mitral valve.40
◆ When passing sutures through the annuloplasty ring, equal suture distances should be taken
along the anterior aspect of the ring because the anterior annulus seldom dilates. However,
less travel on the posterior aspect of the annuloplasty ring should be taken to correct posterior
annular dilation (see Fig. 18.4D). Take note of the markings on the annuloplasty ring; the
commissures are typically marked to assist you in spacing sutures properly. Count the number
of sutures that must be placed through the anterior and posterior portions of the ring and
space them accordingly. When placing sutures through the annuloplasty ring, only pass the
needle through the designated sewing band and not through the metal skeleton.
LCC NCC
10 mm
Circumflex
2 mm coronary
artery
A B
C
Figure 18.4
Figure 18.4 (A) Placement of annuloplasty sutures. (B) Pertinent surgical anatomy. Note proximity of aortic valve leaflets and circumflex
coronary artery. (C) Appropriate sizing of annuloplasty ring. (D) More travel is required posteriorly to correct posterior annular dilation.
5. Correcting Posterior Leaflet Prolapse
◆ Posterior leaflet prolapse and/or flail are the most common lesions in patients with degenerative
mitral regurgitation. Traditionally, resection of the prolapsed leaflet was performed; however,
nonresectional techniques are increasingly being used.
◆ Triangular resection is a common technique that can be effectively used when the amount of
tissue to be resected is not extensive (Fig. 18.5). This technique is also useful in the setting
of isolated segment flail. First, stay sutures are placed around normal chordae flanking the
prolapsed segment of the leaflet; this helps delineate the area of prolapse and adequately
expose the leaflet. Next, the area of prolapse is excised with two diagonal incisions toward
the annulus, which form a triangular area of resection. Using polypropylene sutures, the
leaflet free edges on each side of the resection are reapproximated.
Figure 18.5
Figure 18.5 Triangular resection.

◆ If the area of redundant leaflet tissue to be resected is more extensive, a quadrangular resection
may be needed (Fig. 18.6A). As in triangular resection, stay sutures are placed around normal
chordae to flank the area of resection. Next, two perpendicular incisions are made from the
leaflet free margin toward the annulus, removing a quadrangular segment of leaflet. Using
2-0 sutures, an annular plication stitch is placed spanning the gap between the resected leaflet.
Tension is placed on this suture and an additional simple interrupted or figure-of-eight annular
suture is placed, bringing the leaflet free edges close enough for reapproximation with running
polypropylene sutures. These annular stitches do not require reinforcement because the
prosthetic annuloplasty ring will serve this purpose.
A
Figure 18.6
Figure 18.6 (A) Quadrangular resection with annular plication. (B) Quadrangular resection with sliding leaflet plasty.
B
◆ In situations in which a large part of posterior leaflet must be resected, or when the posterior
leaflet height must be reduced, a sliding leaflet plasty can be performed after quadrangular
resection (Fig. 18.6B). The P1 and P3 segments are detached from the annulus with two
additional incisions. Using running polypropylene sutures, P1 and P3 are reapproximated to
the annulus, with more travel along the annulus than the leaflet tissue to allow for medial
translocation. If the gap between leaflets is large, or if they cannot be approximated without
tension, annular plication may be required, being cautious not to kink the circumflex coronary
artery with overly aggressive bites.
◆ An alternative to the sliding leaflet plasty in cases of large and redundant leaflets is leaflet
height reduction (see Fig. 18.7).40 First, the leaflet is partially detached from the annulus.
Next, a curvilinear crescent-shaped portion of the leaflet corresponding to the detached edge
is excised. The leaflet is reattached to the annulus with running monofilament sutures. Fol-
lowing leaflet height adjustment, the line of coaptation may need to be adjusted using artificial
neochords, which are described in further detail in the following sections. Leaflet height
reduction can also be used on the anterior leaflet and is especially helpful in the prevention
or treatment of SAM of the mitral valve.
◆ Posterior leaflet height can also be reduced using the butterfly technique, which also avoids
annular plication and may reduce the risk of SAM (Fig. 18.8).41 The prolapsed segment of
posterior leaflet is first excised with a triangular resection, followed by a second triangular
resection mirroring the first. The free edges of resected tissue are then reapproximated with
polypropylene sutures. In addition to avoiding annular plication, this technique often allows
for the implantation of a larger annuloplasty ring.
Figure 18.7
Figure 18.8
Figure 18.7 Posterior leaflet height reduction.
Figure 18.8 Butterfly technique.

◆ The so-called haircut technique is another nonresectional method of correcting posterior

leaflet redundancy and/or prolapse without compromising annular continuity (Fig. 18.9).42
In this technique, a prolapsed P2 segment with multiple ruptured chords is trimmed, or given
a haircut, at approximately the same height as the adjacent P1 and P2 segments. If possible,
viable chords are salvaged for reimplantation later in the procedure. Next, the P1-P2 and
P2-P3 clefts are closed. The preserved chords are reattached to the free edge of the P2 segment;
if no chordae are salvageable, transfer of secondary chords can be performed, or neochords
can be placed. A smooth posterior coaptation surface is restored along with valve competency
as a result of the haircut. This method is particularly useful in the setting of annular calcification
or diminutive P1 and P3 scallops.
Preserved
chords
Figure 18.9
Figure 18.9 Haircut technique.

◆ The simplified nonresectional leaflet remodeling technique, a modification of the McGoon

plication repair, can also be used to create a smooth, nonprolapsed coaptation surface (Fig.
18.10).43,44 The free edge of the prolapsed leaflet segment is inverted into the left ventricle,
imbricating redundant leaflet tissue in a triangular shape. The leaflet folds on each side of
the imbricated segment are approximated, creating a smooth posterior coaptation surface.
Importantly, the inverted segment forms a triangular shape (analogous to a triangular resec-
tion), with a narrower amount of inverted tissue closer to the annulus to preserve annular
continuity.
Figure 18.10
Figure 18.10 Nonresectional leaflet remodeling technique.

◆ One of the limitations of the simplified nonresectional leaflet remodeling technique is the
theoretical possibility that the posterior leaflet, which remains mobile and somewhat redundant,
can move anteriorly, resulting in SAM of the mitral valve. To account for this possibility, the
posterior ventricular anchoring neochordoplasty technique was developed (Fig. 18.11).45 This
technique is a modification of the earlier described simplified nonresectional leaflet remodeling
technique, in which the free edge of the prolapsed leaflet segment is inverted into the left
ventricle. However, it is attached and anchored to the ventricular wall using a single polytet-
rafluoroethylene (PTFE) suture. This anchoring suture is placed 3 to 4 mm deep and tied
loosely, being careful not to place undue tension on the ventricular wall, causing necrosis
and possible late neochord failure. The same anchoring suture is used to reapproximate the
leaflet folds on each side of imbricated leaflet segment. This technique effectively remodels
the posterior leaflet while simultaneously anchoring the posterior leaflet, reducing the risk
of SAM.
◆ The use of artificial neochords can also be helpful in the repair of posterior leaflet prolapse.
Techniques for neochord placement are discussed in detail in the following section on anterior
leaflet prolapse; these principles are entirely applicable to posterior leaflet prolapse as well.
6. Correcting Anterior Leaflet Prolapse
◆ In degenerative mitral valve disease, pathology of the anterior mitral leaflet is far less common
than that of the posterior leaflet, accounting for fewer than 15% of cases. Even in cases of
bileaflet prolapse, often only posterior leaflet intervention is required for a satisfactory repair.46
Despite this, there are circumstances that require repair of the anterior mitral leaflet, and the
following sections describe techniques commonly used in this setting. We prefer to preserve
as much leaflet tissue as possible by using chordal techniques on the anterior leaflet. Of note,
most of the following techniques can also be used on the posterior leaflet and can be especially
helpful in cases with insufficient leaflet tissue.
Figure 18.11
Figure 18.11 Posterior ventricular anchoring neochordoplasty (PVAN) technique.

◆ In the rare case of a billowing and redundant anterior leaflet, a very limited triangular resection
can be considered, as described earlier.47 We prefer to limit resections of the anterior leaflet
to no greater than 10% of the total leaflet surface area. More extensive resections reduce the
area of coaptation and decrease the durability of valve repair.
◆ If anterior leaflet prolapse is present, and an area of adjacent, normal posterior leaflet tissue
with intact chordae of appropriate length is available, a chordal transposition can be performed
(Fig. 18.12). A 2- to 3-mm-wide strip of adjacent normal posterior leaflet with the attached
chordae is resected free from the posterior leaflet, careful to keep the attached chordae intact.
With polypropylene sutures, the segment of posterior leaflet is secured to the anterior leaflet,
thereby transferring functional chordae to the anterior leaflet. The posterior leaflet defect
is repaired with polypropylene sutures. There is no need for neochord measurements and
adjustments, which is the primary advantage of chordal transposition. However, this technique
requires that a normal segment of posterior leaflet be sacrificed.
◆ When a diseased valve lacks enough normal chordae to function properly, and chordal
transposition is not possible, artificial neochordae placement can be helpful. However, this
technique can be challenging for several reasons. Determining optimal neochordae length
can be difficult and requires careful measurement. Once an optimal length has been determined,
keeping the PTFE sutures at this length is also not always easy because this material is prone
to slippage. Finally, adequate exposure of the papillary muscle heads and underside of the
mitral valve leaflets is not always possible. Despite these challenges, there are several strategies
that can be used to use artificial neochordae successfully in mitral valve repair. Multiple
neochords may be required and, in practice, we prefer to place chordae in pairs to balance
out the forces on the prolapsed segment and improve durability.
◆ The first strategy to create an effective artificial neochord is termed the loop technique (Fig.
18.13). First, the correct plane of apposition should be determined, usually from an adjacent,
nonprolapsing valve segment. Using a pair of calipers or other measuring device, the distance
between this plane and the papillary muscle head is determined. Next, keeping the calipers
at the same setting, a PTFE loop is created over the measuring instrument, tying a knot over
a pledget to secure the suture at this distance. Next, each needle is passed through the pledget
an additional two times to lock the loop distance and prevent sliding. After this has been
completed, the needles are passed from anterior to posterior through the corresponding
papillary muscle and tied over another pledget. The loop is now secured to the papillary
muscle; to secure the loop to the leaflet, a second PTFE suture attaches the loop to the
prolapsed leaflet, with the knot oriented toward the ventricular cavity.
◆ The second method of placing artificial neochordae is known as the freehand technique. In
this method, a PTFE suture is passed through the papillary muscle and then through the
edge of the prolapsed leaflet segment. This suture is clamped and set aside while an annuloplasty
ring is implanted. Following annuloplasty, the ventricle is pressurized using a saline-filled
bulb syringe. Then, the PTFE suture is tied and secured at the level at which optimal coaptation
occurs, resulting in elimination or minimization of visible regurgitation through the valve.
This technique is faster and very simple, but requires the surgeon to be able to judge the
appropriate neochord length accurately and ostensibly tie a large air knot securely, without
slipping. Adjacent papillary muscles with chordae of normal length can sometimes be used
as a reference point.
Figure 18.12
Figure 18.13
Figure 18.12 Chordal transposition.
Figure 18.13 Neochord placement.

◆ The double orifice edge-to-edge repair, also known as the Alfieri stitch, is a technique that
can be used to repair anterior, posterior, or bileaflet prolapse (Fig. 18.14).48 In this technique,
using a figure-of-eight polypropylene stitch, the prolapsing segment of leaflet is tied to its
opposite leaflet segment. This creates a double-orifice mitral valve. The position of this stitch
varies, depending on the amount of redundant leaflet tissue; a valve with an excess of tissue
will require a deeper stitch to prevent SAM. If leaflet tissue is thin and frail, reinforcing the
stitch with autologous pericardium or pledgets may be required. To prevent iatrogenic mitral
stenosis, at least 2.5 cm2 of total valve area is required, which can be measured with Hegar
dilators.30
Figure 18.14
Figure 18.14 Alfieri stitch—double orifice edge-to-edge repair.

7. Correcting Commissural Prolapse
◆ Commissural prolapse can be repaired with or without resection. The simplest method to
correct commissural prolapse is to obliterate the commissure with a running polypropylene
suture, inverting the prolapsed segment of leaflet (Fig. 18.15A). Alternatively, triangular resection
can be performed if the amount of prolapse is limited, involving 5 mm or less of the com-
missural edge (see Fig. 18.15B).40 If a more substantial area of prolapse exists, a quadrangular
resection with sliding plasty of the adjacent paracommissural segments is performed (see Fig.
18.15C). It is helpful to restore the neocommissure’s area of coaptation with inverting sutures.
◆ If papillary muscle rupture is the cause of commissural prolapse, the papillary muscle should
be reattached to the ventricular wall to restore appropriate commissural height. To reattach

a ruptured papillary muscle, necrotic tissue must first be excised, typically leaving only the
fibrous head of the papillary muscle attached to the chordae. The remaining papillary muscle
head is then grasped and retracted caudally until it meets the ventricular wall at a point where
leaflet height is restored; this point is marked. Next, an 8- to 10-mm incision is made in the
ventricular wall at a depth of no more than 5 mm, avoiding coronary vasculature. Using 4-0
monofilament sutures, buried horizontal mattress sutures are used to anchor the residual
papillary muscle head into the ventricular wall.
◆ In the case of papillary muscle elongation, a papillary muscle sliding plasty or papillary
muscle-shortening procedure can be performed. In cases in which only some of the chordae
attached to a papillary muscle are elongated, the papillary muscle can be incised longitudinally.
The segment of papillary muscle attached to the elongated chords is then slid downward and
secured at a lower level to the normal portion of papillary muscle, using one or two interrupted
monofilament sutures. The suture should not pass through the chordae. The distance that
the papillary muscle segment is slid downward should equal the distance of leaflet prolapse.
A papillary muscle-shortening procedure is another option, whereby a wedge of papillary
muscle is resected from the papillary muscle segment with chordal elongation. The wedge
defect is closed with interrupted monofilament sutures. If an entire papillary muscle has
chordal elongation, the abnormal papillary muscle can be anchored to an adjacent papillary
muscle of normal height.
8. Addressing Annular Calcification
◆ Calcification of the mitral annulus often makes valve repair more challenging and can lead
to paravalvular leak, dehiscence, and atrioventricular groove disruption. For effective repair,
the calcified tissue should be débrided. In most cases, the calcified tissue is encased in a
capsule of fibrotic tissue, which allows for en bloc resection. Following débridement, annular
reconstruction is typically required, although it may be possible, using pituitary rongeurs, to
débride enough of the calcified tissue carefully and selectively to provide adequate leaflet
mobility and coaptation, without the need for annular reconstruction.49 For annular reconstruc-
tion, various techniques have been described.
◆ Tirone David and colleagues have described a technique using bovine pericardium to reconstruct
the annulus.50–52 In cases of posterior annular reconstruction, a 2-cm wide semicircular patch
is created. Using 3-0 polypropylene sutures in a continuous running fashion, the left ventricular
endocardium is sutured to one side of the patch, and the other side is secured to the left
atrial wall. Next, the detached portion of the leaflet is sutured to the patch at the level of the
annulus. A circumferential pericardial patch can be used for complete annular reconstruction,
with an annuloplasty ring being used to attach the leaflets to the patch, providing rigidity.
C
Figure 18.15
Figure 18.15 Correcting commissural prolapse. (A) Commissure obliteration by inversion of prolapsed segment. (B) Triangular resection
of prolapsed segment. (C) Quadrangular resection for larger prolapsed segment.
◆ Carpentier et al. have advocated for the use of figure-of-eight atrioventricular mattress sutures
for annular reconstruction to minimize the amount of foreign material used (Fig. 18.16).53
In addition, the use of figure-of-eight mattress sutures serve to decrease annular size and
displace the circumflex vessels away from the annular reconstruction. First, a braided 2-0
suture is passed through the atrial edge, followed by the ventricular edge, being mindful of
the circumflex coronary artery. Depth of the ventricular bites should be approximately one-third
of the ventricular thickness. Next, with approximately 1 cm of travel, the suture is again
passed through the ventricular edge and then returned up through the atrial edge, with the
free ends of suture being on the atrial side. When tightening the suture and closing
the atrioventricular junction, the assistant uses forceps to pull the atrial edge downward. The
same sutures are used for annuloplasty ring placement later in the operation. Next, 4-0
polyester sutures in a continuous running fashion are used to reinforce the neoatrioventricular
junction and prevent paravalvular blood flow from separating the neoatrioventricular junction.
The leaflets are reattached to the neoannulus with running 4-0 polypropylene sutures. Finally,
the free ends of the figure-of-eight mattress sutures are used to attach an annuloplasty ring,
completing the repair. Carpentier and associates53 have stressed the importance of being
extremely delicate when lowering the annuloplasty ring, applying only the desired amount
of tension on the suture. When tying the suture, the sutures should not be pulled upward;
rather, the finger should push the annuloplasty ring downward.
Figure 18.16
Figure 18.16 Annular reconstruction, Carpentier method.

9. Evaluating the Repair
◆ The repair should be evaluated at multiple time points during the operation so that the
surgeon may modify the repair strategy. At a minimum, the repair should be tested after leaflet
repair or neochord placement but prior to annuloplasty ring placement. Once the annuloplasty
ring has been placed, but prior to tying the sutures, the repair should be evaluated again.
Once the repair procedure has been completed, the valve is evaluated one final time prior to
weaning from cardiopulmonary bypass.
◆ The saline test is an excellent method to assess the quality of a repair (Fig. 18.17A). First,
with the aortic root vent unclamped, the left ventricle is filled with saline to evacuate air and
prevent coronary artery air embolism. After successful evacuation of air, the aortic root vent
is clamped, and a bulb syringe is used again to inject pressurized saline into the left ventricle
through the mitral valve. The mitral valve should prevent the pressurized saline from leaking
retrograde. The surgeon should also see a symmetric line of coaptation parallel to the posterior
aspect of the annuloplasty ring. The coaptation line ideally should be a safe distance away
from the left ventricular outflow tract to prevent SAM of the mitral valve.
◆ To evaluate the repair further, the ink test can be used (see Fig. 18.17B). With the left ventricle
pressurized during the saline test (as previously mentioned), a marking pen is used to trace
the coaptation line. The line of coaptation should ideally be 4 to 10 mm deep. If the depth
is less than 4 mm, further correction should be performed, which may include resection of
restrictive chordae, downsizing the annuloplasty ring, or cleft closure techniques. If the depth
is greater than 10 mm, the patient may be at increased risk of developing SAM of the mitral
valve, and the surgeon should consider reducing posterior leaflet height.
◆ Transesophageal echocardiography should be used as a final test of the quality of valvular
repair after the patient has been separated from cardiopulmonary bypass, but prior to
decannulation.
◆ Left atrial enlargement is extremely common due to the pathophysiology of mitral regurgitation;
as such, atrial fibrillation is common before and after surgery in patients with mitral regurgita-
tion. Atrial fibrillation prophylaxis is important.
◆ Careful attention should be paid to the possibility of the patient developing SAM of the mitral
valve, which is a complication of mitral valve repair occurring in up to 10% of patients.54

SAM is most often caused when a redundant posterior leaflet shifts the plane of leaflet coaptation
anteriorly, which then displaces the anterior leaflet into the left ventricular outflow tract,
resulting in obstruction and late systolic mitral regurgitation.
◆ In addition to redundant posterior leaflet tissue, SAM can also be caused by failing to reduce
the posterior leaflet height adequately or undersizing the annuloplasty ring and is occasionally
due to anterior leaflet pathology.
◆ Most cases of postrepair SAM, when mild or moderate, can be managed conservatively. They
generally resolve in the weeks to months following repair when ventriculoaortic gradients
normalize, and left ventricular outflow tract remodeling occurs.54
◆ When managing patients with SAM conservatively, maintaining adequate filling of the left
ventricle is critically important to prevent left ventricular outflow tract collapse. Ventricular
underfilling is prevented by maintaining preload through volume resuscitation, increasing
afterload with alpha agonists, and preserving diastolic filling with heart rate reduction, either
via beta blockade or by decreasing the temporary pacemaker rate. Inotropes should be minimized,
if possible, to prevent hyperdynamic contraction of the left ventricle.
◆ If the previous maneuvers are unsuccessful in treating postrepair SAM, the patient must
undergo re-repair to correct the underlying lesion; valve replacement is very rarely indicated.
A B
Good coaption
depth
C D
Figure 18.17
Figure 18.17 (A) Saline test. (B) Ink test.

◆ Careful evaluation of the valve to determine the precise lesion causing regurgitation is the
most important step of the operation because it guides all other decisions with regard to
repairing the valve.
◆ Excellent exposure is necessary for successful repair of complex valvular lesions. Multiple
maneuvers can be used to improve exposure. For example, after performing the pericardiotomy,
remove the retractor and suture the pericardium to the right side of the skin incision before
replacing the retractor; this rotates the heart and optimizes exposure of the mitral valve.
Leftward traction on the caval snares can also assist in rotating the heart and optimizing
exposure.
◆ When placing annuloplasty sutures, we start with the 6 o’clock suture. This can then be used
for traction when placing subsequent annuloplasty stitches.

◆ Proper sizing of the annuloplasty ring is critical. Overly restrictive annuloplasty rings can
result in SAM of the mitral valve or iatrogenic functional mitral stenosis.

◆ To de-air more expeditiously, turn off the left ventricular vent early during closure of the left
side of the heart while having the perfusionist add blood to the patient’s circulation.
References
1. Rabkin E, Aikawa M, Stone JR, et al. Activated interstitial myofibroblasts express catabolic enzymes and mediate matrix remodeling in
myxomatous heart valves. Circulation. 2001;104(21):2525–2532.
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American Indians: the Strong Heart Study. Am J Med. 2001;111(9):679–685.
3. Freed LA, Levy D, Levine RA, et al. Prevalence and clinical outcome of mitral-valve prolapse. N Engl J Med. 1999;341(1):1–7.
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5. Hayek E, Gring CN, Griffin BP. Mitral valve prolapse. Lancet. 2005;365(9458):507–518.
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Association. Circulation. 2015;131(4):e29–e322.
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patients. N Engl J Med. 1985;313(21):1305–1309.
8. Mills P, Rose J, Hollingsworth J, et al. Long-term prognosis of mitral-valve prolapse. N Engl J Med. 1977;297(1):13–18.
9. Düren DR, Becker AE, Dunning AJ. Long-term follow-up of idiopathic mitral valve prolapse in 300 patients: a prospective study. J Am
Coll Cardiol. 1988;11(1):42–47.
10. St John Sutton M, Weyman AE. Mitral valve prolapse prevalence and complications: an ongoing dialogue. Circulation.
2002;106(11):1305–1307.
11. Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a
report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol.
2014;63(22):e57–e185.
12. Gillinov AM, Blackstone EH, Nowicki ER, et al. Valve repair versus valve replacement for degenerative mitral valve disease. J Thorac
Cardiovasc Surg. 2008;135(4):885–893.
13. Gillinov AM, Cosgrove DM, Blackstone EH, et al. Durability of mitral valve repair for degenerative disease. J Thorac Cardiovasc Surg.
1998;116(5):734–743.
14. Cohn LH, Couper GS, Aranki SF, et al. Long-term results of mitral valve reconstruction for regurgitation of the myxomatous mitral
valve. J Thorac Cardiovasc Surg. 1994;107(1):143–150.
15. David TE, Ivanov J, Armstrong S, et al. Late results of heart valve replacement with the Hancock II bioprosthesis. J Thorac Cardiovasc
Surg. 2001;121(2):268–277.
16. Sand ME, Naftel DC, Blackstone EH, et al. A comparison of repair and replacement for mitral valve incompetence. J Thorac Cardiovasc
Surg. 1987;94(2):208–219.
17. Lee EM, Shapiro LM, Wells FC. Superiority of mitral valve repair in surgery for degenerative mitral regurgitation. Eur Heart J.
1997;18(4):655–663.
18. Akins CW, Hilgenberg AD, Buckley MJ, et al. Mitral valve reconstruction versus replacement for degenerative or ischemic mitral
regurgitation. Ann Thorac Surg. 1994;58(3):668–675.
19. Galloway AC, Colvin SB, Baumann FG, et al. A comparison of mitral valve reconstruction with mitral valve replacement:
intermediate-term results. Ann Thorac Surg. 1989;47(5):655–662.
20. Enriquez-Sarano M, Schaff HV, Orszulak TA, et al. Valve repair improves the outcome of surgery for mitral regurgitation. A
multivariate analysis. Circulation. 1995;91(4):1022–1028.
21. Cohn LH, Kowalker W, Bhatia S, et al. Comparative morbidity of mitral valve repair versus replacement for mitral regurgitation with
and without coronary artery disease. Ann Thorac Surg. 1988;45(3):284–290.
22. Savage EB, Ferguson TB, DiSesa VJ. Use of mitral valve repair: analysis of contemporary United States experience reported to the
Society of Thoracic Surgeons National Cardiac Database. Ann Thorac Surg. 2003;75(3):820–825.
23. Gammie JS, Sheng S, Griffith BP, et al. Trends in mitral valve surgery in the United States: results from the Society of Thoracic
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24. Bolling SF, Li S, O’Brien SM, et al. Predictors of mitral valve repair: clinical and surgeon factors. Ann Thorac Surg.
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25. Goldstone AB, Atluri P, Szeto WY, et al. Minimally invasive approach provides at least equivalent results for surgical correction of
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26. McClure RS, Athanasopoulos LV, McGurk S, et al. One thousand minimally invasive mitral valve operations: early outcomes, late
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outcomes. Ann Thorac Surg. 2009;88(4):1185–1190.
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34. Goldstone AB, Woo YJ. Surgical treatment of the mitral valve. In: Sellke FW, del Nido PJ, Swanson SJ, eds. Sabiston and Spencer
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35. Suri RM, Thalji NM. Minimally invasive heart valve surgery: how and why in 2012. Curr Cardiol Rep. 2012;14(2):171–179.
36. Gammie JS, Zhao Y, Peterson ED, et al. J. Maxwell Chamberlain Memorial Paper for adult cardiac surgery. Less-invasive mitral valve
operations: trends and outcomes from the Society of Thoracic Surgeons Adult Cardiac Surgery Database. Ann Thorac Surg.
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37. Kaczorowski DJ, Blank M, Woo YJ. Intracardiac exposure for transventricular mitral valve ring annuloplasty repair during Dor
ventriculoplasty. J Heart Lung Transplant. 2012;31(11):1236–1238.
38. Goldstone AB, Woo YJ. Alternative approaches for mitral valve repair. Ann Cardiothorac Surg. 2015;4(5):469–473.
39. Frederick JR, Woo YJ. Transaortic mitral valve replacement. Ann Thorac Surg. 2012;94(1):302–304.
40. Carpentier A, Adams DH, Filsoufi F. Carpentier’s Reconstructive Valve Surgery. Philadelphia: Saunders; 2010.
41. Asai T, Kinoshita T, Hosoba S, et al. Butterfly resection is safe and avoids systolic anterior motion in posterior leaflet prolapse repair.
Ann Thorac Surg. 2011;92(6):2097–2102.
42. Chu MWA, Gersch KA, Rodriguez E, et al. Robotic “haircut” mitral valve repair: posterior leaflet-plasty. Ann Thorac Surg.
2008;85(4):1460–1462.
43. MacArthur JW, Cohen JE, Goldstone AB, et al. Nonresectional single-suture leaflet remodeling for degenerative mitral regurgitation
facilitates minimally invasive mitral valve repair. Ann Thorac Surg. 2013;96(5):1603–1606.
44. Woo YJ, MacArthur JW. Simplified nonresectional leaflet remodeling mitral valve repair for degenerative mitral regurgitation. J Thorac
Cardiovasc Surg. 2012;143(3):749–753.
45. Woo YJ, MacArthur JW. Posterior ventricular anchoring neochordal repair of degenerative mitral regurgitation efficiently remodels and
repositions posterior leaflet prolapse. Eur J Cardiothorac Surg. 2013;44(3):485–489.
46. Gillinov AM, Cosgrove DM, Wahi S, et al. Is anterior leaflet repair always necessary in repair of bileaflet mitral valve prolapse? Ann
Thorac Surg. 1999;68(3):820–823.
47. Saunders PC, Grossi EA, Schwartz CF, et al. Anterior leaflet resection of the mitral valve. Semin Thorac Cardiovasc Surg.
2004;16(2):188–193.
48. Alfieri O, Maisano F, De Bonis M, et al. The double-orifice technique in mitral valve repair: a simple solution for complex problems. J
Thorac Cardiovasc Surg. 2001;122(4):674–681.
49. Bichell DP, Adams DH, Aranki SF, et al. Repair of mitral regurgitation from myxomatous degeneration in the patient with a severely
calcified posterior annulus. J Card Surg. 1995;10(Pt 1):281–284.
50. David TE, Feindel CM, Armstrong S, Sun Z. Reconstruction of the mitral anulus. A ten-year experience. J Thorac Cardiovasc Surg.
1995;110(5):1323–1332.
51. David TE, Feindel CM. Reconstruction of the mitral anulus. Circulation. 1987;76(Pt 2):III102–III107.
52. David TE, Kuo J, Armstrong S. Aortic and mitral valve replacement with reconstruction of the intervalvular fibrous body. J Thorac
Cardiovasc Surg. 1997;114(5):766–771.
53. Carpentier AF, Pellerin M, Fuzellier JF, Relland JY. Extensive calcification of the mitral valve annulus: pathology and surgical
management. J Thorac Cardiovasc Surg. 1996;111(4):718–729.
54. Brown ML, Abel MD, Click RL, et al. Systolic anterior motion after mitral valve repair: Is surgical intervention necessary? J Thorac
Cardiovasc Surg. 2007;133(1):136–143.
CHAPTER
19
Mitral Valve Replacement

Zhaozhuo Niu, Thierry G. Mesana, Marc Ruel, and Vincent Chan
Step 1. Anatomy
◆ The mitral valve is a complex structure comprised of an anterior and posterior leaflet that is
connected to the left ventricle via attachments to papillary muscles through the chordae
tendineae.
◆ It is anchored to the mitral annulus, which is in close relation to the circumflex coronary
artery laterally, coronary sinus medially, and aortic valve anteriorly.

◆ Shown in Fig. 19.1 is the mitral annulus in a lateral view, along with view of the mitral valve
from the top of the heart showing its proximity to the aortic and tricuspid valves.
306
Chapter 19 • Mitral Valve Replacement306.e1
Keywords
mitral valve
mitral valve replacement
Chapter 19 • Mitral Valve Replacement 307
Anterior leaflet
Anterolateral Posteromedial
commissure commissure
Posterior
leaflet
Chordae
tendineae
Lateral papillary Medial papillary

muscle muscle
Left anterior Pulmonary

descending valve
artery
Aortic valve
Left main
artery
Right
coronary
Circumflex artery
artery A1
P1
Tricuspid
valve
Mitral valve A2
P2
A3
P3
Coronary
sinus
B
Figure 19.1
Step 2. Access to the Mitral Valve
◆ Exposure of the mitral valve must be optimized to facilitate efficient and effective surgery.
Although not described in detail, complete drainage of the right atrium must be achieved
prior to arresting the heart and opening the left atrium.
◆ Left atriotomy via Sondergaard’s groove: The interatrial plane is dissected to separate a portion
of the right atrium that overhangs the left atrium toward the septum. This incision is extended
superiorly toward the left atrial roof. It is extended inferiorly anterior to the inferior pulmonary
veins, but posterior to the inferior vena cava (Fig. 19.2).
RA
SVC
IVC
LA
RSPV
A
RA
SVC
LA IVC
B RSPV
Left atrial
appendage
SVC
IVC
C RSPV
Figure 19.2
◆ Extended vertical transseptal biatriotomy: The right atrium is opened from the right atrial
appendage toward the inferior vena cava. The interatrial septum is then incised down to
the fossa ovalis and extended cephalad onto the dome of the left atrium. This approach is
particularly useful in the setting of reoperative valve surgery with an aortic valve prosthesis
in place (Fig. 19.3).1
Roof of LA
RA
SVC
IVC
RSPV
Interatrial
septum
B
Figure 19.3 C
◆ Khonsari biatriotomy: This extends from the right atrial appendage toward the right superior
pulmonary vein to expose the interatrial septum, which is then incised transversely through
the fossa ovalis (Fig. 19.4).2
Figure 19.4 C
Step 3. Suture Placement for Mitral Valve Replacement
◆ Continuous suture: This approach to anchoring a prosthesis is typically performed when the
mitral annulus is tough and fibrous without much annular calcification. The major advantage
of this technique relates to surgical speed, which may be advantageous in robotic or minimally
invasive mitral surgery. This is performed with a 3-0 Prolene or Gore-Tex sutures (Fig. 19.5).
B
Figure 19.5
◆ Interrupted sutures without pledgets: This technique is performed in the setting of mitral
annular calcification or following failed prosthesis removal at the time of reoperative mitral
replacement. The major advantage of this technique is that the sewing cuff of the mitral
prosthesis will be seated precisely within the plane of the mitral annulus, without any distortion.
This is performed with 3-0 Ethibond sutures (Fig. 19.6).
◆ Interrupted sutures with pledgets: These sutures can be placed from the atrium toward the
ventricle (pledgets sitting on the atrial surface of the mitral valve) or vice versa (pledgets
sitting on the ventricular surface of the mitral valve; Fig. 19.7).
◆ Although both approaches can be applied for bioprosthetic or mechanical valve replacement,
it is advantageous to place pledgets on the atrial surface when using a mechanical valve. This
minimizes the risk of pledget embolization into the left ventricle if a suture tears during tying.
A B
Figure 19.6
A B
Figure 19.7
Step 4. Prosthesis Orientation
◆ Bioprosthesis: The largest leaflet cusp should face the left ventricular outflow tract to prevent
outflow obstruction (Fig. 19.8).
B
Figure 19.8
◆ Mechanical prosthesis: Modern bileaflet valves are positioned in an antianatomic position

with the pivot guards orientated in an anterior-posterior direction (Fig. 19.9).
B
Figure 19.9
Step 5. Chordal Preservation
◆ Maintenance of the ventricular-annular continuity at the time of mitral valve replacement has
been associated with more favorable ventricle remodeling and better survival compared to
nonchordal sparing valve replacement.
1. Preservation of the Posterior Leaflet
◆ The most common approach to chordal preservation involves complete resection of the
anterior leaflet in which the posterior leaflet is retained. Replacement sutures are placed
through the annulus and through a portion of the posterior leaflet (Fig. 19.10).3
◆ Some have also described resection of the central portion of the posterior leaflet, with reat-
tachment of the posterior leaflet free edge with the valve replacement sutures.
Aa
Ab
Figure 19.10 Continued
Ba
Bb
2. Anterior Leaflet Preservation
◆ This has been described with excision of a central trapezoidal segment of the anterior leaflet.
The remaining tissue is taken by the valve suture. Others have described using Prolene sutures
to reapproximate the remaining leaflet tissue to the annulus before valve suture placement
(Fig. 19.11A).4
◆ Others have also described complete detachment of the anterior leaflet with resection of the
middle portion of the leaflet. The remaining leaflet tissue is that reapproximated to the
anterolateral and posteromedial commissures, respectively.5
◆ Initially described for implantation of a tilting disk mechanical prosthesis, reattachment of
the detached anterior leaflet to the posterior annulus has been used by some.
◆ The Khonsari I technique is applied for rheumatic valves in which the primary chordate are
destroyed and subvalvular apparatus are thickened. In this technique, second-order chords
are preserved in bundles and then reattached radially to the annulus in their anatomic position
using pledgetted valve sutures.6,7
3. Neochordae Placement
◆ Polytetrafluoroethylene sutures are placed on the papillary muscles and attached to the mitral
annulus at 2, 5, 7, and 10 o’clock positions (Fig. 19.12).
A B
Figure 19.11
A B
Figure 19.12
Step 6. Annular Reconstruction
◆ Inpatients with destruction of the posterior annulus, secondary endocarditis, or following

radical débridement in patients with severe annular calcification, a pericardial patch is sewn
into the left ventricle cavity with Prolene sutures. Valve sutures are then secured to the patch
before the atrial surface is reapproximated (Fig. 19.13).
Step 7. Mitral Annular Calcification
◆ Mitral annular calcification is common and represents a challenging cardiac lesion.

◆ Mitral annular calcification in younger patients with degenerative disease tends to involve
the posterior annulus (Fig. 19.14). In these patients, the calcification is dense and can be
removed en bloc, with subsequent reconstruction of the annulus, described previously.
◆ In patients with a history of renal dysfunction requiring renal replacement therapy, or mediastinal
irradiation, or those of advanced age, the calcification of the mitral annulus may be friable,
with extension into the ventricle cavity.
◆ In these patients, valve explants may be challenging. I recommend that resection begin with
the anterior leaflet, thereby facilitating visualization of the subvalvular structures. Importantly,
this aids in the identification of the mitral annulus, which may not be obvious. Débridement
of the annulus is performed with sharp dissection using a no. 11 blade and bluntly with a
rongeur. Mitral replacement with interrupted suture placement is useful because it allows the
mitral prosthesis to be seated within the mitral annulus. Also, interrupted suture placement
may mitigate tension on the annulus, which can result in calcium fracturing when tying.
A B
Figure 19.13
A B
Figure 19.14
◆ For impenetrable calcium involving the portion of the mitral annulus from the 12 to 3 o’clock
positions, sutures may be placed across the interatrial septum via the right atrium. Impenetrable
calcium involving the mitral annulus from the 9 to 12 o’clock positions may require suture
placement externally on the left atrial roof onto the mitral annulus (Fig. 19.15).
◆ Another strategy for mitral prosthesis implantation involves the intraatrial insertion of the
prosthesis, as described by Gandjbakhch.8 In this technique, a Dacron collar is sewn onto a

valve prosthesis. An inner row of interrupted pledgetted valve sutures (pledgets on the atrial
surface) are placed before the free end of the collar is sewn to the left atrium with running
Prolene sutures.
B
Figure 19.15
References
1. Guiraudon GM, Ofiesh JG, Kaushik R. Extended vertical transatrial septal approach to the mitral valve. Ann Thorac Surg.
1991;52(5):1058–1060; discussion 1060–1062.
2. Khonsari S, Sintek CF. Transatrial approach revisited. Ann Thorac Surg. 1990;50:1002.
3. Feikes HL, Daugharthy JB, Perry JE, et al. Preservation of all chordae tendinae and papillary muscles during mitral valve replacement
with a tilting disc valve. J Cardiac Surg. 1990;2:81.
4. David TE. Mitral valve replacement with preservation of chordae tendinae: Rationale and technical consideration. Ann Thorac Surg.
1986;41:680.
5. Miki S, Kusuhara K, Ueda Y, et al. Mitral valve replacement with preservation of chordae tendinae and papillary muscles. Ann Thorac
Surg. 1988;45:28.
6. Okita Y, Miki S, Ueda Y, Tahata T, Sakai T, Matsuyama K. Mitral valve replacement with maintenance of mitral annulopapillary muscle
continuity in patients with mitral stenosis. J Thorac Cardiovasc Surg. 1994;108:42–51.
7. Wasir H, Choudhary SK, Airan B, Srivastava S, Kumar AS. Mitral valve replacement with chordal preservation in a rheumatic
population. J Heart Valve Dis. 2001;10:84–89.
8. Nataf P, Pavie A, Jault F, Bors V, Cabrol C, Gandjbakhch I. Intraatrial insertion of a mitral prosthesis in a destroyed or calcified mitral
annulus. Ann Thorac Surg. 1994;58(1):163–167.
CHAPTER
20
Minimally Invasive Mitral

Valve Surgery: Partial
Sternotomy Approach
Gurjyot Bajwa and Tomislav Mihaljevic
◆ Mitral valve dysfunction is a common pathologic process. The process may involve any
component of the valve or subvalvular structures, including the valve leaflets, the annulus,
the papillary muscles, the chordae tendineae, and the left ventricular wall.
◆ The anatomic description of the mitral valve is best visualized using a three-dimensional
approach to its location in the heart. The anterior portion of the mitral valve annulus is
positioned posterior to the aortic annulus and is bordered by the left and right fibrous trigones.
The atrioventricular (AV) node and the bundle of His are adjacent to the right trigone. The
circumflex artery runs along the posterior annulus of the mitral valve and may be at risk
during mitral valve repair or replacement (Fig. 20.1).
◆ Chordae tendineae extend from the anterior and posterior papillary muscles to both leaflets.
Primary chordae attach to the free margin of the leaflet, whereas secondary chordae attach
to the middle and posterior aspects of the leaflets closer to the annulus.
1. Indications
◆ Most common indications for mitral valve replacement are rheumatic mitral stenosis and
infective endocarditis. Replacement is less commonly performed for degenerative disease and
functional mitral regurgitation.
◆ Mitral valve repair is indicated in those with severe myxomatous disease with the presence
of gross redundancy of both anterior and posterior leaflets, especially in the younger population.
In older adults, mitral regurgitation usually is a result of fibroelastic deficiency disease.
332
Chapter 20 • Minimally Invasive Mitral Valve Surgery: Partial Sternotomy Approach332.e1
Keywords
minimally invasive cardiac surgery

minimally invasive mitral valve replacement
Chapter 20 • Minimally Invasive Mitral Valve Surgery: Partial Sternotomy Approach 333
Right fibrous
trigone
Left fibrous
trigone
Circumflex artery
Anterior mitral
valve leaflet
Commissures
Posterior mitral
valve leaflet
Bundle of His
Figure 20.1
2. Operative Risk
◆ Long-standing, severe mitral stenosis results in pulmonary hypertension, right ventricular

dysfunction, and a variable degree of tricuspid valve regurgitation. If severe, this can result
in secondary hepatic and renal dysfunction, with a resultant increase in operative risk.
◆ Mitral annular calcifications are frequently present in older adults, especially in cases of
rheumatic mitral stenosis. Calcifications typically involve the posterior aspect of the mitral
annulus and can extend to the base of the posterior leaflet and the base of the left ventricle.
Severe calcification of the mitral annulus appears as a horseshoe sign on the preoperative
chest radiograph or coronary angiogram (Fig. 20.2).
◆ Standard preoperative assessment of mitral valve disease is performed by transthoracic or
transesophageal echocardiography. Transesophageal echocardiography allows more precise

assessment of the anatomy and function of the mitral valve and represents the gold standard
in preoperative assessment and planning of the operation. It is an essential tool intraoperatively
for assessment of the valve repair or replacement after weaning from cardiopulmonary bypass.
◆ Mechanical prostheses are indicated for patients younger than 65 years; biologic valves are
used more commonly in older adults. This paradigm may shift as the valves evolve in quality
and durability, along with the possibility of the use of catheter-based prostheses.
◆ Selection of the surgical approach depends on the cause of the mitral valve disease, the
presence of concomitant coronary or valvular disease, body habitus, and anatomic chest wall
deformities.
◆ Most patients who require isolated mitral valve surgery are candidates for a minimally invasive
approach. Relative contraindications to a minimally invasive approach include morbid obesity

and extensive mitral annular calcifications.
Step 2. Conduct of the Operation
1. Incision
◆ The standard incision for minimally invasive mitral valve repair or replacement is a 6- to
8-cm skin incision and a partial upper sternotomy, extending to the left fourth intercostal
space. This approach is described in detail in this chapter (Fig. 20.3).
Figure 20.2
6- to 8-cm
Manubrium
skin incision
Sternal body
Left fourth
intercostal space
Figure 20.3
2. Dissection
◆ A small sternal retractor with removable blades (Baxter Healthcare, Deerfield, IL) is used to
retract the sternum before proceeding with the dissection. The thymic remnants are divided
and ligated with nonabsorbable sutures, and the upper pericardium is divided along the
midline.
◆ The retractor is then removed and a pericardial sac is formed by placing stay sutures in the
skin using 2-0 silk sutures. Transient hypotension may occur when the edges of the pericardium
are pulled up and toward the skin owing to the displacement of the superior mediastinum
and an associated decrease in venous return to the right atrium.
◆ The sternal retractor is reinserted to expose the great vessels and the right atrium. Cardio-
pulmonary bypass is initiated by cannulation of the ascending aorta and the superior and
inferior venae cavae. The ascending aorta is cannulated by a flexible aortic cannula (21 F),
whereas bicaval cannulation is accomplished by placing flexible venous cannulae (24 F) into
the distal superior vena cava (SVC) and through the right atrial appendage into the inferior
vena cava (IVC). Vacuum-assisted venous drainage is used in all cases. Finally, an antegrade
cardioplegia cannula is placed in the proximal ascending aorta (Fig. 20.4).
◆ After initiation of bypass, the right atrium is isolated by encircling both the SVC and IVC
using flexible vessel loops. To place these loops, the pericardial reflections around the vessels
must be dissected. The isolation of the IVC is facilitated by the use of a semicircular Favaloro
clamp (Fig. 20.5).
Sternal retractor
Antegrade
cardioplegia
cannula
Pericardial
reflection Pericardium
Flexible
aortic cannula
Incision line for right
Flexible atriotomy
venous cannula
Figure 20.4
Flexible aortic
clamp Sternal retractor
Antegrade
cardioplegia
cannula
Pericardial Pericardium
reflection
Cannula for
retrograde
cardioplegia
Flexible aortic
cannula
Coronary sinus
Flexible
Direction of trans-
vessel loop
septal incision
Reflected right
atrial appendage
Flexible
venous cannula
Figure 20.5
◆ Cross-clamping of the aorta is performed with a Cosgrove Flex Clamp (Edwards Lifesciences,
Irvine, CA) so that there is minimal obstruction of the surgical field. A modified Buckberg
solution is administered as the main component of cold, antegrade blood cardioplegia.
◆ Then, 2-0 silk sutures are placed into the right atrial appendage medial to the insertion site
of the IVC cannula to ensure retraction of the atrial wall edges. A right atriotomy is performed,
with the incision extending between the SVC and aorta superiorly and the base of the right
atrium inferiorly. A cannula for retrograde cardioplegia can be inserted directly into the coronary
sinus at this point (Fig. 20.6).
◆ A transseptal incision is performed through the midportion of the fossa ovalis. It is extended
superiorly across the roof of the left atrium between the SVC and the aortic root.
◆ Exposure of the mitral valve is achieved by placing two or three pledgeted 3-0 polypropylene
stay sutures into the medial aspect of the incised septum. Further retraction of the interatrial
septum is provided by two low-profile, handheld retractors (Fig. 20.7).
Flexible aortic
Sternal retractor
clamp
Antegrade
cardioplegia
cannula
Pericardial
Flexible aortic
cannula
Flexible
Incision line for
vessel loop
right atriotomy
Flexible
venous cannula Semicircular
Favaloro clamp
Figure 20.6
Sternal retractor
Flexible aortic
clamp
Pericardial
Antegrade
cardioplegia
cannula Cannula for
retrograde
cardioplegia
Flexible aortic
cannula
Hand-held retractor
Flexible
vessel loop
Reflected right
atrial appendage
Flexible
venous cannula
Mitral valve
Figure 20.7
◆ Once the mitral valve is exposed, the anterior leaflet is incised, leaving a residual rim of
approximately 5 mm; two small areas of the leaflet that contain chordae from the anterior
leaflet and posterior papillary muscles are retained. Gentle traction on the partly detached
anterior leaflet allows for excellent visualization of the anterior portion of the mitral annulus
and secure placement of the everted pledgeted sutures (2-0 Ethibond sutures; Fig. 20.8).
◆ The retained areas of the anterior leaflet containing the chordae are attached to the lateral
and medial annulus with pledgeted 2-0 Ethibond sutures (Fig. 20.9A). This placement preserves
the chordae and ensures that they will not obstruct the left ventricular outflow tract or cause
uneven heaping of tissue on the posterior leaflet. An alternative approach to preserve the
chordae is simply to incise a portion of the anterior leaflet and fold the rest of the leaflet onto
the posterior aspect of the annulus (see Fig. 20.9B).
◆ Next, pledgeted sutures are placed along the posterior annulus by running a needle through
the annulus and then into the body of the leaflet, around any annular calcification (see
Fig. 20.9C).
Residual rim of anterior leaflet
Pledgeted sutures
Retained
portions of
anterior leaflet
Posterior leaflet
Figure 20.8

Annular calcification
Retained
portions of
anterior leaflet
Pledgeted sutures
Rim of posterior annulus
A B
Taut posterior leaflet
C
Figure 20.9
◆ Calcification of the posterior leaflet should be débrided. In patients for whom extensive
decalcification is needed, the annulus is reconstructed with a strip of autologous pericardium
(Fig. 20.10).
◆ Depending on the age of the patient, a biologic or mechanical prosthesis is used for valve
replacement. The sutures are placed into the valve sewing ring, and the valve is lowered into
place and secured (Fig. 20.11). Technical considerations should include orienting the valve
to keep the struts from obstructing the left ventricular outflow tract in the case of a biologic
prosthesis being used. If a mechanical valve is used, attention needs to be directed toward
the mobility of the leaflets, without obstruction from the subvalvular apparatus.
Retained
portions of
anterior leaflet
Calcification Calcification
removed
Calcification
removed
Figure 20.10
Mitral valve
replacement
Figure 20.11
◆ Repair of the mitral valve is feasible through the same exposure. Depending on the pathology
of the mitral valve causing the mitral valve regurgitation, leaflet repair is conducted. The
repair is completed with a partial annuloplasty band (Fig. 20.12).
2. Closure
◆ Air must be displaced from the left ventricle to the left atrium before the aortic cross-clamp
is removed, either by filling the left ventricle with saline or by administering antegrade car-
dioplegia. Running 4-0 polypropylene sutures are then used to close the interatrial septum
and the right atrium sequentially.
◆ Mediastinal and right pleural tubes are placed. Pacing wires are placed into the anterior surface
of the right ventricle. The patient is weaned from cardiopulmonary bypass after adequate
de-airing.
◆ Simple stainless steel wires are used for the sternal closure in the usual fashion.
◆ Patients who have undergone uncomplicated, minimally invasive mitral valve repair or replace-
ment can be extubated in the operating room. Early extubation allows for faster recovery and
a shorter intensive care unit stay.
◆ Patients with long-standing mitral stenosis and severe pulmonary hypertension with right
ventricular dysfunction often benefit from inotropic support with phosphodiesterase inhibitors
(e.g., milrinone) and pulmonary vasodilators (e.g., nitric oxide, sildenafil).
◆ Long-term warfarin anticoagulation with an ideal international ratio of 2.5 to 3.5 is indicated
for patients receiving mechanical prostheses, with consideration given to the administration
of low-dose aspirin in addition to warfarin.
◆ Patients with atrial fibrillation who have undergone mitral valve repair or replacement with
a biologic prosthesis maybe maintained on anticoagulation for the first 6 to 12 weeks or as

long as they remain in atrial fibrillation and are not contraindicated for anticoagulation.
◆ Emergency cardioversion is seldom successful in patients with chronic atrial fibrillation who
have undergone mitral valve surgery.
1. Advantages
◆ A partial sternotomy allows excellent access to the aortic and tricuspid valves, allowing for
multivalve minimally invasive surgery.
◆ This approach provides an excellent cosmetic result in both men and women, with a very
low incidence of sternal nonunion, because most of the sternum is left intact.
A B
C
Figure 20.12 Reprinted with permission, Cleveland Clinic Center for Medical Art and Photography © 2008-2017. All Rights Reserved.
2. Disadvantages
◆ A transseptal approach provides excellent exposure of the mitral valve but may cause transient
postoperative dysfunction of the sinus node due to transection of the nodal artery. However,
the incidence of permanent postoperative sinus node dysfunction is no different from that in
patients operated on through a conventional sternotomy and left atrial approach.
◆ The stay sutures on the pericardium should be attached to the drapes, which allows for
traction and lifting of the mediastinum toward the sternum. This approach helps expose the
anatomic structures, better especially in a deep chest.
◆ The operative field should be flooded with continuous CO2 to reduce intracardiac air and
peripheral embolization. CO2 dissolves more readily in blood, hence displacing other components
of air.
◆ The partial sternotomy and its extension into the fourth intercostal space via a J incision
should be carried out with care to avoid injury to the left internal thoracic artery and vein.
An oscillating saw with a narrow 1-cm blade may be used to make J the incision; its use is
more controlled, instead of curving the regular saw to the left side in one step.
◆ The superior part of the transseptal incision should be at least 1 cm lateral to the base of the
aortic root to avoid injury to the aortic valve during closure of the incision. A lesser margin
may distort the aortic root, leading to aortic insufficiency due to traction caused by external
sutures.
◆ Sutures along the lateral aspect of the mitral annulus should be placed with care to avoid
injury to the circumflex artery, especially in a left dominant system with the artery running
through the AV groove.
◆ Inspection before decannulation should include the dome of the left atrium, with care taken
to allow for meticulous hemostasis of the suture line. This area is very difficult to expose in
a minimally invasive approach once the heart is full and cardiopulmonary bypass has been
withdrawn.
◆ Mediastinal chest tubes should be placed while the heart is still decompressed on cardiopul-
monary bypass. This allows for excellent visualization of the operative field. Pacing wires are
placed in the same fashion.
◆ Meticulous closure with specific attention to hemostasis should be performed. There should
be a higher index of suspicion for tamponade with increased chest tube output because the
pericardium is not opened in its entirety.
Bibliography
Byrne JG, Mitchell ME, Adams DH, et al. Minimally invasive direct access mitral valve surgery. Semin Thorac Cardiovasc Surg.
1999;11:212–222.
Gillinov AM, Banbury MK, Cosgrove DM. Hemisternotomy approach for aortic and mitral valve surgery. J Card Surg. 2000;15:15–20.
Gillinov AM, Cosgrove DM. Minimally invasive mitral valve surgery: mini-sternotomy with extended transseptal approach. Semin Thorac
Gillinov AM, Cosgrove DM III. Mitral valve repair. In: Cohn LH, Edmunds LH Jr, eds. Cardiac Surgery in the Adult. New York:
McGraw-Hill; 2003:933–950.
Mihaljevic T, Cohn LH, Unic D, et al. One thousand minimally invasive valve operations: early and late results. Ann Surg.
2004;240:529–53434.
Nair RU, Sharpe DA. Limited lower sternotomy for minimally invasive mitral valve replacement. Ann Thorac Surg. 1998;65:273–274.
CHAPTER
21
Robotic Mitral
Valve Surgery
Hoda Javadikasgari, A. Marc Gillinov, Stephanie Mick,
Tomislav Mihaljevic, and Rakesh M. Suri
◆ The 2014 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines
strongly recommend (class I) prompt surgical correction of mitral regurgitation (MR) for
patients in stages D (severe symptomatic MR) and C2 (severe asymptomatic MR with left
ventricular ejection fraction [LVEF] < 60% or left ventricular end-systolic diameter [LVESD]
> 40 mm).1 Recently, several studies have supported the advantages of surgical correction of
primary MR, even in patients in stage C1 (severe asymptomatic MR with LVEF > 60% or
LVESD < 40 mm) to prevent excess long-term mortality and heart failure risks.2,3
◆ Modified cardiopulmonary bypass techniques were introduced in 1995 and enabled safe and
effective minimally invasive mitral valve surgery. However, difficulties performing complex
mitral valve repair using two-dimensional vision and long-shafted instruments limited their
adoption. During the late 1990s, development of the da Vinci Surgical System (Intuitive
Surgical, Sunnyvale, CA) made safe robotic cardiac surgery possible. The da Vinci Surgical
System has allowed surgeons to perform complex reconstructive operations using a combination
of telemanipulation and three-dimensional (3D) visualization. The first robotic mitral valve
operation was performed by Carpentier et al. in 1998 using the da Vinci Surgical System.4
In 2000, Dr. Chitwood and colleagues at East Carolina University (ECU) performed the first
mitral valve repair in the United States as part of the initial US Food and Drug Administration
(FDA) clinical trial.5
◆ The most important benefits of robotic mitral valve surgery include excellent surgical dexterity
with precise movements of instruments in the closed chest, high-definition 3D visualization

with the line of vision parallel to the flow of the blood into the valve, excellent visualization
of the subvalvular apparatus, and superior cosmetic results, with more rapid recovery than
with the use of conventional approaches.
347
Chapter 21 • Robotic Mitral Valve Surgery347.e1
Abstract
Robotic mitral valve surgery was introduced in 1998 to reproduce excellent conventional sternotomy
results with less invasive techniques. This technology is now routinely performed for delivering
complete anatomic correction of all categories of mitral valve prolapse, regardless of disease
complexity, with or without concomitant tricuspid valve repair and atrial fibrillation ablation
procedures. Recent studies have demonstrated broad advantages of robotic mitral valve surgery,
including reduced bleeding, extubation on the operating room table, shorter hospital length of
stay, quicker return to normal activities, and a superior cosmetic result. Here we discuss the
current status of robotic mitral valve surgery techniques.
Keywords
mitral valve
repair
replacement
prolapse
robotic
◆ The heart is covered anteriorly by the body of the sternum and the third to sixth costal
cartilages of both sides. The coronary sulcus, separating the atria and ventricles, spans from
the upper medial end of the third left costal cartilage to the middle of the right sixth chon-
drosternal joint. The anterior interventricular sulcus spans from the third left intercostal space
(ICS) 2.5 cm to the left of the midline to a point 1.2 cm medial to the apex. The aortic valve
is at the level of the third ICS behind the sternum. The pulmonary valve is at the level of the
left third ICS. The tricuspid valve is behind the sternum at the level of the fourth to fifth
intercostal junction. The mitral valve is located behind the sternum at the level of the fourth
intercostal junction.
◆ The mitral valve apparatus consists of the anterior and posterior leaflets, two commissures,
which are the areas where the anterior and posterior leaflets meet, the mitral annulus, and
the subvalvular apparatus, including the chordae tendineae and papillary muscles (Fig. 21.1).
◆ Each leaflet has three segments including the A1 (anterior segment), A2 (middle segment),
and A3 (posterior segment) of the anterior leaflet and P1 (anterior scallop), P2 (middle
scallop), and P3 (posterior scallop) of the posterior leaflet. The anterior mitral annulus shares
fibrous continuity with the aortic valve annulus (left coronary cusp and half of the noncoronary
cusp) and is also adjacent to the atrioventricular node and the bundle of His. The circumflex
artery courses along the posterior annulus and is at risk of injury during mitral valve repair
or replacement (Fig. 21.2). The subvalvular apparatus includes two papillary muscles (antero-
lateral and posteromedial) and the thin fibrous structures—chordae tendineae—that support
both leaflets and prevent leaflet prolapse. The primary chordae attach to the free margin of
the leaflets, and the secondary and tertiary chordae insert into the leaflet body, closer to the
annulus.
◆ Degenerative, ischemic, rheumatic, and infectious processes are the major causes of mitral
valve disease and can affect any component of the valve or subvalvular apparatus. Robotic
mitral valve surgery is appropriate for both degenerative and functional mitral valve disease.
However, degenerative mitral valve disease is the most common indication for robotic surgery.
Furthermore, concomitant left atrial appendage (LAA) closure, ablation for atrial fibrillation,
and tricuspid repair can also be performed using the same robotic platform.
Chapter 21 • Robotic Mitral Valve Surgery 349
Aorta
Left coronary
cusp
Non-coronary
cusp
Left trigone
Right coronary
cusp Left venticle
Anterolateral
Right trigone papillary muscle
Posteromedial
papillary muscle
Anterior leaflet
of mitral valve
Chordae
tendineae
Figure 21.1
Right fibrous
trigone
Circumflex artery
Left fibrous
trigone
Anterior mitral
valve leaflet
Commissures
Posterior mitral
valve leaflet
Bundle of His
Figure 21.2
Figure 21.1 Anatomy of mitral valve apparatus.
Figure 21.2 Cross-sectional view of the mitral valve.

Table 21.1 Contraindications for robotic mitral valve repair

CONTRAINDICATIONS RELATIVE CONTRAINDICATIONS
Previous right thoracotomy Previous sternotomy
Significant aortic root, ascending aortic dilation Mild aortic stenosis or regurgitation
Moderate or severe aortic valve regurgitation Reduced left ventricular function (EF < 50%)
Severe pulmonary hypertension (>50 mm Hg) Variable pulmonary hypertension (>50 mm Hg)
Right ventricular dysfunction Limited peripheral vascular disease
Generalized peripheral vascular disease Chest deformity (pectus, scoliosis)
Contraindications to retrograde perfusion (e.g., aortoiliac atherosclerotic Asymptomatic mild coronary disease
disease)
Mitral annular calcification Moderate pulmonary dysfunction
Myocardial infarction or ischemia < 30 days Asymptomatic cerebrovascular disease
Coronary artery disease requiring CABG
Severe pulmonary dysfunction
Symptomatic cerebrovascular disease or stroke < 30 days
Severe liver dysfunction
Significant bleeding disorder
CABG, Coronary artery bypass grafting; EF, ejection fraction.
◆ Following the 2014 ACC/AHA guidelines,1 in centers with expertise in both mitral valve and
robotic surgery, most patients with severe primary MR with appropriate vascular and coronary
anatomy may reasonably be considered for early robotic mitral valve repair, regardless of the
complexity of mitral valve disease. Patients should be screened for comorbid conditions that
may preclude the selection of the robotic technique. Table 21.1 demonstrates plausible and
relative contraindications to robotic mitral valve surgery. However, many of the relative
contraindications can be managed to allow a safe robotic mitral valve operation.6
◆ Repair techniques in patients with functional valve disease relate to the degree of annular
and ventricular dilation, papillary muscle displacement, dynamic cardiac function, and degree
of leaflet tethering.
◆ Patients at risk for coronary artery disease should undergo a cardiac catheterization or computed
tomography (CT) angiography. Patients with significant risk factors for carotid or peripheral
vascular disease should be screened by ultrasound and CT. A right heart catheterization may
be indicated for patients who have significant pulmonary hypertension, particularly with
depressed right ventricular function. Finally, patients with sternal or thoracic deformities
should be evaluated by CT to determine whether robotic instrument trajectories will be
compromised. A transthoracic echocardiography (TTE) or transesophageal echocardiography
(TEE) study should be performed to confirm the diagnosis and determine the repair plan.
TEE is also essential in the operative room to delineate mitral valve anatomy in detail, and
intraoperative femoral ultrasound should be peformed to confirm the adequacy of vessels for
cannulation.
◆ All patients undergoing robotic mitral valve surgery undergo the following steps:
1. Patient setup and port placement
2. Cannulation, docking of robotic arms, and exposure of the mitral valve
3. Mitral valve surgery, tricuspid valve repair, and atrial fibrillation procedures
4. Weaning from bypass, decannulation, and closing of incisions
1. Patient Setup and Port Placement
◆ The patient is intubated with a double-lumen endotracheal tube, and a TEE probe is placed.
Pulmonary artery vent and retrograde coronary sinus cardioplegia catheters (CardioVations,
Ethicon, Somerville, NJ) may be placed via the right internal jugular vein under TEE guidance.
The patient is positioned at the right edge of the operating room table with a transverse roll
under the chest and an arm board supporting the right arm. The right femoral artery and
vein are exposed via an oblique incision above the groin crease and assessed for appropriateness
for cannulation.
◆ Port placement is done after femoral vessel exposure has confirmed adequacy for use in
cannulation for cardiopulmonary bypass. Local anesthetic may be used at all port sites to aid
with postoperative pain control. The endoscope camera port is placed in the fourth ICS, 2
to 3 cm lateral to the nipple. In female patients, the breast is retracted superiorly and the
incision is placed in the inframammary crease to enter the chest in the fourth or fifth ICS.
The working port incision (for a 15-mm soft rubber retractor) is placed in the fourth ICS
4 cm lateral to the camera port. The left instrument port is placed one interspace above and
approximately halfway between the shoulder and the camera port. The right instrument port
is two or three interspaces below and near the anterior axillary line. The fourth robotic port,
for the atrial retractor instrument, is placed in the fifth ICS medial to the camera port. A
10-G angiocatheter, which can accommodate the so-called crochet hook for suture retrieval,
is placed in the midaxillary line for posterior pericardial traction sutures. Two other angiocatheters
are placed medially and laterally to the central angiocatheter. A Chitwood transthoracic cross-
clamp and a small suction vent are placed via stab wounds in the axilla (Fig. 21.3).
2. Cannulation and Docking
◆ A purse-string suture is placed in the anterior surface of the femoral vein, and then a guidewire
is passed through the femoral vein and into the superior vena cava (SVC) under TEE guidance.
Seeing the guidewire pass up into the SVC is very important to ensure the proper positioning
of the venous cannula. A 25F CardioVations Quickdraw venous cannula is passed over the
wire and positioned so that the tip is several centimeters up the inferior vena cava (IVC). The
femoral artery is cannulated using the Seldinger technique (Fig. 21.4). Cardiopulmonary
bypass is initiated.
Figure 21.3 Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography
© 2008-2017. All Rights Reserved.
Figure 21.3 Patient setup and port placement.
Figure 21.4 Cannulation of the femoral vessels.

◆ The pericardium is opened with electrocautery anterior to the phrenic nerve. The pericardiotomy
extends from near the IVC to up over the ascending aorta. Two traction sutures are placed
on the posterior pericardial edge to expose the site of the left atriotomy. A traction stitch on
the anterior pericardium facilitates aortic exposure (Fig. 21.5).
◆ The table is rotated 15 degrees to the left and placed in reverse Trendelenberg to lower the
hips and gain extra clearance for the right instrument arm of the robot. The da Vinci robot
is brought to the surgical field; the arms are connected to the ports, and the camera and
instruments are introduced into the chest.
3. Aortic Occlusion, Cardioplegia, and Exposure
◆ Aortic occlusion is achieved using the endoballoon or Chitwood clamp; cardioplegia is delivered
antegrade and readministered every 15 to 20 minutes throughout the cross-clamp time.
◆ A left atriotomy incision is made anterior to the right pulmonary vein (Fig. 21.6). The intuitive
surgical atrial retractor is positioned to elevate the atrial septum and provide exposure. The
atrial retractor position can be adjusted to optimize exposure for patent foramen ovale closure,
closure of the LAA, or exposure of the mitral valve. The small suction vent is positioned in
the left pulmonary vein to clear the surgical field of blood.
Figure 21.5 Opening of the precardium.
Figure 21.6 Left atriotomy.

4. Mitral Valve Repair
Triangular Resection With Ventricularization
◆ This technique is ideal for patients who need posterior leaflet repair with prolapsing, redundant,
and myxomatous tissue. The mitral valve is exposed and evaluated. The normal chordae on
either side of the prolapsing portion are identified to determine the extent of resection. A
triangular-shaped segment of tissue, with the base at the free edge of the posterior leaflet and
the apex at or near the annulus, is excised with curved scissors (Fig. 21.7A). Running 4-0
Prolene sutures (see Fig. 21.7B), with or without a ventricularization technique,7 are used to
close the defect in the leaflet.
◆ The ventricularization technique is performed to normalize the height of the posterior leaflet
and reduce the risk of systolic anterior motion. After triangular resection, each needle of a
double-armed suture is passed through the free edge of one leaflet remnant and then through
the midportion of that leaflet segment to ventricularize the free edge (i.e., move closer to the
ventricle), thereby reducing the leaflet height (see Fig. 21.7C). Each needle is then used for
a running closure of the posterior leaflet defect (see Fig. 21.7D), and the stitch is tied at the
base of the resection (see Fig. 21.7E). The assistant may tie the suture with a knot pusher or
the surgeon can tie it intracorporeally.
Quadrangular Resection With Sliding Repair
◆ A quadrangular resection of the posterior leaflet is necessary for the management of an

extensive, redundant, prolapsing leaflet. The excessively tall posterior leaflet is excised, and
then the remaining portions of the posterior leaflet are detached from the annulus and
advanced centrally, sliding it over to meet the other leaflet component. The leaflet base is
reattached to the annulus with two layers of running 4-0 Prolene sutures, and the leaflet
edges are reapproximated with 4-0 Prolene sutures.
C E
Figure 21.7 Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2008-2017. All Rights
Reserved.
Figure 21.7 (A) Triangular resection of the posterior leaflet. (B) Posterior leaflet repair using running technique. (C) Repair of the posterior
leaflet using ventricularization technique. (D) Running closure of the posterior defect. (E) Final stitch next to the annulus.
Neochordae Implantation
◆ Gore-Tex (WL Gore & Associates, Newark, DE) neochordae placement is greatly facilitated
by the robotic approach due to the excellent exposure and magnified view of the subvalvular
apparatus. The anterior leaflet is lifted upward using a dynamic left atrial retractor. The
neochordae are created using 5-0 polytetrafluoroethylene (PTFE) sutures. One arm of the
suture is passed twice through the fibrous tip of the papillary muscle and then twice through
the free edge of the corresponding prolapsing segment. The second arm is then passed twice
through the free edge of the prolapsing segment. The length of the chordae is adjusted based
on the height of the nearest normal segment of the posterior leaflet, and the sutures are tied
on the atrial side of the mitral valve leaflet (Fig. 21.8).
A B
C D
Figure 21.8 Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2008-2017. All Rights Reserved.
Figure 21.8 Repair of the mitral valve using artificial chordae.

Annuloplasty
◆ All repairs are completed using a flexible, standard-length annuloplasty band. The band is
first secured at the right (A3–P3) trigone, and additional sutures are placed from the medial
to lateral part of the annulus using either running or interrupted Ethibond sutures.
◆ For the interrupted suture technique, 10 to 12 2-0 braided polyester sutures are used to
secure the annuloplasty ring in the standard fashion (Fig. 21.9). For the running suture
technique, three 2-0 braided polyester sutures (Ticron, Covidien, MA) are used to secure the
annuloplasty ring as follows. The first suture is tied down between right trigone and the ring
and run clockwise to the midportion of the ring. The second suture (14 cm in length) is then
passed through the ring and annulus in running fashion to the level of the midportion of the
annulus. The second suture is started at this point with a single interrupted stitch and tied
to the first suture. The remainder of the second suture is then run clockwise to the left trigone.
The third suture (9 cm in length) is passed through the ring, through the left trigone, and
then back through the ring. This third suture is tied down, and the tail is used to secure the
second suture (Fig. 21.10).
5. Mitral Valve Replacement
◆ The subvalvular apparatus and chordae are preserved whenever possible. Appropriate sizing
is performed and 10 to 12 everting, double-armed, mattress sutures with Teflon pledgets are
placed counterclockwise from the 11 o’clock position and fixed sequentially outside the incision
with a small hemostat. The sutures are placed in the prosthesis sewing ring outside the chest.
The prosthesis is lowered into the chest and positioned, and the knots are tied using the knot
pusher or Cor-Knot device (LSI Solutions, Victor, NY) through the working port.
6. Atrial Fibrillation Procedure
◆ All lesions are created by applying the CryoMaze probe (ATS Medical, Minneapolis, MN) for
2 minutes directly to myocardial tissue, with temperatures reaching –140° to –160°C (–284°
to –320°F). Following lesion creation, the probe is separated from the surrounding tissue by
administering warm saline solution.
◆ The pulmonary veins are isolated with a single wide box lesion around all four veins. The
first cryolesion extends from the right inferior pulmonary vein to the mitral annulus. The
next lesion extends from the mitral annulus around the left pulmonary veins, reaching
the upper border of the atriotomy. Great care is taken to ensure complete contact between
the probe and atrial tissue. The complete box lesion can be constructed with two or three
cryolesions; however, if the left atrium is particularly large and redundant, more lesions may
be required. Additional lesions might be required from the pulmonary vein isolation box to
the LAA if this area is not completely ablated.
◆ The final left atrial lesion is an epicardial lesion across the coronary sinus to ensure complete
transmurality at the mitral valve annulus.

◆ The LAA is routinely closed as part of the CryoMaze operation unless there are significant
pericardial adhesions keeping the appendage patent. The LAA is closed in a two-layer fashion
using 3-0 Gore-Tex sutures.
A B
C D
Figure 21.10 Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2008-2017. All Rights
Reserved.
Figure 21.9 Band annuloplasty using interrupted stitches.
Figure 21.10 Band annulolasty using running stitches.

7. Atrial Closure
◆ Once the mitral surgery is complete, the left atriotomy is closed with running 4-0 Gore-Tex
sutures, beginning a suture at each end of the atriotomy and meeting in the middle. The
heart is allowed to fill and de-air via the atriotomy before tying the suture.
8. Tricuspid Valve Repair
◆ After bicaval cannulation, the caval cannulas are backed into the SVC and IVC, and the tapes
around the cavae are tightened. A vertical right atriotomy is made, and the dynamic atrial
retractor is used to retract the anterior right atrial wall. Tricuspid valve repair has evolved
from a classic De Vega repair (double-armed, running, vertical mattress purse-string sutures
of 4-0 PTFE, tied over pledgets) to an annuloplasty band sewn into place with interrupted
2-0 polyester sutures. The right atrium is then closed in two layers with PTFE, and the caval
tapes are released.
9. Removing the Cross-Clamp and Cardioplegia Catheter
◆ All repairs are assessed using saline insufflation to fill and pressurize the left ventricle before
closure, de-airing, and cross-clamp removal. Integrity of the repair (less than or mild residual
MR) and adequacy of de-airing should be confirmed with the patient off cardiopulmonary
bypass before decannulation. Once the heart is beating (and preliminary evaluation of the
repair by TEE looks good), the antegrade cardioplegia catheter is removed from the aorta,
and the puncture site is closed with pledget-reinforced 4-0 Gore-Tex or Prolene mattress
sutures.
10. Final Steps
◆ The pericardium is loosely closed with two sutures to prevent cardiac torsion. A 19F Blake
drain (Ethicon) is brought into the chest via the atrial retractor and the right instrument
ports.
◆ The instruments and ports are all removed, and both lungs are ventilated. The patient is then
separated from cardiopulmonary bypass, and the repair is evaluated by TEE. While a protamine
is administered, the cannulas are removed, the purse-string sutures in the femoral vein are
tied, and the femoral arteriotomy is repaired primarily.
◆ After a protamine is administered, the right lung is deflated, and the camera is reintroduced
into the chest to examine the aortic cardioplegia site, as well as all port and angiocatheter
sites, to ensure good hemostasis.
◆ Postoperative care is routine for cardiac surgery, with special attention to arrhythmia prevention
and maintaining afterload reduction. In the area of postoperative pain control, several factors
should be considered. Pain control after robotic surgery may be achieved with intercostal
nerve block or using cryothermia to freeze the intercostal nerves prior to incision closure.
Compared to sternotomy, patients who have robotic surgery require less intravenous narcotic,
which may allow earlier extubation. All patients should undergo repeated TTE before discharge
from hospital. Lifelong annual echocardiographic surveillance is necessary after mitral valve
repair.
◆ Operating inside the heart with robotic instruments does not allow tactile feedback. However,
this has not been a limitation in practice. Highly disciplined movement of robotic instruments,
advanced echocardiographic imaging, and gaining ocular tactility through experience have
addressed this issue. Furthermore, although cross-clamp and operative times are longer
compared to those of conventional median sternotomy, there has been no significant difference
with regard to postoperative morbidity and mortality.
◆ There are several potential advantages of robotic mitral valve repair in comparison to thoracotomy
and thoracoscopic approaches. The robot facilitates precise movements of instruments in the
closed chest and avoids the difficulties of using long, shafted, endoscopic instruments that
may be experienced during minimally invasive procedures. The high-definition 3D view
facilitates the visualization of the subvalvular apparatus and enables repair of any type of
myxomatous pathology. The cosmetic results are appreciated by female and male patients,
particularly in patients with prior breast reconstruction. Finally, the requirements for heterologous
blood products, the incidence of atrial fibrillation, and postoperative pain have been reported
to be lower, likely due to the reduced surgical trauma.8,9
◆ The collective results of robotic mitral valve repair in experienced groups have now reported
a hospital mortality rate of less than 0.9%, stroke rate of 0.6% to 1.7%, reexploration for
bleeding of 2.2% to 4.7%, and rare chest wall infections.10-15 Furthermore, the incidence of
iatrogenic aortic dissection, phrenic nerve palsy, and groin infections have all decreased to
almost 0%.15
◆ In summary, robotic mitral valve repair is now routinely performed, with or without concomitant
tricuspid valve repair and atrial fibrillation ablation procedures.11,16 This approach is safe,
effective, and durable for complete correction of all categories of mitral valve leaflet prolapse,
regardless of complexity. Furthermore, robotic repair offers reduced blood loss, lower risk of
incisional infection and atrial fibrillation, shorter hospital length of stay, quicker return to
normal activities, and a superior cosmetic result.13,16-17 Therefore, the procedure may be
particularly appealing in asymptomatic stage C1 patients according to ACC/AHA class IIa
guideline recommendations.1
References
2014;63:e57–e185.
2. Suri RM, Vanoverschelde J-L, Grigioni F, et al. Association between early surgical intervention vs watchful waiting and outcomes for
mitral regurgitation due to flail mitral valve leaflets. JAMA. 2013;310:609–616.
3. Yazdchi F, Koch CG, Mihaljevic T, et al. Increasing disadvantage of “watchful waiting” for repairing degenerative mitral valve disease.
Ann Thorac Surg. 2015;99:1992–2000.
4. Carpentier A, Loulmet D, Aupècle B, et al. Computer-assisted open heart surgery. First case operated on with success. C R Acad Sci III.
1998;321:437–442.
5. Nifong LW, Chu VF, Bailey BM, et al. Robotic mitral valve repair: experience with the da Vinci system. Ann Thorac Surg.
2003;75:438–443.
6. Suri RM, Dearani JA, Mihaljevic T, et al. Mitral valve repair using robotic technology: safe, effective, and durable. J Thorac Cardiovasc
Surg. 2016;151:1450–1454.
7. Suri RM, Burkhart HM, Schaff HV. A novel method of leaflet reconstruction after triangular resection for posterior mitral valve
prolapse. Ann Thorac Surg. 2010;89:e53–e56.
8. Ryan WH, Brinkman WT, Dewey TM, et al. Mitral valve surgery: comparison of outcomes in matched sternotomy and port access
groups. J Heart Valve Dis. 2010;19:51–58.
9. Suri RM, Antiel RM, Burkhart HM, et al. Quality of life after early mitral valve repair using conventional and robotic approaches. Ann
Thorac Surg. 2012;93:761–769.
10. Ramzy D, Trento A, Cheng W, et al. Three hundred robotic-assisted mitral valve repairs: the Cedars-Sinai experience. J Thorac
11. Nifong LW, Rodriguez E, Chitwood WR. 540 consecutive robotic mitral valve repairs including concomitant atrial fibrillation
cryoablation. Ann Thorac Surg. 2012;94:38–43.
12. Suri RM, Taggarse A, Burkhart HM, et al. Robotic mitral valve repair for simple and complex degenerative disease: mid-term clinical
and echocardiographic quality outcomes. Circulation. 2015;132:1961–1968.
13. Mihaljevic T, Jarrett CM, Gillinov AM, et al. Robotic repair of posterior mitral valve prolapse versus conventional approaches:
potential realized. J Thorac Cardiovasc Surg. 2011;141:72–80, e74.
14. Murphy DA, Moss E, Binongo J, et al. The Expanding Role of Endoscopic Robotics in Mitral Valve Surgery: 1,257 Consecutive
Procedures. Ann Thorac Surg. 2015;100:1675–1682.
15. Trento A, Ramzy D, De Robertis M, et al. Ten Years with Robotic Assisted Mitral Valve Repair: One Center’s Experience. Florence, Italy:
ICCAD; 2015.
16. Suri RM, Burkhart HM, Daly RC, et al. Robotic mitral valve repair for all prolapse subsets using techniques identical to open
valvuloplasty: establishing the benchmark against which percutaneous interventions should be judged. J Thorac Cardiovasc Surg.
2011;142:970–979.
17. Paul S, Isaacs AJ, Jalbert J, et al. A population-based analysis of robotic-assisted mitral valve repair. Ann Thorac Surg.
2015;99:1546–1553.
CHAPTER
22
Percutaneous Mitral
Valve Repair Techniques
Jolian Dahl and Gorav Ailawadi
◆ Percutaneous therapies have changed how the modern cardiothoracic surgeon approaches
the treatment of valvular heart disease. Although much of this evolution has come with the
advent of transcatheter aortic valve replacement, considerable obstacles inherent to mitral
valve disease have been overcome to develop multiple percutaneous technologies.
◆ Surgery is often difficult because mitral valve disease is both caused by and develops in parallel
to many comorbidities that increase surgical risk. This has been demonstrated by reports that
as many as 50% of patients with severe mitral regurgitation (MR) are not candidates for
surgery.1,2
◆ The challenge of developing effective percutaneous mitral valve repair technology stems from
the complexity and variation of both the pathophysiology of mitral valve disease and the
anatomy of the mitral valve apparatus.
◆ Degenerative MR (DMR; Video 22.1) develops when disease of the valve itself prevents sufficient
mitral leaflet coaptation via leaflet or chordal elongation, chordal rupture, or annular deforma-
tion, whereas functional MR (FMR) develops when left ventricular dysfunction and deformation
prevent sufficient coaptation of anatomically normal leaflets via annular dilation or leaflet
tethering.
◆ Patients with central, discrete regurgitant jets with relatively narrow bases and single-leaflet
prolapse or flail may benefit from percutaneous edge-to-edge repair.3

◆ Patients with enlarged hearts, annular dilation, minimal tenting, and central jets may benefit
from percutaneous annuloplasty.3

◆ Successful coronary sinus–based annuloplasty is more easily achieved in patients with a large
coronary sinus and a large great cardiac vein, with minimal tortuosity. Moreover, effective
reduction of the septolateral diameter can only be achieved if the coronary sinus and great
cardiac vein lie in the same plane as the mitral annulus (Fig. 22.1).
364
Chapter 22 • Percutaneous Mitral Valve Repair Techniques364.e1
Abstract
This chapter describes established and emerging percutaneous mitral valve repair techniques.
The goal of any percutaneous procedure is to achieve a durable correction of mitral disease with
clinical efficacy similar to that of well-established open surgical interventions. Knowing which
patients will benefit most from percutaneous approach and which approach to apply is exceedingly
challenging given the complex and varied pathophysiology and anatomy of mitral valve disease.
Surgical risk is often prohibitive given that mitral valve disease is both caused by and develops
in parallel to many comorbidities that increase surgical risk. By applying concepts that have
made surgical repair successful to the engineering of percutaneous technologies, restoring proper
mitral valve function with catheter based techniques can be performed without many of the
risks inherent to surgery. Percutaneous therapies therefore represent an expanding toolbox for
the modern valvular heart disease center that strives to repair mitral valve disease in patients
at all levels of surgical risk. Although catheter based repairs for MR are only approved in patients
at prohibitive surgical risk, as more data is collected, percutaneous repair may one day be used
as a viable option to surgical candidates who wish to avoid surgery.
Keywords
percutaneous mitral valve repair

mitral stenosis
degenerative mitral regurgitation
functional mitral regurgitation
balloon mitral valvuloplasty
MitraClip
EVEREST trials
COAPT trial
Carillon Mitral Contour System
AMADEUS trials
TITAN trials
AccuCinch Ventriculoplasty System
Cardioband System
IRIS complete annuloplasty ring
Chapter 22 • Percutaneous Mitral Valve Repair Techniques 365
Circumflex
coronary artery
Left anterior
descending
coronary artery
Coronary
Great cardiac
sinus
vein
Anterior
intraventricular
vein
Posterior
mitral annulus
Figure 22.1
◆ The goal of any percutaneous procedure is to achieve a durable correction of mitral disease with
clinical efficacy similar to that of well-established open surgical interventions. Most approaches
to percutaneous mitral valve repair are modeled after established surgical techniques.
◆ By applying concepts that have made surgical repair successful to the engineering of percutaneous
technologies, restoring proper mitral valve function can be performed without the risks
inherent to surgery.4,5
1. Percutaneous Treatment of Mitral Stenosis
◆ Worldwide, mitral stenosis (MS) most commonly results from rheumatic valvular disease,
typically with fusion of the leaflets at the commissures.
◆ Balloon mitral valvuloplasty (BMV) splits the fused commissures, allowing the mitral valve
to open more fully, and is the most well-established catheter-based repair of mitral disease
since the 1990s.6
◆ The applicability and efficacy of BMV are limited, with optimal outcomes in patients with a
mitral valve that is relatively thin and free of calcification, resulting in greater leaflet mobility
when the fused commissures are divided and minimizing the risk of embolic complications.
◆ BMV lacks utility when concomitant left atrial clot or more than mild to moderate MR is
present. Once either of these is present, mitral valve surgery is preferred unless the patient
is at prohibitive surgical risk.
◆ BMV has limited efficacy in those with senile calcific MS because it is caused not by com-
missural fusion but by calcification that extends into the leaflets from their origination in the
annulus.
2. Percutaneous Treatment of Mitral Regurgitation
Percutaneous Edge-to-Edge Repair
◆ Although uncommonly used in conventional surgical repair of MR, the edge-to-edge repair,
first described by Alfieri in 1991, has been shown to be effective at decreasing MR without
significant risk of MS in selected patients.7,8 The MitraClip procedure (Abbott Laboratories,
Abbott Park, IL) is a percutaneously delivered device that mimics the sutures placed in an
Alfieri repair. Whereas the original Alfieri technique (Fig. 22.2) combined an edge-to-edge
suture with annuloplasty, the MitraClip procedure is currently performed in isolation without
annuloplasty.9 Although debated, isolated reports have documented adequate outcomes with
surgical edge-to-edge repair without annuloplasty, providing the basis for the use of the
MitraClip procedure as a sole therapy.10
Broken chordae Edge-to-edge

dual-orifice repair
as popularized by
Alfieri
Figure 22.2
◆ Degenerative and functional MR often necessitate very different treatment approaches but, as
an intervention that was hoped to offer benefit to patients with either cause, the MitraClip
procedure was initially studied in a heterogeneous population. Surgical mitral repair has
provided excellent outcomes for patients with DMR, but the benefit to patients with FMR is
controversial.6,11-14 Although there exists a gold standard for treating FMR in nonsurgical
patients, no such standard exists for treating DMR. Given the inferior efficacy when compared
to surgical repair and the lack of a gold standard for nonsurgical patients with degenerative
pathology, the US Food and Drug Administration (FDA) approved the MitraClip procedure
in 2013 as an alternative treatment option for symptomatic patients with severe (≥ 3+) DMR
at prohibitive surgical risk.
◆ Currently, a functional cause of MR is not an approved indication for the MitraClip procedure.
Severe FMR certainly worsens heart failure physiology and symptoms by contributing to
volume overload and progressive dilation, but it is yet unclear whether correcting the MR
actually improves survival. The EVEREST II (Endovascular Valve Edge to Edge Repair Study)
trial has shown that FMR is a significant predictor of mortality on multivariable analysis
(hazards ratio [HR], 2.7; confidence interval [CI], 1.4–5; p = 0.003),15 so although the repair
of MR may improve symptoms, it may not address the causal pathophysiology or affect the
clinical trajectory likely determined by the underlying left heart dysfunction.16 FMR is primarily
treated via goal-directed medical therapy aimed at improving underlying left ventricular
dysfunction with beta blockade, diuretic use, angiotensin-converting enzyme inhibitors and,
if indications are found, cardiac resynchronization.6 It is therefore recommended to ensure
that patients receive maximal medical therapy prior to considering mitral intervention.17
◆ Patients with DMR must meet many anatomic criteria to have the MitraClip device placed.
Although reported to have caused only one case of MS after 5 years of follow-up in the clinical
trial, there have been other reports of MS following MitraClip placement.18 As such, a resting
effective orifice area over 4 cm2 is required to minimize this long-term risk of MS.19
◆ Considering that the Alfieri technique can only address poor coaptation at one place along
the valve orifice, multiple foci of MR preclude the use of the MitraClip. Ideally it should be
used when a single primary regurgitant jet is present.
◆ Although initial studies excluded patients with excessively calcified leaflet edges out of concern
for capture failure, this has often been overcome in subsequent clinical experience with
multiple clip placement, with reports of as many as 40% of patients receiving a second clip
and some even receiving a third.
Percutaneous Annuloplasty
◆ Surgical repair of MR is often accomplished by reducing the septolateral diameter of the mitral
annulus, thereby increasing coaptation with the placement of a rigid, undersized annuloplasty
ring.20-22 Several technologies have been developed to accomplish annuloplasty percutaneously
and, because it can halt the progressive dilation of the mitral annulus often responsible for
FMR, it may be of greater benefit than MitraClip placement for those with functional pathology.
These therapies have been developed either to anchor a device to the annulus directly or
indirectly reduce septolateral diameter with a device in close proximity to the annulus.
◆ As the only available technology that indirectly reduces mitral annular diameter, the Carillon
Mitral Contour System (Cardiac Dimensions, Kirkland, WA) takes advantage of the proximity
of the coronary sinus to the mitral annulus.
◆ Although the Carillion System obtained CE Mark approval in 2011 for commercial use in
the European Union, it continues to be investigational in the United States with the first
randomized controlled trial anticipated to begin enrollment in 2017. It is yet to be seen
whether this technology will be able to overcome the challenges encountered in initial efficacy
studies. Sufficient reduction in MR could not be achieved in many patients because anatomic
variability led to device placement in a coronary sinus too far removed from the annulus or
above the annular plane in the wall of the left atrium.23-26
◆ Furthermore, because as many as 80% of patients have been reported to have a coronary
artery course between the coronary sinus and mitral annulus, the device had to be withdrawn
in 16% of patients due to impingement of the left circumflex artery or its major branches.23-27
◆ Several technologies have emerged to anchor either an annuloplasty ring or plication sutures
directly to the mitral annulus via transvenous, transseptal, or retrograde transaortic valve
delivery systems.
◆ Although the company that developed the only technology available for percutaneous placement
of individual suture plication stitches has shifted focus to its application to tricuspid disease,
the various technologies that accomplish more complete annuloplasty are in the early stages
of development, and the patient populations that will most likely benefit from each have yet
to be identified.
◆ BMV is performed by introducing a long, specially curved, retractable needle in a sheath

through the femoral vein into the right atrium and puncturing the atrial septum at the fossa
ovalis to gain access to the left atrium (Fig. 22.3A). One or two large, high-pressure balloon
catheters are then positioned across the stenotic mitral orifice (see Fig. 22.3B) and inflated
until the orifice is stretched or adhesions between leaflets are torn, thus increasing the valve
area and decreasing the transvalvular pressure gradient (see Fig. 22.3C).
Fossa
ovalis
Trans-septal
sheath
A B
C
Figure 22.3
◆ The MitraClip system (Fig. 22.4) is composed of a steerable guide catheter through which
the MitraClip device is delivered and then positioned by a highly maneuverable clip delivery
system (CDS).
◆ The 24 F guide catheter is advanced into the left atrium over a guidewire that is placed via the
right femoral vein across the fossa ovalis under fluoroscopic and echocardiographic guidance.
The septum is ideally perforated posteriorly, away from the aortic valve, and at a height of 3.5
to 4 cm (Fig. 22.5; Video 22.2). The height depends on the plane of leaflet coaptation with
DMR often necessitating higher placement due to coaptation closer to the annular plane and
FMR often necessitating lower placement due to coaptation below the annular placement.11
◆ Once appropriate positioning has been confirmed, the guidewire is exchanged for a 0.035-inch
Amplatz Super Stiff guidewire (Boston Scientific, Marlborough, MA) with a 7-cm floppy tip;
systemic heparin is administered for an activated clotting time (ACT) goal of more than 250
seconds before the 24 F guide catheter is advanced into the left atrium.
◆ The MitraClip at the tip of the CDS is advanced through the guide catheter into the left
atrium, where it is opened to 180 degrees (Fig. 22.6A) to allow for easier orientation
perpendicular to the mitral leaflets under three-dimensional echocardiographic guidance
A B
Figure 22.4 Courtesy of Abbott Vascular
Figure 22.5
A B
Figure 22.6
(see Fig. 22.6B). The device is then advanced across the mitral valve and closed to 120 degrees
to allow for mitral leaflet insertion as the device is slowly withdrawn (Fig. 22.7).
◆ The leaflets are captured between cobalt chromium outer grasper and inner gripper arms (see
Fig. 22.4B; Video 22.3). Once adequate leaflet insertion has been ensured on multiple two-
dimensional transesophageal echocardiography (TEE) views, the previously partially closed
arms are fully closed, and the MR reduction is assessed (Fig. 22.8; Video 22.4). If MR reduction
is inadequate, the graspers can be released and the device repositioned, or additional devices
can be placed.
◆ Once MR reduction is satisfactory, the device is deployed, the CDS and guidance catheter are
withdrawn, protamine is given until the ACT normalizes, and the femoral sheath is removed.
B
Figure 22.7
Figure 22.8
Indirect: Annuloplasty via Device Placement Inside the Coronary Sinus

◆ The Carillon Mitral Contour System (Cardiac Dimensions, Kirkland, WA) is delivered via a
9 F catheter placed through the right internal jugular vein and anchored in the coronary
sinus near the ostium and anterior commissure.
◆ Annular circumference is reduced as the nitinol ribbon connecting the distal and proximal
anchors is shortened, allowing for improved leaflet coaptation (Fig. 22.9).20,21

Figure 22.9
Direct: Annuloplasty via Device Attachment to the Mitral Annulus

◆ Two technologies exist for both retrograde-transaortic valve and transvenous-transseptal device
delivery.
◆ The Mitralign device (Mitralign, Tewksbury, MA) reduces annular dimensions via direct suture
plication. Two wires are delivered retrograde up the aorta and across the aortic valve and
penetrate the mitral annulus at adjacent points. Under TEE and fluoroscopic guidance, the
wires are used to place pledgets on both atrial and ventricular sides of the annulus, and a
suture is placed through both pledgeted points and then tightened until the desired plication
is achieved before being held in place by a steel lock (Fig. 22.10).28
◆ The AccuCinch Ventriculoplasty System (Ancora Heart, Santa Clara, CA) provides a near-
circumferential plication system delivered retrograde through the aortic valve and anchored
to the ventricular side of the annulus. The AccuCinch delivers a series of anchors into the
basal ventricle directly beneath the annulus that are connected via a nitinol wire, which is
tightened, thereby reducing mitral annular and left ventricular basilar circumference (Fig.
22.11).29 The developers thought that this system would have a greater impact on ventricular
geometry than with other approaches to annuloplasty.
Aorta Left atrium
Left ventricle
A B
C
Figure 22.10
Figure 22.11
◆ The Cardioband System (Edwards Lifesciences, Irvine, CA) is a tubular Dacron band that is
anchored every 8 mm as it is extruded from a 24 F sheath around the posterior circumference
of the mitral annulus from the posterior to anterior commissure. The internal tension cable
connecting each anchor is tightened and adjusted until the desired reduction in mitral dimen-
sions has been achieved (Fig. 22.12).30
◆ The IRIS complete annuloplasty ring (Millipede, Santa Rosa, CA) is also placed above the
mitral annulus and delivered transvenously through the atrial septum. Instead of a system
that transmits tension between anchors connected by cable, IRIS is a collapsible nitinol ring
whose interlaced double-zigzag frame is anchored at every intersection. The distance between
each anchor can be adjusted individually via a screw at the apex of each zigzag, allowing for
the device to decrease annular dimensions while maintaining the saddle-shaped geometry of
the valve.
◆ Patients are monitored for the return of MS with serial transesophageal echocardiograms, as
well as for symptoms of pulmonary edema and low cardiac output.
◆ Aspirin is started postprocedurally, and patients are observed for 1 to 2 days before
discharge.
◆ In addition to routine cardiac medical optimization, serial echocardiograms are obtained to
evaluate the degree and durability of the reduction of MR.

◆ Although there are legitimate concerns that the presence of MitraClip devices impairs the
ability to perform subsequent surgical repair, surgical MV reconstruction can be performed

in select cases as late as 5 years after the implantation. Unfortunately, the feasibility of surgical
repair cannot be predicted at the time of MitraClip insertion should severe MR recur.31
◆ Both the feasibility study AMADEUS and the initial safety and efficacy trial TITAN have
demonstrated that the Carillon system improves MR and functional status as well as provides
favorable LV remodeling up to 2 years after device placement.22,32
◆ In addition to routine cardiac medical optimization, similar to percutaneous edge-to-edge
repair, serial echocardiograms are obtained to evaluate the degree and durability of the reduction
of MR.
A B
Figure 22.12
◆ Although the increase in valve area provided by BMV is occasionally short-lived and usually
inferior to the increase provided by surgical repair or replacement, BMV can be repeated
multiple times, often allowing surgery to be delayed for decades or avoided altogether.
◆ Careful patient selection is necessary because performing BMV on some valves will result in
the development of problematic MR or systemic emboli.
◆ After the safety and feasibility of MitraClip was established with the EVEREST I clinical trial,
EVEREST II evaluated the safety and efficacy of MitraClip when compared to conventional
surgical mitral repair.15,33
◆ Although EVEREST II demonstrated the superior safety of MitraClip, with significantly fewer
major adverse events at 30 days (15% vs. 48% with surgery; p < 0.001), there was no difference
when the main driver, bleeding requiring transfusion (13% vs. 42% with surgery; p < 0.001),
was excluded (5% vs. 10% with surgery; p = 0.23).14
◆ In terms of efficacy, EVEREST II has demonstrated that surgical repair performs better than
percutaneous repair with greater combined freedom from death, surgery for mitral valve
dysfunction, and the recurrence of 3+ or greater MR both at 12 months (73% vs. 55% with
MitraClip; p = 0.007) and 5 years (64% vs. 44% with MitraClip; p = 0.007).
◆ The decreased efficacy of MitraClip was driven by the increased rate of recurrence of 3+ or
greater MR (12.3% vs. 1.8% with surgery; p = 0.02) and the need for surgery or reoperation
for mitral valve dysfunction (27.9% vs. 8.9% with surgery; p = 0.003) with no significant
difference in mortality at 5 years of follow-up (21% vs. 27% with surgery; p = 0.4) and
treatment strategy not being associated with survival on multivariable analysis (HR, 0.94;
95% CI, 0.51–1.7; p = 0.85).
◆ However, investigators identified an early hazard of surgery for mitral valve dysfunction in
the percutaneous group, with 78% of surgeries being performed before 6 months, beyond
which there was no difference (78% with MitraClip vs. 76% with surgery; p = 0.77). Furthermore,
combined efficacy was no different at 5 years in the patient population that was event-free
at 1 year, suggesting that the lower efficacy of percutaneous therapy may be minimized as
more is learned about optimal patient selection and device placement.
◆ Despite there being more residual or recurrent severe MR after the MitraClip procedure,
percutaneous repair succeeds in providing a durable improvement in left ventricular dimensions,

New York Heart Association functional classification, and quality of life measures. These are
findings that have been confirmed in multiple studies other than those performed by the
EVEREST group.
◆ EVEREST II was not able to provide a rationale for approval in patients with FMR because
73% of the study population had degenerative pathology. The EVEREST II high-risk follow-up
study has helped address the question of whether the MitraClip procedure can provide clinical
benefit to patients with FMR, demonstrating a trend toward increased survival with MitraClip
when compared to medical management only (76% vs. 55%; p = 0.05) and a 46% reduction
in readmission rate for congestive heart failure exacerbations.34
◆ In combination with the results of many nonrandomized European studies and registries,
evidence has mounted to support the claim that the risk of recurrent MR with the MitraClip
procedure may outweigh the risks of mitral valve surgery in high-risk patients. In all of these
studies, investigators found that despite percutaneous repair being associated with a higher
rate of recurrent MR, percutaneous repair provides a substantial proportion of patients with
a reduction in MR, as well as lasting symptomatic relief and positive left ventricular remodeling.34-39
◆ To determine whether the MitraClip procedure provides benefit beyond that seen with optimal
medical therapy more definitively, the Cardiovascular Outcomes Assessment of the MitraClip
Percutaneous Therapy (COAPT) for Heart Failure Patients with FMR trial has been enrolling
patients (NCT #01626079). This study, which compares groups randomized to standard
medical therapy or MitraClip placement in addition to standard medical therapy, should
clarify the appropriate role of the MitraClip procedure in patients with FMR at a high or
prohibitive surgical risk.
Indirect: Annuloplasty via Device Placement Inside the Coronary Sinus

◆ Although deemed safe, early generations of the Carillon System were found to have asymptomatic
fractures on follow-up imaging; thus, TITAN II was performed to confirm the safety of an
updated iteration. The results of TITAN II were consistent with the findings of previous
studies, except that only one fracture occurred.26 The updated Carillon device will soon be
evaluated in a randomized, blinded clinical trial (NCT #02325830) in the United States.
Direct: Annuloplasty via Device Attachment to the Mitral Annulus

◆ Similar to the limited efficacy of annular plication sutures in open repair, Mitralign has shown
modest improvements in MR grade and symptomatic relief at 6 months.40,41 The company

has therefore abandoned efforts to obtain FDA approval for the use of their technology for
mitral annular plication and has instead focused their efforts on applying the Mitralign technology
on tricuspid annuloplasty, with the first safety and efficacy study evaluating the newly termed
TriAlign technology due to finalize enrollment in 2018.
◆ The first study evaluating the safety and efficacy of the AccuCinch system has been actively
recruiting participants at multiple centers in Austria and Germany (NCT #00800046), with
plans to begin enrollment soon in the United States.
◆ Cardioband obtained CE Mark approval in 2015 and has since been shown to be safe and
to have provided significant improvement in MR and heart failure symptoms at 6 months.41

A trial in the United States will soon begin, with the goal of obtaining FDA approval.
◆ The IRIS complete annuloplasty ring has been placed in multiple patients, with the first study
to evaluate the safety and efficacy of the device expected to complete enrollment in 2018
(NCT #02607527).
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9. Maisano F, Schreuder JJ, Oppizzi M, et al. The double-orifice technique as a standardized approach to treat mitral regurgitation due to
severe myxomatous disease: surgical technique. Eur J Cardiothorac Surg. 2000;17:201–205.
10. Maisano F, Vigano G, Blasio A, et al. Surgical isolated edge-to-edge mitral valve repair without annuloplasty: clinical proof of the
principle for an endovascular approach. EuroIntervention. 2006;2:181–186.
11. Schoen FJ. Evolving concepts of cardiac valve dynamics: the continuum of development, functional structure, pathobiology, and
tissue engineering. Circulation. 2008;118(18):1864–1880.
12. Enomoto Y, Gorman JH 3rd, Moainie SL, et al. Surgical treatment of ischemic mitral regurgitation might not influence ventricular
remodeling. J Thorac Cardiovasc Surg. 2005;129:504–511.
13. Diodato MD, Moon MR, Pasque MK, et al. Repair of ischemic mitral regurgitation does not increase mortality or improve long-term
survival in patients undergoing coronary artery revascularization: a propensity analysis. Ann Thorac Surg. 2004;78:794–799.
14. Wu AH, Aaronson KD, Bolling SF, et al. Impact of mitral valve annuloplasty on mortality risk in patients with mitral regurgitation and
left ventricular systolic dysfunction. J Am Coll Cardiol. 2005;45:381–387.
15. Feldman T, et al. Randomized Comparison of Percutaneous Repair and Surgery for Mitral Regurgitation: 5-Year Results of EVEREST
II. J Am Coll Cardiol. 2015;66(25):2844–2854.
16. Filsoufi F, Chikwe J, Adams DH. Acquired disease of the mitral valve. In: Sabiston and Spencer Surgery of the Chest. 8th ed. Elsevier;
1948:1207–1240.
17. Enriquez-Sarano M, Akins CW, Vahanian A. Mitral regurgitation. Lancet. 2009;373:1382–1394.
18. Pope NH, Lim S, Ailawadi G. Late calcific mitral stenosis after mitraclip procedure in a dialysis-dependent patient. Ann Thorac Surg.
2013;95:e113–e114.
19. Herrmann HC, Kar S, Siegel R, et al. Effect of percutaneous mitral repair with the mitraclip device on mitral valve area and gradient.
EuroIntervention. 2009;4:437–442.
20. Maniu CV, Patel JB, Reuter DG, et al. Acute and chronic reduction of functional mitral regurgitation in experimental heart failure by
percutaneous mitral annuloplasty. J Am Coll Cardiol. 2004;44(8):1652–1661.
21. Sorajja P, Nishimura RA, Thompson J, Zehr K. A novel method of percutaneous mitral valve repair for ischaemic mitral regurgitation.
JACC Cardiovasc Interv. 2008;1:663–672.
22. Schofer J, et al. Percutaneous mitral annuloplasty for functional mitral regurgitation: results of the CARILLON Mitral Annuloplasty
Device European Union Study. Circulation. 2009;120(4):326–333.
23. Choure AJ, Garcia MJ, Hesse B, et al. In vivo analysis of the anatomical relationship of coronary sinus to mitral annulus and left
circumflex coronary artery using cardiac multidetector computed tomography: implications for percutaneous coronary sinus mitral
annuloplasty. J Am Coll Cardiol. 2006;48:1938–1945.
24. Gopal A, Shah A, Shareghi S, et al. The role of cardiovascular computed tomographic angiography for coronary sinus mitral
annuloplasty. J Invasive Cardiol. 2010;22:67–73.
25. Sponga S, Bertrand OF, Philippon F, et al. Reversible circumflex coronary artery occlusion during percutaneous transvenous mitral
annuloplasty with the Viacor system. J Am Coll Cardiol. 2012;59:288.
26. Lipiecki J, Siminiak T, Sievert H, et al. Coronary sinus-based percutaneous annuloplasty as treatment for functional mitral
regurgitation: the TITAN II trial. Open Heart. 2016;3(2):e000411.
27. Tops LF, Van de Veire NR, Schuijf JD, et al. Noninvasive evaluation of coronary sinus anatomy and its relation to the mitral valve
annulus: implications for percutaneous mitral annuloplasty. Circulation. 2007;115(11):1426–1432.
28. Nickenig G, Hammerstingl C. The Mitralign transcatheter direct mitral valve annuloplasty system. EuroIntervention. 2015;11(suppl
W):W62–W63.
29. Gooley RP, Meredith IT. The AccuCinch transcatheter direct mitral valve annuloplasty system. EuroIntervention. 2015;11(suppl
W):W60–W61.
30. Taramasso M, et al. Transcatheter direct mitral annuloplasty with Cardioband: feasibility and efficacy trial in an acutepreclinical
model. EuroIntervention. 2016;12(11):e1428–e1434.
31. Rogers JH, Yeo KK, Carroll JD, et al. Late surgical mitral valve repair after percutaneous repair with the MitraClip system. J Card Surg.
2009;24:677–681.
32. Siminiak T, et al. Treatment of functional mitral regurgitation by percutaneous annuloplasty: results of the TITAN Trial. Eur J Heart
Fail. 2012;14(8):931–938.
33. Feldman T, Wasserman HS, Herrmann HC, et al. Percutaneous mitral valve repair using the edge-to-edge technique: six-month results
of the EVEREST Phase I Clinical Trial. J Am Coll Cardiol. 2005;46:2134–2140.
34. Whitlow PL, Feldman T, Pedersen WR, et al. Acute and 12-month results with catheter-based mitral valve leaflet repair the EVEREST
II (Endovascular Valve Edge-to-Edge Repair) High Risk Study. J Am Coll Cardiol. 2012;59:130–139.
35. Glower DD, Kar S, Trento A, et al. Percutaneous mitral valve repair for mitral regurgitation in high-risk patients: results of the
EVEREST II study. J Am Coll Cardiol. 2014;64(2):172–181.
36. Maisano F, Franzen O, Baldus S, et al. Percutaneous mitral valve interventions in the real world: early and one year results from the
ACCESS-EU, a prospective, multicenter, non-randomized postapproval study of the MitraClip therapy in Europe. J Am Coll Cardiol.
2013;62:1052–1061.
37. Braun D, Lesevic H, Orban M, et al. Percutaneous edge-to-edge repair of the mitral valve in patients with degenerative versus
functional mitral regurgitation. Catheter Cardiovasc Interv. 2014;84(1):137–146.
38. Nickenig G, Estevez-Loureiro R, Franzen O, et al. Transcatheter Valve Treatment Sentinel Registry Investigators of the
EURObservational Research Programme of the European Society of Cardiology. Percutaneous mitral valve edge-to-edge repair:
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2014;64(9):875–884.
39. Taramasso M, Maisano F, Latib A, et al. Clinical outcomes of MitraClip for the treatment of functional mitral regurgitation.
EuroIntervention. 2014;10(6):746–752.
40. Barlow CW, Ali ZA, Lim E, et al. Modified technique for mitral repair without ring annuloplasty. Ann Thorac Surg. 2003;75:298–300.
41. Nickenig G, et al. Transcatheter mitral annuloplasty in chronic functional mitral regurgitation: 6-month results with the Cardioband
percutaneous mitral repair system. JACC Cardiovasc Interv. 2016;9(19):2039–2047.
CHAPTER
23
Tricuspid Valve
Operations
Elsayed Elmistekawy and Thierry G. Mesana
◆ The tricuspid valve is located between the right atrium (RA) and right ventricle and has a
valve area of 4 to 6 cm. The tricuspid valve is composed of three leaflets—the anterior,
posterior, and septal. The leaflets are supported by chordae tendineae and papillary muscles.
Compared with the mitral valve, the leaflets and chordae tendineae of the tricuspid valve are
thinner and the tricuspid orifice is larger and more triangular.
◆ The anterior leaflet is the largest of the three leaflets and extends through the anterior portion
of the annulus. Its chordae attach to the anterior and septal papillary muscles. The posterior
leaflet is the smallest leaflet and extends through the inferior and posterior edges of the
annulus; its chordae originate from the posterior and anterior papillary muscles. The septal
leaflet is the most medial and is attached directly to the interventricular septum; it is larger
than the posterior leaflet, and its chordae attach to the posterior and septal papillary muscles.
The septal leaflet is relatively immobile due to its attachment to the fibrous structure of the
heart.1
◆ The tricuspid valve is a continuous veil of thin fibrous tissue. Three commissures are delineated
by fan-shaped chordae of the three leaflets:
◆ Anteroseptal commissure—where the basal attachment of the tricuspid valve reaches its
highest level at the membranous interventricular septum and where the anterior and septal
walls of the right ventricle join
◆ Anteroposterior commissure—forms a deep indentation in the leaflet tissue between the
anterior and posterior leaflets
◆ Posteroseptal commissure—a deep indentation in the leaflet tissue at the junction of the
posterior and septal walls of the right ventricle.2
384
Chapter 23 • Tricuspid Valve Operations384.e1
Abstract
Tricuspid valve surgery has evolved from an almost ignored valve in the past to an important
valve that is critical to address at the time of left valve intervention. The incidence of tricuspid
regurgitation associated with left valvular disease is quite significant and most common in
conjunction with mitral valve disease; however, association with aortic valve pathology is not
uncommon. Most commonly, tricuspid regurgitation is functional or secondary to dilation of
the annulus, as a consequence of right ventricle dilation secondary to pulmonary hypertension.
However, organic (rheumatic, endocarditis, or degenerative in origin) is not uncommon. The
purposes of this chapter are to shed light on the anatomy of the tricuspid valve, and elucidate
the etiology and pathogenesis of tricuspid valve disease, mainly tricuspid valve regurgitation,
with a special focus on secondary tricuspid valve regurgitation. Indications for surgery as well
as different surgical approaches (including different repair techniques and valve replacement)
to correct tricuspid valve regurgitation are discussed in detail. A transcatheter approach for
tricuspid valve repair or replacement is attractive, desirable, and beneficial to this high-risk
population as an alternative to surgery.
Keywords
tricuspid valve
secondary tricuspid regurgitation
tricuspid valve repair
tricuspid valve replacement
Chapter 23 • Tricuspid Valve Operations 385
1. Tricuspid Valve Annulus
◆ The tricuspid valve annulus is part of the fibrous skeleton of the heart. It consists of a ring
of collagenous tissue that generally extends around the line of attachment of the leaflets of
the tricuspid valve. It is very thin and difficult to identify. The tricuspid annulus is a complex
three-dimensional (3D) structure; the normal tricuspid valve annulus is saddle-shaped, with
the highest points located in an anteroposterior orientation and the lowest points at the area
of the septal leaflet. With the development of functional tricuspid regurgitation (TR), changes
in the 3D annular shape lead to loss of the saddle shape and more flattening of the annulus;
that is, the tricuspid annulus becomes dilated and more planar and circular and hence,
restoration of the 3D shape of the annulus may be an important therapeutic goal beyond
that of annular reduction alone.
◆ Normal tricuspid valve annulus diameter in adults is 28 ± 5 mm in the four-chamber view.
Significant tricuspid annular dilation is defined by a diastolic diameter of more than 21 mm/
m2 (> 35 mm).3
2. Relation of the Tricuspid Valve to Other Structures
◆ Structures surrounding the tricuspid valve that are of major surgical significance include the
coronary sinus, atrioventricular (AV) node, membranous septum, bundle of His, and right
coronary artery (Fig. 23.1).
◆ The conduction system is near the septal leaflet and its anterior septal commissure. The AV
node lies in the atrial septum bordering the septal leaflet, superior and anterior to the coronary
sinus. Its exact location can be approximated at the apex of the triangle of Koch, a triangle
composed of the septal annulus and tendon of Todaro as its sides and the coronary sinus
orifice as its base. Extending from the AV node is the bundle of His, which penetrates the
right trigone under the interventricular component of the membranous septum (≈ 5 mm
inferior to the anterior septal commissure) and runs along the crest of the muscular septum.
The membranous septum usually lies beneath the septal leaflet inferior to the anterior septal
commissure. The right coronary artery runs anterior to the anterior leaflet annulus and may
be injured by deep sutures in the annulus.
1. Causes of Tricuspid Valve Diseases
Tricuspid Stenosis
◆ This is usually rheumatic in origin. On rare occasions, infective endocarditis, congenital abnormali-
ties, or carcinoid disease may be implicated. Rheumatic tricuspid involvement usually results in
both tricuspid stenosis and regurgitation, and it typically coexists with mitral or aortic rheumatic
disease. The hallmark features of rheumatic tricuspid stenosis are commissural fusion and leaflet
thickening, but calcification is usually absent. Carcinoid syndrome leads to focal or diffuse deposits
of fibrous tissue on the endocardium of the valve leaflets and cardiac chambers. The tricuspid
valve in carcinoid syndrome is thickened, with retracted leaflets fixed in a semiopen position,
resulting in both tricuspid stenosis and regurgitation, and usually not amenable for repair.
Right atrial Tricuspid

appendage valve
Pulmonary
artery
Aorta
Coronary
sinus
Superior Inferior
vena cava vena cava
The Right
atrium
A
Left anterior Pulmonary

descending valve
artery
Aortic valve
Left main
artery
Right
coronary
Circumflex artery
artery
Tricuspid
valve
Mitral valve
Coronary
valve
B
Figure 23.1
Figure 23.1 (A and B) Anatomy and relations of tricuspid valve.

Tricuspid Valve Regurgitation
◆ TR can occur with abnormal or normal valve leaflets. Causes of TR associated with abnormalities
of the tricuspid leaflets include rheumatic valve disease, endocarditis, carcinoid syndrome,
radiation therapy, Marfan syndrome, papillary muscle dysfunction, and congenital disorders
such as Ebstein anomaly. Penetrating and nonpenetrating trauma, iatrogenic damages during
cardiac surgery, biopsies, catheter placement in right heart chambers, and placement or
extraction of pacemakers and defibrillator leads are also rare causes of TR.4
Degenerative Tricuspid Regurgitation
◆ Tricuspid prolapse is generally associated with mitral valve prolapse and is defined as a
midsystole posterior leaflet displacement beyond the annular plane. The coaptation line is
above the annular plane. Tricuspid prolapse usually involves more than one leaflet, and often
the three leaflets are affected. The most common phenotype of tricuspid prolapse is diffuse
myxomatous degeneration (Barlow disease). A flail tricuspid leaflet is observed when the free
edge of a leaflet is completely reversed in the RA, usually as a consequence of ruptured
chordae. It also is common in infective endocarditis in association with vegetations.5
Secondary Tricuspid Regurgitation
◆ Approximately 80% of cases of significant TR are functional in nature. Regurgitation develops

with normal tricuspid valve leaflets as a result of right ventricular (RV) dysfunction and tricuspid
annular dilation (functional regurgitation), usually in the context of left-sided valvular disease.
Pulmonary hypertension or RV dysfunction leads to elevations of RV systolic and diastolic
pressures, RV cavity enlargement, and tricuspid annular dilation.6 The circumference of the
tricuspid annulus lengthens primarily along the attachments of the anterior and posterior
leaflets. The septal leaflet portion, on the other hand, is fixed between the right and left
trigones and the atrial and ventricular septa, preventing its lengthening. As annular and
ventricular dilation progress, the cordal–papillary muscle complex becomes functionally
shortened, with tethering of the leaflets, although it remains normal in appearance. This
combination of RV enlargement and tricuspid annular dilation prevents leaflet coaptation and
leads to valvular incompetence7,8 (Fig. 23.2).
◆ Previously, it was believed that functional TR decreased or even disappeared after surgical
correction of left-sided valve disease. This concept influenced cardiac surgery practice for
many years. More experience, however, has led to better appreciation of the potential for
progression of functional TR and tricuspid annular dilation after left-sided surgery. This effect
may occur in spite of the complete correction of the mitral and aortic disease and the resolution
of pulmonary hypertension after surgery. Tricuspid annular dilation is the strongest and most
consistent risk factor for the development of late TR after left-sided valve surgery.
Anterior
Posterior
Septal
Figure 23.2
Figure 23.2 Triscupid valve annulus mode of dilation.

◆ Severe TR and its resultant RV dysfunction and venous congestion contribute to an increase
in early and late morbidity and mortality after left-sided valve surgery. Moreover, reoperation
to correct worsening postoperative TR is associated with a high operative mortality rate and
disappointing long-term results. Therefore, a proactive strategy of prophylactic repair of a
dilated tricuspid annulus at the time of the initial left-sided valve surgery, regardless of the
degree of TR, has been advocated as a strategy to help reduce the incidence of late TR and
RV failure and the complexity and higher risk of redo surgery. Concomitant mitral and tricuspid
valve repair is associated with significant RV reverse remodeling and improvement in functional
class postoperatively.9
2. Assessment of the Tricuspid Valve
◆ Imaging of the tricuspid valve is a challenging process. Functional TR is dynamic in nature,

so the degree of severity of TR may change, especially under general anesthesia, and the
decision for tricuspid valve intervention should be made before surgery based on preoperative
echocardiography and careful clinical assessment of the patient.
◆ Tricuspid valve analysis can be achieved with two-dimensional (2D)–transthoracic echocardiog-
raphy (TTE) imaging (the technique of choice). 3D-TTE can be used as an additive approach.
Transesophageal echocardiography (TEE) is advised in case of suboptimal TTE images to evaluate
the severity of TR. TTE helps determine cause, measures the size of right-sided chambers
and the inferior vena cava (IVC), assesses RV systolic function, estimates pulmonary artery
systolic pressure, and characterizes any associated left-sided heart disease. TEE describes the
morphology and pathophysiology of the tricuspid valve and grades the severity of tricuspid
valve regurgitation. It is of note that TEE usually underestimates the measurement of the
tricuspid valve annulus. The evaluation of tricuspid valve annulus dilation is a matter of
ongoing controversy and is less precise compared with mitral valve annulus assessment.10,11
◆ Cardiovascular magnetic resonance (CMR) is another imaging modality for the tricuspid valve
that allows visualization of the anatomy and function of the tricuspid valve. It also permits
quantification of the regurgitant volume and regurgitant fraction.1
3. Indications for Tricuspid Valve Intervention
◆ The 2014 American College of Cardiology/American Heart Association valve guidelines has
indicated the following recommendations:
1. Tricuspid valve repair for patients with severe functional TR who are undergoing concurrent
surgery for mitral valve disease (Class I, level of evidence C).
2. Tricuspid valve intervention for severe primary TR in symptomatic patients (Class IIa,
level of evidence C). When the tricuspid valve leaflets are too diseased and not amenable
to repair, tricuspid valve replacement is believed to be reasonable for patients with
severe TR.
3. Tricuspid valve repair may be considered for less than severe TR in patients undergoing
mitral valve surgery in the presence of pulmonary hypertension or tricuspid annular
dilation (Class IIa, level of evidence B).
4. Tricuspid valve repair may be considered for patients with moderate functional TR and
pulmonary artery hypertension at the time of left-sided valve surgery (Class IIa, level of
evidence C).
Table 23.1 Indications for tricuspid valve surgery

CLASS TRICUSPID VALVE SURGERY LEVEL OF EVIDENCE
TRICUSPID VALVE REGURGITATION
Tricuspid valve surgery is recommended for patients with severe tricuspid regurgitation (TR; symptomatic or C
nonsymptomatic) undergoing left-sided valve surgery. Tricuspid valve repair can be beneficial for patients with
mild, moderate, or greater functional TR at the time of left-sided valve surgery with tricuspid annular dilation or
prior evidence of right heart failure.
I Tricuspid valve surgery can be beneficial for patients with symptoms due to severe primary TR that are B
unresponsive to medical therapy.
IIa Tricuspid valve repair may be considered for patients with moderate functional TR and pulmonary artery C
hypertension at the time of left-sided valve surgery.
Tricuspid valve surgery may be considered for asymptomatic or minimally symptomatic patients with severe
primary TR and progressive degrees of moderate or greater right ventricular (RV) dilation and/or systolic
dysfunction.
IIb Reoperation for isolated tricuspid valve repair or replacement may be considered for persistent symptoms due to C
severe TR in patients who have undergone previous left-sided valve surgery and who do not have severe
pulmonary hypertension or significant RV systolic dysfunction.
TRICUSPID VALVE STENOSIS
I Tricuspid valve surgery is recommended for patients with severe tricuspid stenosis (TS) at the time of operation for C
left-sided valve disease. Tricuspid valve surgery is recommended for patients with isolated, symptomatic, severe TS.
IIb Percutaneous balloon tricuspid commissurotomy might be considered in patients with isolated tricuspid severe C
tenosis
5. Tricuspid valve surgery may be considered for asymptomatic or minimally symptomatic

patients with severe primary TR and progressive degree of moderate or greater RV dilation
and/or systolic dysfunction (Class IIa, level of evidence C).
6. Reoperation for isolated tricuspid valve repair or replacement may be considered for
persistent symptoms due to severe TR in patients who have undergone previous left-sided
valve surgery and who do not have severe pulmonary hypertension or significant RV
systolic dysfunction (Class IIa, level of evidence C).12
◆ American College of Cardiology/American Heart Association practice guidelines have recom-
mended against tricuspid surgery for patients with only mild primary TR. Tricuspid surgery
is also not indicated for patients with some degree of TR who are asymptomatic, when there
is no concurrent left-sided valve disease, or when severe pulmonary hypertension is absent. 12
◆ Several cardiac surgery centers currently advocate for the routine repair of the dilated tricuspid
annulus at the time of left-sided heart surgery, regardless of the degree of TR.13 At our center,
we consider valve repair even if there is no associated TR or only a mild degree of TR when the
tricuspid annulus diameter is 40 mm or more with the presence of pulmonary hypertension
(PH; defined as a mean pulmonary artery pressure ≥25 mm Hg at rest) or 45 mm or more in the
absence of PH. Such repair could reduce the risk of RV dysfunction, both in the perioperative
period and in the long term, as well as the need for a second operation (Table 23.1).
◆ Functional TR in association with aortic stenosis may persist or even become progressive after
aortic valve replacement alone; it is usually associated with left ventricular (LV) diastolic
dysfunction. A concomitant tricuspid valve procedure should be considered in select patients
with aortic stenosis at the time of aortic valve replacement.14,15
4. Choice of Repair Technique
◆ Previously, it was believed that the type of tricuspid valve repair performed was of little
importance as long as the size of the tricuspid annulus was secured to avoid progressive
dilation. For patients with functional TR secondary to left-sided valve disease, the De Vega
annuloplasty was thought to be the most appropriate procedure to reduce the size of the
tricuspid annulus. However, recent data have demonstrated poor long-term results with the
use of the De Vega technique. Although it is a safe and simple procedure, 30% or more of
patients may develop recurrent moderate to severe TR after a De Vega repair, with progressive
annular dilation and recurrence of symptoms.
◆ Long-term studies have also illustrated poor long-term durability and high rates of recurrent
TR with the use of flexible rings and bands (Duran, Medtronic, Minneapolis, MN; Cosgrove-
Edwards, Edwards Lifesciences, Irvine, CA; Peri-Guard, Synovis, MN). Only rigid rings have
yielded good long-term results, with the bulk of evidence favoring the semirigid Carpentier-
Edwards ring (Edwards Lifesciences) as the most durable after tricuspid valve repair.
◆ 3D rings that aim to restore the annular geometry, such as contour 3D (Medtronic), GeoForm
(Edwards Lifesciences), and 3D MC3 (Edwards Lifesciences) rings are being increasingly used
for the treatment of functional tricuspid valve regurgitation with documented good results.16-18
◆ At our center, we perform tricuspid valve repairs using 3D annuloplasty bands for all patients
with a tricuspid annular dilation of greater than 40 mm, regardless of the presence of TR, at
the time of concurrent left-sided valve surgery. The De Vega repair is reserved for older patients
undergoing left-sided valve surgery who have 2+ TR or less and a tricuspid annular dimension
of less than 40 mm. Also, in case of the presence of PH and concerns about postoperative
RV dysfunction and the possibility of increasing TR, a quick De Vega repair helps those older
patients pass the postoperative phase. In patients with a large annulus (> 50 mm) and severe
TR, we perform annuloplasty and edge-to-edge techniques (Fig. 23.3).
5. Choice of Prosthetic Valve Type
◆ Repair of the tricuspid valve is superior to valve replacement because it is associated with
lower hospital mortality rates, better long-term survival, better preservation of ventricular
function, fewer thromboembolic complications, and reduced risk of endocarditis. However,
in the context of organic tricuspid disease with severe leaflet thickening and cordal retraction,
tricuspid valve replacement is the preferred surgical intervention.19
◆ The choice of prosthesis type in the tricuspid position has been debated in the cardiac surgery
community for many years. A meta-analysis has summarized the published literature by
comparing outcomes reported for contemporary mechanical and bioprosthetic tricuspid valves.
A total of 11 studies, with 646 mechanical and 514 biologic tricuspid prostheses and 6046
follow-up years, were analyzed. Studies that reported prosthetic models from before 1970
were excluded. Overall, the pooled survival and reoperation data did not favor either prosthesis
type. Furthermore, the incidence of mechanical valve thrombosis was comparable with the
incidence of bioprosthetic valve deterioration.19 Therefore, the type of prosthetic valve is not
a risk factor for adverse outcomes after tricuspid valve replacement, and there is no evidence
favoring one prosthetic type or the other. In our experience, we almost never used a mechanical
valve in the tricuspid position in the current era of the percutaneous valve; a bioprosthetic
valve allows safe valve-in-valve implantation.
◆ As in other valve positions, there is no gold standard prosthetic valve available for tricuspid
valve replacement. We believe that the choice between a mechanical and bioprosthetic valve
in the tricuspid position should be individualized according to the surgeon’s clinical judgment,
patient characteristics, anticoagulation considerations, likelihood of pregnancy, socioeconomic
status, and lifestyle issues. A patient with drug addiction and a history of endocarditis, who
may have difficulty with anticoagulation compliance, should have a bioprosthesis implanted.
Secondary tricuspid valve regurgitation
Severe Less than Severe
ANNULUS ANNULUS
>40 MM <40 MM Dilated Nondilated
Annulus annulus
40 mm or
greater
Tethered Non Tethered
leaflets leaflets
Pulmonary No Pulmonary
Hypertension Hypertension
ANNULOPLASTY
+ ANNULOPLASTY Modified De Vega Conservative
Edge to Edge
Figure 23.3
Figure 23.3 Our approach for surgical treatment of secondary tricuspid valve regurgitation.
6. Prosthesis and Ring Size
◆ Although not supported by good evidence, it is currently popular to implant undersized rings
to improve coaptation during the repair of mitral regurgitation. This strategy may also apply
to the repair of functional TR. However, there are no data to support the practice of implanting
undersized rings in the tricuspid position. Long-term data from the Cleveland Clinic have
demonstrated that the use of a small tricuspid ring for the repair of functional TR does not
protect against the development of recurrent late TR. Use of the anterior leaflet for tricuspid
valve sizing may be inaccurate to determine tricuspid annular size in functional TR because
the tricuspid annulus is dynamic and may change in circumference during systole, with a
reduction in annular dimension.20
◆ We generally implant a tricuspid prosthesis (band or valve) identical or close in size to the
mitral valve prosthesis used during concurrent mitral repair or replacement.
◆ When replacing the tricuspid valve, it is almost always possible to place a large bioprosthetic
or mechanical valve. Prostheses with an internal diameter greater than 27 mm do not have
clinically significant gradients, and thus hemodynamic performance is rarely an issue in
tricuspid valve replacement; the patient prosthetic mismatch has not been reported in tricuspid
valve replacement as a significant problem.
Step 3. Tricuspid Valve Endocarditis
◆ In tricuspid valve endocarditis, the tricuspid valve may be infected in isolation or in the
context of other infected valves. In contrast to left-sided endocarditis, right-sided native valve
endocarditis usually involves previously normal valves. Isolated tricuspid bacterial endocarditis
is usually seen in the presence of intravenous drug use, long-standing central venous catheters,
cardiac implantable electronic devices, or congenital heart disease. The most common organisms
include Pseudomonas aeruginosa, Staphylococcus aureus, gram-negative bacilli and, occasionally,
Candida albicans.21
◆ Medical management is the first line of treatment and is generally successful. Surgical interven-
tion is only required for a subset of patients with persistent right-sided heart failure despite
medical therapy, recurrent pulmonary septic emboli, septic shock, abscess formation, failure
of antimicrobial therapy to control the infection, or presence of a large vegetation risk of
pulmonary embolization. If at all possible, tricuspid valve repair with partial valve excision
and reconstruction should be considered in tricuspid endocarditis, even with less than optimum
results in terms of TR. This is because the main goal of surgery is to eradicate infection, in
contrast to the mitral valve, for which eradication of both infection and regurgitation are the
main goals. For significant destruction of the valve, however, tricuspid valve excision or
replacement may be offered.22
◆ In patients with ongoing intravenous drug addiction, valve excision may prove to be a useful
approach that avoids the subsequent risk of prosthetic valve endocarditis. However, the
resultant severe TR after valve excision compromises postoperative cardiac function and
exposes the patient to a second reoperation for prosthesis implantation. Therefore, primary
bioprosthetic valve replacement is usually preferred over total valve excision.
◆ Different tricuspid valve repair techniques have been described for tricuspid valve endocarditis.
Some are simple such as débridement of vegetations, leaflet resection and reconstruction with
pericardial patch (autologous or bovine), other repair techniques such as sliding plasty,
bicuspidization, edge-to-edge repair, and ring annuloplasty. Resection of more than one leaflet
mandates valve replacement.23
◆ Tricuspid valve surgery may be recommended for infective endocarditis secondary to drug
abuse. However, redo surgery in these patients constitutes a controversial and ethical issue
because the long-term survival depends to a great degree on whether the patient stops the
drug abuse.24
1. Surgical Access and Exposure
◆ Tricuspid valve surgery may be performed through a full sternotomy, right anterior thoracotomy,
minimally invasive approach using port access or robotic surgery and, recently, percutaneously.25-27
Our standard approach is the median sternotomy approach, which gives full access to the
mitral, aortic, and tricuspid valves. In a redo operation in a patient with a dilated RV, femoral
cannulation to decompress the heart before the redo sternotomy may be contemplated. Bicaval
cannulation with snares is essential to isolate the RA and avoid an air lock in the cardiopulmonary
bypass circuit. The IVC cannula is placed in the right atrial appendage and turned inferiorly,
whereas the superior vena cava (SVC) cannula is inserted into the body of the RA close to
the SVC and turned superiorly. This strategy of crossing the cannulas permits them to be
easily retracted from the operative field during mitral and tricuspid surgery (Fig. 23.4). In
select cases of redo mitral and tricuspid valve surgery, direct cannulation of the SVC and IVC
helps expose both valves, especially if a transseptal approach is used.
◆ The operation is performed under cardiopulmonary bypass and mild hypothermia, with or
without the use of aortic cross-clamping. During isolated tricuspid surgery, we may avoid
cross-clamping the aorta. Not cross-clamping prevents cardiac ischemia and enables the
evaluation of tricuspid valve motion and the consequences of each suture placement (conduction
tissue). A sump sucker is placed in the coronary sinus to improve exposure.
◆ During multivalve surgery, aortic cross-clamping is essential, and we use antegrade cold blood
cardioplegia supplemented with retrograde cardioplegia—direct cannulation of the coronary
sinus. We repair the tricuspid valve at the end of the operation, after the left-sided lesions
have been addressed, while the patient is being rewarmed. Some centers advocate removing
the cross-clamp at this point, but we keep it in place because it improves surgical exposure
by working on a bloodless field and motionless heart and puts less stress on the heart while
adding just a few minutes to the total aortic cross-clamp time.
◆ The tricuspid valve is exposed through a conventional oblique right atriotomy, starting from
the atrial appendage and passing approximately 2 cm posterior to and parallel with the AV
groove toward, but not close to, the IVC. The atriotomy edges are retracted with sutures or
a retraction device.
◆ Meticulous closure of the RA is important to reduce the risk of bleeding, especially in the
presence of right-sided dysfunction and pulmonary hypertension. Sometimes, it is essential
to support the suture line with pericardium or felt. We always use a double suture line for
RA closure. The repair is assessed by careful inspection of the valve by echocardiography and
direct visualization by the surgeon.
SVC cannula IVC cannula at

at R atrial body R atrial appendage
SVC
IVC
Alternative
cannulation sites
Snare Snare
around around
SVC IVC
Figure 23.4
Figure 23.4 Cannulation for tricuspid valve surgery.

Step 5. Procedures
De Vega Technique
◆ De Vega annuloplasty is a simple and inexpensive procedure that does not interfere with the
conduction or leaflet tissue while effectively reducing the tricuspid annulus size.28 Because
of its simplicity, it requires little additional cross-clamp time and can be performed concomitantly
with aortic and mitral surgery.29
◆ The De Vega technique is most applicable to those patients with TR as a result of mild annular
dilation (< 50 mm) in whom it is anticipated that good long-term function does not depend
on the integrity of the repair. In these situations, the De Vega annuloplasty provides a competent
tricuspid valve during the early postoperative course, while the heart remodels after surgical
treatment of the left-sided valvular lesions. This may diminish the risk of immediate postoperative
RV dysfunction.30
◆ We use the De Vega repair in patients undergoing left-sided valve surgery who have 2+ TR
or less and a tricuspid annular dimension less than 50 mm. If there is more than 2+ TR or
annular dilation greater than 50 mm, an annuloplasty band should be the norm.
◆ We use a modification of the De Vega technique that involves the use of two double-armed,
pledgeted, 3-0 polytetrafluoroethylene sutures (Fig. 23.5). The first suture is passed as a
circular stitch in a counterclockwise direction from the posterior-septal commissure to the
middle of the anterior leaflet. Deep bites are taken every 5 to 6 mm into the endocardium
and fibrous ring at the junction of the tricuspid annulus and RV free wall. The second limb
of the first suture is run parallel to and 1 to 2 mm outside the previous suture in the same
counterclockwise direction. At the middle of the anterior leaflet, both sutures are placed
through a second pledget. Another double-armed, pledgeted, 3-0 Gore-Tex suture is passed
as a circular stitch in the same manner in a clockwise direction, starting from the anterior-septal
commissure to the middle of the anterior leaflet. The two sutures are then tightened and tied,
producing a purse string effect to reduce the length of the anterior and posterior sections of
the annulus and provide adequate leaflet coaptation. The orifice should be able to admit 2.5
to 3 fingerbreadths snugly through the valve, or a 30-mm Hegar sizer may be used.
Step 6. Bicuspidization
◆ Bicuspidization of the tricuspid valve would be considered as a simple technique complementary

to annuloplasty in case of a very large annulus or significant tethering or prolapse of the
leaflets to repair TR and may achieve good long-term results. Essentially, this procedure
converts the tricuspid valve into a bicuspid valve. Interrupted 4-0 polypropylene sutures can
be placed between the anterior and posterior leaflets (more often) or between the posterior
and septal leaflets to create a bicuspid valve (Fig. 23.6). This process is always combined
with an annuloplasty band and occasionally with an edge-to-edge repair similar to the Alfieri
technique for mitral valve repair, as described in the following. Concurrently, the posterior
annulus may be plicated with a 2-0 or 3-0 polyester suture, with or without pledgets. This
usually yields excellent leaflet coaptation while ensuring an adequate orifice for flow.31
Figure 23.5
Tricuspid Bicuspid Bicuspid

(anterior to posterior suture) (posterior to septal suture)
Figure 23.6
Figure 23.5 De Vega technique.
Figure 23.6 Bicuspidization of tricuspid valve.

1. Annuloplasty Band Insertion
◆ To produce a reduction of the tricuspid annulus with the best long-term durability, an annu-
loplasty ring or band should be used. The options include the use of a rigid ring (e.g.,
Carpentier-Edwards), flexible ring (e.g., Duran), or flexible band (e.g., Cosgrove annuloplasty
system) or 3D annuloplasty rings (e.g., contour 3D, GeoForm, 3D MC3).16-18 The area of the
anterior leaflet or the length of the base of the septal leaflet (intertrigonal distance) may be
used to determine the appropriate size. Alternatively, we prefer to implant a tricuspid band
identical in size to the mitral band used during the left-sided valve repair. These ring and
band devices are designed to restore the valve to its normal configuration and, importantly,
to avoid suture placement in the region of the AV node.32
◆ Gentle tension is applied to the tricuspid leaflets during placement of the annulus sutures to
identify the exact location of the thin tricuspid annulus. Mattress sutures are placed circum-
ferentially, with wider bites (7 to 8 mm) on the annulus and smaller corresponding bites
(4–5 mm) through the fabric of the ring or band (Fig. 23.7). We use finer sutures and needles,
typically 4-0 polypropylene, with strong bites passing into the deeper part of the annulus to
avoid tearing of the sutures through the fragile annular tissue
2. Edge-to-Edge and Clover Leaf Repair
◆ In the setting of complex lesions and severe residual TR, an edge-to-edge tricuspid valve
repair may be used as an effective adjuvant procedure to annuloplasty repair.33 The edge-to-edge
technique was originally described by Alfieri for the purpose of mitral valve repair and may
be applied to the tricuspid valve in a similar fashion.34 One technique of edge-to-edge repair
involves the use of a stay suture attaching the free edges of each of the three leaflets at the
site of the regurgitation. A 4-0 or 5-0 polytetrafluoroethylene suture reinforced with a small
pericardial pledget is passed through the middle point of the free edge of each of the leaflets,
just at the level where the leaflet turns down to attach to the primary chordae. This effectively
creates a triple-orifice tricuspid valve, producing a clover-shaped valve (Fig. 23.8A). A second
suture is always used to reinforce the repair.
◆ Alternatively, a double-orifice technique may be used. This is achieved first by bicuspidization
of the tricuspid valve with a plication suture along the posterior leaflet annulus. Subsequently,
the edge-to-edge repair approximates the septal and anterior leaflets using 4-0 or 5-0 Gore-Tex
U stitches at the midpoint of these two leaflets. This achieves a double-orifice edge-to-edge
repair in a manner similar to the Alfieri mitral repair. A second suture is used to reinforce
the repair, and the two orifices are measured with sizers to ensure that each is at least 14 mm
in diameter (see Fig. 23.8B).
◆ In complex tricuspid valve lesions, such as myxomatous degeneration with prolapse or flail
leaflets, stitching the ventral areas of the three leaflets produce what is called a clover-shaped
valve (Fig. 23.9). This technique should be supported with ring annuloplasty.35
Figure 23.7
Annuloplasty
ring
Clover
shaped
Figure 23.9
Figure 23.8
Figure 23.7 Annuloplasty band insertion.
Figure 23.8 Edge-to-edge repair of tricuspid valve.
Figure 23.9 Clover leaf repair of tricuspid valve.

3. Assessment of Tricuspid Valve Repair
◆ Assessment of tricuspid valve competence after repair is achieved by filling the RV with cold
saline and applying pressure on the main pulmonary artery to observe leaflet apposition.
Residual leakage or distortion mandates additional repair maneuvers to achieve coaptation.
Although open assessment of the tricuspid valve is important, the most accurate evaluation
of the adequacy of tricuspid repair is performed using TEE after the patient has been weaned
from cardiopulmonary bypass. If the result appears inadequate, further repair should be
performed; alternatively, replacement may be necessary.
◆ As opposed to MV repair, residual mild TR is considered a good and accepted result of tricuspid
valve repair. TR function and RV function need to be assessed at the same time, particularly
for functional TR repair.
Step 7. Tricuspid Valve Replacement
◆ When the severity of valvular distortion prevents a satisfactory repair procedure, valve replace-
ment becomes mandatory. Ideally, the subvalvular apparatus should be retained to optimize
postoperative RV function, with the leaflet tissues incorporated into the suturing of the
prosthesis to the annulus. If the subvalvular apparatus and leaflet tissues are diseased to the
point that they will interfere with prosthesis insertion or function, their resection is necessary.
However, a 2- to 3-mm fringe of leaflet tissue is left on the annulus, and the septal leaflet is
always preserved. The cordal attachments are divided deep in the RV.19
◆ As in mitral valve replacement, the prosthesis size is selected based on the diameter of the
AV ring sizing the anterior leaflet. Interrupted pledgeted mattress sutures (2-0 or 3-0 polyester)
are passed through the annulus using an intraannular everting technique (Fig. 23.10, 1).
Along the area occupied by the septal leaflet, the sutures are placed in the fringe of leaflet
tissue to avoid damaging the AV node and bundle of His. The sutures are then passed through
the sewing ring of the prosthesis (see Fig. 23.10, 2a), and the prosthesis is parachuted down
into the annulus. Subsequently, the sutures are tied and cut (see Fig. 23.10, 3a). Care is taken
to avoid injury to the RV endocardium as the prosthesis is passed into the decompressed
ventricle. Alternatively, pledgeted mattress sutures may be placed along the septal annulus
only, followed by continuous running sutures along the anterior and posterior sections of the
annulus (see Fig. 23.10, 2b and 3b).
Step 8. Special Situations
1. Tricuspid Valve Endocarditis Repair
◆ There is a growing interest in applying Carpentier repair techniques in patients with tricuspid
valve endocarditis. Pericardial patching of perforations and ring annuloplasty are standard
techniques to produce competent valves and avoid replacement. Moreover, limited resection
of a diseased anterior or septal leaflet may be performed. The affected portion is excised in
a trapezoidal fashion, and 2-0 polyester sutures are used to plicate that specific annulus
segment locally. Subsequently, the resected leaflet edges are reapproximated with interrupted
5-0 or 6-0 polypropylene sutures. A permanent pacemaker may be necessary in those patients
who require septal leaflet resection and repair (e.g., patients with complete heart block). If
the posterior leaflet is involved, the diseased tissue is removed, and bicuspidization of the
tricuspid valve usually results in a competent valve.
1a 1b
2a 2b
3a 3b
Figure 23.10
Figure 23.10 Tricuspid valve replacement.

2. Tricuspid Valve Endocarditis Resection
◆ There is an inherent risk involved with valve replacement in patients with ongoing intravenous
drug addiction. With active tricuspid valve endocarditis in the setting of drug addiction, the
three leaflets and their chordae can simply be excised. A 2- to 3-mm fringe of leaflet tissue
is left on the annulus to enable late prosthesis insertion during a reoperation when the
addiction is under better control.
3. Redo Tricuspid Valve Intervention
◆ Development and/or progression of tricuspid valve regurgitation after correction of left-sided

valve surgery as a result of untreated tricuspid valve regurgitation at the time of left-sided
valve surgery or as a result of failed tricuspid valve repair present a challenging situation.
One of the challenges for patients with long-standing tricuspid insufficiency is the surgical
indications caused by the presence of variable degrees of RV dysfunction, such as pulmonary
hypertension and the consequences of severe, chronic, right-sided dysfunction.
◆ Another challenge is performing surgery in a patient who has a distorted tricuspid valve morphol-
ogy in the form of severe dilation of the tricuspid annulus, which is usually associated with
significant tethering of the tricuspid leaflet and advanced remodeling of the right ventricle. In
those cases, tricuspid valve repair alone is often unable to restore durable competence of the
tricuspid valve, and most of those patients will need tricuspid valve replacement.
◆ Finally, there is the challenge of surgical access and exposure in redo settings, with adhesion
of the RV to the posterior sternal surface and the possibility of injury to other vital structures
during redo sternal reentry. The right anterolateral thoracotomy may offer a safe reentry for
isolated tricuspid valve repair; otherwise, secure femoral access and/or initiation of cardio-
pulmonary bypass peripherally may be required before sternal reentry. In the case of peripheral
cardiopulmonary bypass, control of the vena cava may be a challenging task.36
◆ The hospital mortality is usually higher, and the late outcome is often disappointing; inadequate
patient selection might be a contributing factor. The predominant causes of death are low
cardiac output syndrome and continuing heart failure. The major factors limiting survival
are the preoperative condition of the right ventricle, severity of secondary renal and hepatic
impairment, and presence of preoperative, severe pulmonary hypertension, for which TR is
considered as a safety valve. This highlights the importance of performing surgery early, before
the development of significant right-sided dysfunction, and the careful selection of patients
for surgery.36
◆ Weaning from cardiopulmonary bypass and early postoperative care may be particularly
challenging in patients with severe preoperative pulmonary hypertension (e.g., mitral stenosis)
and RV dysfunction. RV preload should be optimized with volume infusions to improve
contractility. However, a right atrial pressure higher than 18 mm Hg may lead to overdilation
of the RV. TEE may be helpful in titrating the patient’s volume status. Inotropic support with
intravenous milrinone or dobutamine is usually necessary to allow weaning from cardiopul-
monary bypass. In severe cases of pulmonary hypertension, however, pulmonary vasodilators
(e.g., inhaled nitric oxide, intravenous prostaglandins) may be required to reduce RV afterload
in the early postoperative period. Later in the postoperative period, when patients are off
inotropic support and recovering on the ward, diuretic agents are aggressively used to treat
the characteristic fluid retention in these patients.
◆ Complete heart block can occur after surgery owing to damage to the conduction system during
tricuspid valve procedures (1%–2%). This risk may be increased more than 10% especially in
multivalvular procedures, and the presence of preoperative left bundle branch block.7
◆ Ideally, the anchoring sutures for the tricuspid prosthesis should be placed well away from
the conduction tissue. After concurrent tricuspid and mitral valve replacement, complete
heart block is fairly common. The presence of two rigid prosthetic sewing rings is thought
to produce ongoing trauma and eventually lead to AV node dysfunction, either in the immediate
postoperative period or months to years after surgery. Approximately 10% of patients receiving
double-valve replacement require insertion of a pacemaker in the postoperative period, and
the prevalence of this is 25% up to 10 years after surgery. Because of this risk of complete
heart block during the initial hospital stay, electrocardiographic monitoring should be continued
until discharge. Consideration should also be given to placing permanent epicardial pacemaker
leads at the time of surgery.
◆ Long-term anticoagulation is necessary when mechanical prostheses have been inserted in
any of the valve positions. Warfarin administration is started on the evening of postoperative
day 1 or 2. Occasionally, intravenous heparin is used until the international normalized ratio
is therapeutic, particularly in the context of two or more mechanical prostheses and atrial
fibrillation. However, there does not appear to be any evidence to support the practice of
intravenous heparin therapy early in the postoperative course in a patient with a single
mechanical prosthesis. Long-term anticoagulation is controversial if a bioprosthesis is used
in the tricuspid position when bioprostheses have been used for other valve replacements.
Regardless, a large number of patients with tricuspid bioprostheses eventually develop other
indications (e.g., atrial fibrillation) for long-term anticoagulant treatment.37
Step 10. Results of Tricuspid Valve Intervention
◆ The recurrence rate of significant tricuspid insufficiency after tricuspid annuloplasty is around
8% to 15% as soon as 1 month after surgery and has been attributed to several factors. These
include the severity of preoperative TR, pulmonary hypertension, presence of RV dilation,
presence of pacemakers, LV dysfunction, increased LV remodeling, severe tethering of the
tricuspid leaflets, and use of the De Vega technique rather than ring annuloplasty. Most of
the published studies, both randomized and observational, have demonstrated that ring
annuloplasty repairs are more durable than suture annuloplasty, particularly in patients with
severe tricuspid annular dilation or pulmonary hypertension.38
◆ Long-term survival after tricuspid valve surgery for severe TR is affected by several preoperative
factors, including advanced heart failure symptoms, comorbidity, and end-organ dysfunction,
more than by the type of surgery or cause of TR. Ring annuloplasty may be associated with
better results compared with the De Vega technique. The results of annuloplasty alone are
not always consistent. Among other factors, this may be related to the degree of narrowing
of the tricuspid orifice; hence, it has been suggested that the size of the tricuspid annulus
should be reduced appropriately, considering the patient’s body size, to prevent recurrent TR.
◆ Tricuspid valve replacement is associated with the adverse impact of prosthesis-related com-
plications, which tend to appear late in the follow-up. There are no technical differences
between replacement with bioprostheses and mechanical valves. However, mechanical valves
in the tricuspid position in multivalvular procedures are generally associated with a higher
mortality rate and also with an increased incidence of thromboembolic complications and
valvular dysfunction by pannus, although thrombolysis appears to lead to more favorable
results here. On the other hand, bioprostheses appear to degenerate faster in the tricuspid
position, especially in younger patients. However, with the advent of percutaneous valve-in-
valve implantation, this may be less of a problem in the future.19
Percutaneous Tricuspid Valve Interventions
◆ A transcatheter approach for tricuspid valve repair or replacement is attractive, desirable, and
beneficial to this high-risk population as an alternative to surgery but is still not currently ready
to be in routine use. Some of the concepts that have been developed for the percutaneous
treatment of mitral regurgitation may be adapted to percutaneous repair of the tricuspid
valve—percutaneous annuloplasty, edge-to-edge repair, similar to the use of a MitraClip
(Abbott, Abbott Park, IL). Different new devices are currently under preclinical development.
◆ The first percutaneous transcatheter valve-in-valve implantation in a stenosed tricuspid valve
bioprosthesis was done in 2011, among other case reports with small patient numbers.39
To date, two percutaneous devices have been described for transcatheter valve implantation
in failing bioprosthetic valves. These are the Edwards SAPIEN valve (Edwards Lifesciences)
and its iterations and the Melody valve (Medtronic). However, none of them have been
approved or certified to be delivered in the tricuspid position. Therefore, implantation of
these devices in tricuspid position is off-label use. The feasibility of percutaneous deployment
of stent-mounted valves (e.g., SAPIEN, SAPIEN XT, Melody) into the venous system (IVC
and/or SVC) is still being investigated. The focus is not on the TR itself, but rather on its
hemodynamic disturbance. These procedures are therefore termed caval valve implantation.40
◆ The transcatheter approach to the tricuspid valve presents challenging technical issues, such
as the large dimension of the tricuspid annulus, slow flow of the right heart side, and trabeculated
structure of the right ventricle. With regard to access, the angulation of the annulus in relation
to the SVC and IVC should be considered. In contrast to the left ventricle, the RV wall is
thinner than the LV wall; multiple chordae may prevent the advance of the delivery system
and represent a technical challenge to the transapical approach.41
◆ Tricuspid valve repair may also be considered for less than severe TR in patients undergoing
mitral valve surgery when there is pulmonary hypertension or tricuspid annular dilation. In
patients requiring a redo operation for tricuspid valve surgery, the RV is often dilated and
adherent to the posterior sternum. Great care should be exercised during the redo sternotomy.
If a preoperative computed tomography (CT) scan has shown that there is less than 5 mm
of space between the RV and posterior sternal table, peripheral cardiopulmonary bypass initiation
is required.
◆ We use a combination of sharp dissection, oscillating saw, and sternal elevation to perform
the redo sternotomy. Blunt digital dissection should be avoided because of the risk of injury
to the often friable RV free wall.
◆ Bicaval cannulation is necessary during tricuspid operations. The SVC cannula may be placed
in the body of the RA and steered superiorly, or it may be placed directly in the SVC itself.
The sinoatrial (SA) node rests at the anteromedial junction of the RA and SVC. Therefore,
the cannulation site should be 2 cm superior or inferior to this region to avoid SA node injury.
The atrial incision should be well away from the SA node, and the superior extension of the
incision should be limited to 1 to 2 cm from the superior margin of the RA.
◆ One of the major challenges of tricuspid surgery lies in the placement of sutures. The depths
of the suture bites in the annulus must be substantial to avoid tearing through the tissues.
However, the sutures should be placed well away from the conduction tissue, coronary sinus,
and right coronary artery to avoid iatrogenic injury.
◆ Long-term surgical follow-up studies have demonstrated that 2+ TR or more and severe
tricuspid annular dilation predict the development of late severe TR and the need for tricuspid
reoperation. Therefore, ensuring the adequacy of tricuspid repair during the initial operation
is critically important.
◆ Special care should be taken to assess the foramen ovale for patency in all tricuspid operations.
These lesions can easily be closed with sutures to reduce the possibility of systemic desaturation
from right-to-left shunting, especially in the context of pulmonary hypertension, and to reduce
the risk of paradoxic embolization.
◆ Consideration should be given to placing permanent epicardial ventricular pacing leads in
patients undergoing combined mitral and tricuspid valve replacement; up to 25% postoperative
complete heart block and transvenous endocardial lead placement might be difficult in tricuspid
valve replacement or repair with edge-to-edge repair. RV free wall epicardial pacemaker leads
can be placed with ease at the time of surgery, and they can be buried in a pocket anterior
to the posterior rectus sheath in the left upper quadrant for later permanent pacemaker
implantation, if required.
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31. Khonsari S, Sintek CF. Cardiac Surgery: Safeguards and Pitfalls in Operative Technique. 3rd ed. New York: Lippincott Williams &
Wilkins; 2003.
32. De Bonis M, Taramasso M, Lapenna E, et al. Management of tricuspid regurgitation. F1000Prime Rep. 2014;6:58.
33. Lai YQ, Meng X, Bai T, et al. Edge-to-edge tricuspid valve repair: an adjuvant technique for residual tricuspid regurgitation. Ann
Thorac Surg. 2006;81:2179–2182.
34. Alfieri O, De Bonis M. The role of the edge-to-edge repair in the surgical treatment of mitral regurgitation. J Card Surg.
2010;25:536–541.
35. Lapenna E, De Bonis M, Verzini A, et al. The clover technique for the treatment of complex tricuspid valve insufficiency: midterm
clinical and echocardiographic results in 66 patients. Eur J Cardiothorac Surg. 2010;37:1297–1303.
36. Pfannmüller B, Moz M, Misfeld M, et al. Isolated tricuspid valve surgery in patients with previous cardiac surgery. Thorac Cardiovasc
Surg. 2013;146:841–847.
37. Kulik A, Rubens FD, Wells PS, et al. Early postoperative anticoagulation after mechanical valve replacement: a systematic review. Ann
Thorac Surg. 2006;81:770–781.
38. McCarthy PM, Bhudia SK, Rajeswaran J, et al. Tricuspid valve repair: Durability and risk factors for failure. J Thorac Cardiovasc Surg.
2004;127:674–685.
39. Wagner R, Daehnert I, Lurz P. Percutaneous pulmonary and tricuspid valve implantations: an update. World J Cardiol.
2015;7:167–177.
40. Cullen MW, Cabalka AK, Alli OO, et al. Transvenous, antegrade Melody valve-in-valve implantation for bioprosthetic mitral and
tricuspid valve dysfunction: a case series in children and adults. JACC Cardiovasc Interv. 2013;6:598–605.
41. Van Garsse LA, Ter Bekke RM, van Ommen VG. Percutaneous transcatheter valve-in-valve implantation in stenosed tricuspid valve
bioprosthesis. Circulation. 2011;123:e219–e221.
IV·
'
SECTION
Operations
for Aortic Disease
CHAPTER
24
Type A Aortic Dissections

Hlal Moncef and François Dagenais
◆ Type A dissection is defined by the presence of a septum creating two lumens within the
ascending aorta. The DeBakey classification further divides the Stanford type A classification
according to whether the septum is located solely in the ascending aorta (DeBakey type II)
or extends distally within the arch and thoracoabdominal aorta (DeBakey type I; Fig. 24.1).
◆ The septum is secondary to an intimal tear, with separation of the media creating a true
lumen—original aortic lumen lined by intima—and a false lumen, resulting from blood flow
separating the media.
◆ In type A dissection, the primary intimal tear is located predominantly at the right anterolateral
border of the ascending aorta, just above the sinotubular junction. In less than one-third of
cases, the primary intimal tear may be located in the arch or thoracoabdominal aorta.1 In
such cases, the septum in the ascending aorta is secondary to a retrograde extension of the
dissection process.
◆ The dissection process may progress to the following:
◆ aortic rupture, usually within the pericardium
◆ extension to branch vessels such as the coronary ostia, arch vessels, and visceral arteries
◆ reentrance into the true lumen, with creation of reentry tears. Tears owing to the shearing
of branch vessels of the aorta (natural fenestrations) also contribute to equilibrate the
pressure between the true and false lumens.
◆ The dissection process often extends to the aortic root, with loss of commissural support of
the aortic valve (mainly the left noncoronary commissure), and may lead to aortic valve
malcoaptation and aortic insufficiency (Fig. 24.2).
409
Chapter 24 • Type A Aortic Dissections409.e1
Keywords
aortic dissection
surgical techniques
410 Section IV • Operations for Aortic Disease
Stanford Type A
DeBakey Type I Type II
Figure 24.1
Figure 24.2
Chapter 24 • Type A Aortic Dissections 411
◆ Organ malperfusion secondary to branch vessel occlusion may supervene after type A dissection.
The cause of the malperfusion may be dynamic or static (Fig. 24.3).
◆ Dynamic branch vessel malperfusion is caused by high pressure within the false lumen, with
collapse of the true lumen (see Fig. 24.3A). True lumen branch vessels are hypoperfused
because of proximal true lumen aortic collapse or ostial occlusion by the displaced septum.
This represents the most frequent mechanism of malperfusion with type A dissection; it is
usually relieved by successful reperfusion of the true lumen with operative repair.
◆ Static malperfusion is caused by occlusion of a branch vessel secondary to extension of the
dissection process within the branch vessel (see Fig. 24.3B). A branch vessel hematoma and
reentry flap with in the branch vessel resulting in occlusion are examples. Malperfusion often
persists following aortic repair.
◆ Combined malperfusion results from a combination of dynamic and static causes.
◆ A diagnosis of acute type A dissection mandates an emergent operative procedure because

historic reports have established that up to 1% to 2% of patients die each hour following the
insult.2 Early medical therapy may lessen the risk of early rupture but still mandates emergent
operative repair.3 Operative indications should be individualized in older patients with significant
comorbidities or in patients with a severe neurologic deficit and a delayed presentation (> 6
hours) because operative mortality and morbidity rates are very high.
◆ Once the diagnosis is suspected, aggressive medical treatment should be instituted and diagnostic
confirmation obtained, followed by operative repair:

◆ Pulse and dP/dt control using either beta blocker–/nitroprusside or a labetalol (Ttrandate)
strategy
◆ Invasive monitoring
◆ Pain control
◆ Patients with severe malperfusion, such as visceral ischemia with an elevated lactate level,
may initially be managed with an endovascular approach. This can be followed by an open
aortic repair once the malperfusion is relieved and the patient is more stable.4
◆ Although patients may be directed to the operating room solely on the visualization of a
septum within the ascending aorta on transthoracic echocardiography, most patients are
diagnosed by computed tomography (CT) angiography. This may provide additional information,
such as extent of the dissection and involvement of branch vessels, site of the primary intimal
tear, and the presence of pericardial effusion, malperfusion, and aneurysmal dilation.
◆ Coronary angiography is time-consuming and is usually not performed. However, patients
with obvious signs of coronary malperfusion and hemodynamic compromise may initially be
considered for coronary artery stenting, followed by definitive repair. Patients with a previous
coronary artery bypass graft or who have known severe coronary artery disease may be
considered for preoperative coronary angiography or cardiac coronary CT on a selected basis.
True True
lumen lumen
False False
lumen lumen
Intimal
tear
A Dynamic B Static
Figure 24.3
1. Anesthesia Preparation
◆ In addition to the standard monitoring during cardiac surgery, near-infrared spectroscopy

(NIRS) may be of additional value to monitor brain saturation and differences between
hemispheres during the circulatory arrest period.5
◆ Temperature monitoring should include determining the nasopharyngeal, pulmonary artery,
and bladder temperatures.

◆ Pharmacologic additives may be used. In preparation for circulatory arrest, mannitol, 0.5 g/
kg, is administered to promote diuresis. The use of barbiturates such as pentobarbital or the
use of corticosteroids remains controversial.6,7
◆ Transesophageal echocardiography (TEE) is mandatory. The baseline evaluation includes
assessment of myocardial function and the evaluation of pericardial effusion, aortic valve
competency, site of the primary intimal tear, aortic diameters, and concomitant valvular
problems. In addition, TEE is essential to monitor cardiopulmonary bypass (CPB)–induced
malperfusion. Preferential perfusion of the true lumen should be assessed regularly, especially
at critical time points such as CPB initiation, after aortic cross-clamping of the ascending
aorta (if performed), and during resumption of CPB after the circulatory arrest period.
2. Cardiopulmonary Circuit Preparation
◆ The arterial line should be divided into two arms using a “Y” connector to reperfuse the distal
aorta once the distal anastomosis is performed or to select an alternate cannulation site in
case of malperfusion on CPB initiation.
3. Cardiopulmonary Initiation
◆ The femoral artery has been historically used as inflow during type A dissection. The right
axillary artery has emerged as the preferred arterial cannulation site. The femoral artery,
however, is rapidly accessible for hemodynamically unstable patients. The right axillary can-
nulation requires more time but ensures antegrade aortic perfusion, facilitates initiation of
antegrade cerebral perfusion, and is associated with less malperfusion than the femoral artery.8
Right Axillary Artery Cannulation Technique
◆ The right axillary artery dissection and cannulation are performed before sternal opening.
Dissection of the axillary artery, a rare occurrence, is a contraindication to using the artery
as arterial inflow. Dissection of the innominate artery, with or without extension in the proximal
subclavian artery, is not a contraindication per se but is associated with a higher risk of
malperfusion on CPB initiation.9
◆ An infraclavicular incision is performed at the distal third of the clavicula. The fibers of the
pectoralis major are divided, exposing the clavipectoral fascia, which is incised. The axillary
artery lies posterior and cephalic to the axillary vein. Often, an arterial branch of the axillary
artery lies in proximity to the border of the pectoralis minor and may be used to gain access
to the axillary artery. The artery is looped with a Silastic tape. Systemic administration of
5-1000 U of heparin is given before vessel clamping. Cannulation may be carried out by
inserting a cannula directly into the axillary artery or by sewing an 8-mm Dacron graft in an
end-to- side fashion to the axillary artery. A 20 F cannula is then inserted into the graft and
connected to one branch of the arterial line (Fig. 24.4). Vascular complications are reported
to be less with the 8-mm graft technique, especially in the presence of small axillary arteries.10
◆ Alternate arterial cannulation sites are the innominate artery and direct cannulation of the
ascending aorta. An 8-mm graft may be sutured end to side to the innominate artery, free of
significant hematoma or dissection. Direct ascending aortic cannulation is performed using
a Seldinger technique, with a needle puncture at the inner portion of the anterior surface of
the distal ascending aorta (Fig. 24.5). Direct cannulation of the ascending aorta ensures perfusion
of the true lumen and has been proposed as the preferential arterial cannulation method by
some authors.11,12
◆ A double-stage venous cannula is inserted into the right atrium. A retrograde cardioplegia
catheter is positioned in the coronary sinus, and a purse string is fashioned on the left superior
pulmonary vein for left ventricular venting once the aorta has been clamped or the ventricle
is fibrillating.
◆ CPB is then initiated, with care taken to ensure good true lumen perfusion and stability in
other monitoring parameters, such as electrocardiography and NIRS.
4. Temperature Management, Circulatory Arrest, and Aortic Cross-Clamping
◆ Historically, circulatory arrest with deep hypothermia (18°–20°C) has been used to perform
the open distal aortic repair and anastomosis during type I aortic dissection. During the last
decade, moderate hypothermia (24°–28°C) with antegrade cerebral perfusion has been advocated
to reduce CPB time, coagulopathy, and organ dysfunction.
◆ The authors’ temperature management strategy depends on identification of the primary
intimal tear site and arch diameter. CT and TEE may guide the surgeon to identify the site
of the primary intimal tear. In the presence of a primary intimal tear at the sinotubular junction
with the absence of a dilated arch (< 5 cm), moderate hypothermia (24°–28°C, nasopharyngeal)
with antegrade cerebral perfusion is adopted. When the arch is dilated or the location of the
primary intimal tear is uncertain or highly suspected to be in the arch, the risk of a complex
arch procedure is high. This may necessitate a period of circulatory arrest longer than 30
minutes. In such a case, to optimize distal organ protection, the authors will adopt a deep
hypothermia (18°–20°C) strategy.
Pectoralis
minor muscle
Weitlaner
retractor Pectoralis
major muscle
Figure 24.4
Purse string
True lumen
Needle and guidewire
in true lumen
Figure 24.5
◆ The debate is still unresolved as to whether the aorta should be clamped before inducing
circulatory arrest. Aortic cross-clamping is mandatory in case of severe aortic regurgitation
and left ventricle (LV) distention, despite LV venting on ventricular fibrillation. In patients
without LV distention, the aorta may be left unclamped until the desired hypothermia level
is reached for the circulatory arrest period. Unless a significant atheroma burden is suspected,
the authors prefer to cross-clamp the aorta. Advantages include confirming the location of
the primary intimal tear before inducing the circulatory arrest period and assessment of the
aortic root pathology. The aorta should be clamped at the midascending level in case a higher
cross-clamp is required because of an aortic rupture. Further confirmation of good true lumen
perfusion by TEE should be assessed after cross-clamping.
5. Distal Aortic Repair
◆ At the level of hypothermia targeted, the arterial perfusion through the axillary artery is
decreased to 10 mL/kg/min, and the innominate artery is clamped, thus initiating selective
cerebral antegrade perfusion (SACP) through the right carotid artery. A standard hemiarch
anastomosis is usually performed in less than 30 minutes. In such a setting, SACP is only
performed through the right axillary artery without clamping the other, often fragile arch
vessels, unless the cerebral saturation on the left side falls significantly compared to the right
side. When the circulatory arrest time is expected to extend over 30 minutes, such as in cases
of complete arch replacement, a soft-tipped catheter may be inserted into the right carotid
ostium to provide bilateral, antegrade, cerebral protection. In this case, the authors prefer to
perform an arch-first technique using a trifurcated graft, thus resuming complete cerebral
perfusion once the arch vessel anastomoses have been completed.13
◆ Once SACP is initiated, the aortic cross-clamp is released, and the aortic arch is inspected
for tears. In the absence of a tear, the arch is beveled to perform a hemiarch replacement
(Fig. 24.6). A Dacron graft with a single 8-mm reperfusion branch is tailored and anastomosed
using 4-0 polypropylene sutures, with meticulous care to avoid iatrogenic intimal tears.
Reinforcement of the anastomosis with Teflon felt is often performed by incorporating a felt
band between the intima and adventitia (so-called neomedia) or external to the aortic wall.
Alternatively, the adventitia may be trimmed 1 to 2 cm longer than the level of the intima
edge and subsequently inverted in the aortic lumen and tacked to the aortic wall using running
5-0 polypropylene sutures.14 The distal anastomosis is then performed with or without external
Teflon reinforcement. The authors do not use glue to bond the dissected aortic wall because
of the risk of embolization or late aortic wall necrosis.15 In type II DeBakey dissection, a
hematoma extending along the arch is usually found. In such cases, the anastomosis should
be performed, if feasible, in aortic tissue free of dissection and hematoma. Subadventitial
hematoma removal with aortic tissue approximation should be considered in a subset of
patients with extensive hematoma within the mid and distal arches. Once the anastomosis is
completed, de-airing of the graft is performed, the graft is clamped, and CPB is resumed
through the axillary graft in the absence of dissection within the innominate artery or, more
commonly, through the side branch of the Dacron graft using the second branch of the arterial
line (see Fig. 24.6B). Distal line hemostasis is secured using pledgeted polypropylene sutures,
and rewarming to normothermia is initiated.
~2 mm
Felt strip
buttressing Suture
aortic wall
Adventitia
Figure 24.6
◆ In the presence of a tear within the arch, incorporation of the tear within the aortic resection
is done, when feasible. With complex aortic tears or in the presence of a dilated arch (> 5-5,
5 cm) a complete arch replacement should be considered. The decision should be individualized
to the patient’s overall condition and the surgeon’s experience. Although high-volume centers
have reported excellent results for extended arch replacement procedures during type A
dissection, these repairs require expertise and should be performed by surgeons with experience
in nonurgent patients.
◆ In case a full arch resection is required, the authors prefer initially to revascularize the arch
vessels using a trifurcated graft. If feasible, the distal anastomosis is performed proximal to
the left subclavian artery, thus facilitating the anastomosis and minimizing recurrent and
phrenic nerve injuries. In such a case, the left subclavian artery is ligated proximally and
revascularized in situ or extraanatomically through the left thorax over the second rib to the
left axillary artery (Fig. 24.7).16
Figure 24.7
6. Proximal Aortic Repair
◆ Once the distal anastomosis has been completed, the aortic root is inspected for extension
of the dissection process within the root, disease of the aortic valve, and aortic root diameter.
In the absence of aortic root dilation (root < 5 cm), significant aortic valve pathology, connective
tissue disorder, or tears extending close to the coronary ostia, the root may be preserved. The
ascending aorta is trimmed just above the sinotubular junction. Clot present in the false
lumen should be removed. Commissural prolapse is corrected by resuspending the three
commissures at the sinotubular level using 4-0 pledgeted sutures (Fig. 24.8A). The proximal
anastomosis is performed by trimming the arch graft to the desired length or by sewing a
new graft, generally no more than 4 mm larger than the aortic annulus, followed by a graft
to graft anastomosis to the arch graft. The proximal anastomosis may be reinforced with
Teflon felt, as described for the arch repair (see Fig. 24.8B).
◆ In the presence of a diseased aortic valve, a standard aortic valve replacement is performed
and the root preserved, if feasible.

◆ Occasionally, the noncoronary sinus is fragile and extensively damaged by the dissection
process. With such a finding, the authors usually resect the noncoronary sinus. A tongue
equidistant to the length of the resected sinus may be fashioned in the proximal graft and
used to replace the sinus. The author prefers initially to replace the resected sinus with an
isolated tongue graft and subsequently perform the proximal anastomosis at the sinotubular
level (see Fig. 24.8C). This facilitates maintaining the symmetry of the sinus and valve geometry.
Anastomosis is performed using 4-0 polypropylene SH-1 suture-anchoring stitches in healthy
tissue at the base of the leaflet. Care should be taken to lay the Dacron graft within the aorta
to enhance hemostasis.
◆ In case of a dilated root (> 5 cm), an extensive dissection within the root, especially in the
vicinity of the coronary ostia, or in the presence of a connective tissue disorder, a root
replacement should be performed. Selection of the type of conduit should be based according
to the patient’s age, history of bleeding, and aortic annulus size. In experienced hands, a
valve-sparing root procedure may be advocated for young patients, particularly in the presence
of a connective tissue disorder. Dissected coronary buttons should be approximated and
reinforced using O-shaped Teflon felt (see Fig. 24.8D). Occasionally, reconstruction of the
right coronary artery is tedious and dangerous. A vein graft interposition with ligation of
the right coronary ostium should be considered in such a setting, especially if a preoperative
right coronary artery malperfusion was suspected.
◆ Because of extended CPB time, coagulopathy, and fragile suture lines, bleeding may become
a significant issue. Securing hemostasis and suture lines and the administration of allogenic
blood products usually solve most bleeding problems. In cases of diffuse bleeding with no
surgical cause, off-label administration of recombinant factor VIIa may be considered.
◆ Once the operation is completed, one should assess the arterial pulses in all extremities.
Furthermore, malperfusion identified preoperatively should be evaluated for organ reperfusion.

Visceral malperfusion may require on the table or early angiography with stent placement in
case of persistent static malperfusion.
◆ Blood pressure control is mandatory early and late after the procedure. Early blood pressure
control (target systolic blood pressure < 120 mm Hg) reduces anastomotic tension and blood
loss. Postdischarge blood pressure control is key to ensure optimal remodeling of the distal
dissected aortic segments in patients with DeBakey type I dissection, thus minimizing the
risk of early distal aortic dilation.
2 mm
A Adventitia Intima
Aortic root
wall
Pledgets
Felt strip
Sutures
(cross section)
Teflon
“lifesaver”
Coronary Left main

button coronary
artery
C D
Figure 24.8
◆ Imaging surveillance is important to assess the integrity of the proximal aortic repair and
exclude dilation of the residual dissected aortic segments. The authors usually obtain a baseline
thoracoabdominal CT angiogram before discharge if the creatine level is within normal range,
with follow-up CT or magnetic resonance imaging (MRI) scans at 6, 12, and 24 months.
Thereafter, CT or MRI scans are obtained annually in patients with increasing aortic diameter;
the interval may be extended to 18 to 24 months in patients with stable disease. In procedures
in which the native aortic valve was spared, assessment of the aortic valve before discharge,
at 1 year postoperatively, and every 2 years thereafter is advisable.
◆ In the presence of aortic tamponade, the patient should be brought urgently to the operating
room. While a team dissects the femoral vessels for CPB initiation, another surgical team
should open the sternum, and a pinpoint perforation of the pericardium should be performed
with the electrocautery. Often, this will allow decompression of the intrapericardial pressure
and partially relieve the tamponade, permitting time for femoral cannulation.
◆ In case of obvious and severe organ malperfusion, one may choose to revascularize the
jeopardized organ early. Early bypass with reperfusion of an occluded carotid artery or bypass
of a malperfused right coronary artery may be considered in the presence of preoperative
clinical signs suggesting severe organ compromise.
◆ In the presence of regional myocardial dysfunction after CPB weaning, significant coronary
artery stenosis should be considered; addition of a bypass graft may relieve the regional
myocardial dysfunction.
◆ Thrombosis of the false lumen distal to the aortic repair after type I DeBakey dissection is
the most important prognostic factor to avoid late distal aortic dilation. Unfortunately, in
most cases, the false lumen remains patent with a standard hemiarch procedure because of
the presence of multiple distal reentries. Novel procedures using antegrade deployment of
thoracic stent grafts during circulatory arrest have been demonstrated to promote false lumen
thrombosis.17 Optimal patient selection and the increased morbidity related to the procedure
remain to be assessed.
◆ The field of endovascular thoracic stent grafting is rapidly evolving. The use of short grafts
to treat nonoperative candidates with type A dissection have been reported. Refinement in
technology and optimal patient selection will better delineate the usefulness of these emerging
technologies.
References
1. Roberts CS, Roberts WC. Aortic dissection with the entrance tear in the descending thoracic aorta. Analysis of 40 necropsy patients.
Ann Surg. 1991;213:356–368.
2. Coady MA, Rizzo JA, Goldstein LJ, Elefteriades JA. Natural history, pathogenesis, and etiology of thoracic aortic aneurysms and
dissections. Cardiol Clin. 1999;17:615–635.
3. Elefteriades JA. Editorial comment: acute type A aortic dissection: surgical intervention for all. Cardiol Clin. 2010;28:333–334.
4. Patel HJ, Williams DM, Dasika NL, et al. Operative delay for peripheral malperfusion syndrome in acute type A aortic dissection: a
long-term analysis. J Thorac Cardiovasc Surg. 2008;135:1288–1295.
5. Heringlake M, Garbers C, Käbler JH, et al. Preoperative cerebral oxygen saturation and clinical outcomes in cardiac surgery.
Anesthesiology. 2011;114:58–69.
6. Krüger T, Hoffmann I, Blettner M, et al. Intraoperative neuroprotective drugs without beneficial effects? Results of the German
Registry for Acute Aortic Dissection Type A (GERAADA). Eur J Cardiothorac Surg. 2013;44:939–946.
7. Dewhurst AT, Moore SJ, Liban JB. Pharmacological agents as cerebral protectants during deep hypothermic circulatory arrest in adult
thoracic aortic surgery. A survey of current practice. Anaesthesia. 2002;57:1016–1021.
8. Wong DR, Coselli JS, Palmero L, et al. Axillary artery cannulation in surgery for acute or subacute ascending aortic dissections. Ann
Thorac Surg. 2010;90:731–737.
9. Preventza O, Garcia A, Tuluca A, et al. Innominate artery cannulation for proximal aortic surgery: outcomes and neurological events
in 263 patients. Eur J Cardiothorac Surg. 2015;48:937–942.
10. Sabik JF, Nemeh H, Lytle BW, et al. Cannulation of the axillary artery with a side graft reduces morbidity. Ann Thorac Surg.
2004;77:1315–1320.
11. Khaladj N, Shrestha M, Peterss S, et al. Ascending aortic cannulation in acute aortic dissection type A: the Hannover experience. Eur J
12. Kamiya H, Kallenbach K, Halmer D, et al. Comparison of ascending aorta versus femoral artery cannulation for acute aortic dissection
type A. Circulation. 2009;120:S282–S286.
13. Minatoya K, Karck M, Szpakowski E, et al. Ascending aortic cannulation for Stanford type A acute aortic dissection: another option. J
14. Oda T, Minatoya K, Sasaki H, et al. Adventitial inversion technique for type A aortic dissection distal anastomosis. J Thorac Cardiovasc
Surg. 2016;151:1340–1345.
15. Suzuki S, Masuda M, Imoto K. The use of surgical glue in acute type A aortic dissection. Gen Thorac Cardiovasc Surg.
2014;62:207–213.
16. Shetty R, Voisine P, Mathieu P, Dagenais F. Recannulation of the right axillary artery for complex aortic surgeries. Tex Heart Inst J.
2005;32:194–197.
17. Shi E, Gu T, Yu Y, et al. Simplified total arch repair with a stented graft for acute DeBakey type I dissection. J Thorac Cardiovasc Surg.
2014;148:2147–2154.
CHAPTER
25
Aortic Arch Aneurysms

Walter F. DeNino and John S. Ikonomidis
◆ Academic anatomists refer to the aortic arch as that part of the aorta that begins and ends
with a line drawn in cross section across the aorta at a level corresponding to the lesser curve
of the aortic arch. This therefore implies that the arch of the aorta starts at approximately the
level of the superior reflection of the pericardial sac. However, surgical anatomists and surgeons
tend to consider the aortic arch as that portion of the aorta that begins with a line drawn in
cross section across the aorta at the level of the proximal origin of the ostium of the innominate
artery and ending at the distal margin of the ostium of the left subclavian artery.
◆ The aortic arch tapers somewhat from anterior to posterior owing to the takeoff of the three
large arterial branches—innominate artery, left common carotid artery, and left subclavian
artery. In approximately 5% of patients, this anatomic configuration consists of a double
ostium or so-called bovine aortic arch, where the innominate artery and left common carotid
artery arise from a somewhat larger, but single, aortic ostium (Fig. 25.1).
◆ Other anatomic structures of importance during aortic arch surgery include the left recurrent
laryngeal nerve, left phrenic nerve, and right recurrent laryngeal nerve. These become important
when considering separate replacement of the branch vessels in conjunction with aortic arch
surgery.
◆ Aortic arch aneurysms seldom occur as isolated structures, but rather occur in conjunction
with aneurysmal dilation of the proximal ascending aorta or distal aorta. Aneurysmal dilation
often causes the aortic arch aneurysm to shift anteriorly and laterally to the right. Because
most cases of aortic arch aneurysm surgery are performed through a median sternotomy,
this anatomic change brings critical structures more anteriorly and may facilitate the repair
(Fig. 25.2).
424
Chapter 25 • Aortic Arch Aneurysms424.e1
Keywords
aortic arch aneurysm

Chapter 25 • Aortic Arch Aneurysms 425
Normal Bovine
Figure 25.1
Normal Aneurysm
Anterior and
lateral shift
to right
Figure 25.2
Box 25.1 Preoperative Assessment for Aortic Arch Replacement

History and Physical Examination
Family history of aneurysm disease or connective tissue disorders
Cardiovascular risk factors
History of cerebrovascular events
History of renal or pulmonary disease
Previous operations on the vascular system
Previous cardiac surgery through sternotomy
Cardiac murmurs on auscultation
Palpable peripheral pulses
Investigations
Peripheral vascular studies: carotid arteries, lower extremity arteries
Pulmonary function testing
Transthoracic echocardiography
Coronary arteriography
Thin-slice computed tomography angiogram of chest, abdomen, pelvis
◆ Assessment of the patient’s fitness for aortic arch replacement has multiple facets. Most
importantly, the patient needs to be of an age and physical condition that would withstand
a major operation such as this. A careful consideration of noncardiovascular comorbidities
such as respiratory and renal disease should be undertaken because these are significant
independent predictors of poor outcome.
◆ From a cardiovascular point of view, left ventricular function and the presence or absence of
significant valvular disease are important variables to consider. The presence of coronary
disease does not preclude operation, but it would mandate additional coronary artery bypass
procedures that would add to the length of the surgical procedure.
◆ The presence of significant peripheral vascular disease in the carotid arteries, subclavian
arteries, or femoral arteries is an important consideration in terms of determining cannulation

and perfusion strategies during circulatory arrest. Similar anatomic considerations apply to
the configuration of the aortic arch anatomy as far as the great vessels are concerned. A history
of previous stroke or transient ischemic attacks may indicate the presence of significant
cerebrovascular disease, and this must be investigated thoroughly with thin-slice computed
tomography (CT) scans, magnetic resonance imaging (MRI), or cerebral angiography. A recom-
mended standard preoperative workup for patients undergoing aortic arch replacement is
shown in Box 25.1.
1. Pharmacologic Adjuncts
◆ An important consideration with aortic arch replacement is cerebral preservation. Circulatory

arrest in some form is required for aortic arch replacement, so a strategy should be undertaken
to minimize the period and extent of cerebral hypoperfusion.
2. Cannulation Site and Adjunct Perfusion Strategy
◆ Selection of cannulation site is important. In general, for circulatory arrest times anticipated
to be less than 30 minutes, current literature suggests that direct cannulation of the aneurysm
distally, cooling the patient down to 18° to 20°C (64.4°–68°F), and discontinuation of the
pump with no perfusion adjuncts for 10 to 15 minutes is safe.
◆ If it is anticipated that a longer time on circulatory arrest will be required, such as for full
arch replacement, a strategy should be used to maintain some form of cerebral perfusion at
this temperature. This strategy should provide the best cerebral perfusion while minimizing
the clutter in the operative field. Among the currently available techniques of retrograde
cerebral perfusion, direct perfusion of the great vessels with separate cannulae, and selective
perfusion through the right axillary or innominate artery, we recommend selective antegrade
cerebral perfusion, especially if the patient has a bovine aortic arch. We believe that this is
the best strategy because of the following:
1. The vast majority of patients have an intact circle of Willis, and therefore selective antegrade
cerebral perfusion is usually appropriate for most cases of arch replacement;
2. Retrograde cerebral perfusion has been associated with the development of brain edema
and perhaps some neurologic dysfunction, and detailed studies have indicated that very
little blood flow given this way actually reaches the cerebral cortex;
3. Insertion of antegrade catheters into the ostia of the arch vessels is cumbersome, complicates
the operative field, and may dislodge plaques if the arch is involved with atherosclerosis,
possibly contributing to postoperative neurologic sequelae.
◆ The arterial side of the pump should be split to provide perfusion for this cannula and to
enable a separate cannula to be inserted into the aortic arch graft.
Right Axillary Artery
◆ The right axillary artery is accessed through a right infraclavicular incision approximately 2
to 3 cm below the clavicle, inferiorly along the lateral aspect of the clavicle, just before the
deltopectoral groove (Fig. 25.3). This incision is approximately 5 to 7 cm long, depending
on the patient’s habitus, through which a portion of the pectoralis major and usually most,
if not all, of the pectoralis minor is divided. The axillary artery sits in the brachial plexus and
is easily palpable. Electrocautery is not advised during this portion of the dissection to expose
the axillary artery because of the risk of thermal injury to the brachial plexus. It is usually
straightforward to identify and encircles the axillary artery over a distance of 3 to 4 cm.
◆ Cannulation strategies for the axillary artery can include direct cannulation or placement of
a side graft. We prefer a 10-mm Dacron side graft because this maintains perfusion to the
right arm. There also is evidence in the literature that a side graft strategy for cannulation of
the axillary artery may be more beneficial in reducing neurologic injury than direct cannulation.
In addition, because the axillary artery is such a friable vessel, once the graft is anastomosed,
it is not necessary to repair this artery when the cannula is removed. Instead, the graft can
be tied off at the end of the procedure with maintenance of excellent arterial patency.
◆ The patient must be heparinized to avoid clotting of the graft during sternotomy and preparation
for bypass. Also, a right radial artery arterial catheter should be placed beforehand to monitor
arterial pressure during the circulatory arrest period.
Infraclavicular
incision
Axillary
artery
Figure 25.3
Innominate Artery
◆ If the innominate artery is selected, as is our current preference, the sternotomy incision is
extended cephalad approximately 3 cm above the sternal notch, and soft tissue is divided in
the midline. The innominate vein is retracted caudad with a vessel loop. The innominate
artery is circumferentially dissected and controlled proximally and distally. Heparin is admin-
istered, a partial occlusion clamp is placed, and a 10-mm arteriotomy is made with a no. 11
blade scalpel. A 10-mm graft is then anastomosed in an end-to-side fashion without bevel
using 5-0 Prolene sutures (Fig. 25.4). The partial occlusion clamp is removed. The graft is
de-aired and then connected to the arterial limb of the cardiopulmonary bypass circuit.
4. Establishment of Cardiopulmonary Bypass and Systemic Cooling
◆ Extensive dissection is undertaken around the aneurysm, extending as far into the arch as is
thought comfortable before the institution of cardiopulmonary bypass. Double-stage venous
cannulation is performed, an antegrade cardioplegia cannula is placed in the aneurysm, and
a coronary sinus catheter is placed in preparation for cardioplegia administration (Fig. 25.5).
◆ After systemic heparinization and confirmation of an activated clotting time of 400 seconds,
cardiopulmonary bypass is instituted. Systemic cooling with an alpha-stat acid-base management

strategy is immediately begun, and systemic temperature is monitored by nasopharyngeal
and bladder probes. As much of the aortic arch dissection is completed as possible to eliminate
its necessity during the circulatory arrest period. It is usually possible to mobilize the arch
aneurysm to the level of the left subclavian artery, bearing in mind that this is the region of
the left recurrent laryngeal nerve, which should be identified and preserved if feasible. The
innominate vein should be widely mobilized for easy cephalad or caudad retraction.
◆ Ventricular fibrillation usually occurs at a blood temperature around 26° to 28°C (78.8°–82.4°F),
but this can be prevented to some extent with a 100- to 200-mg intravenous bolus of lidocaine.
If the heart fibrillates, care must be taken to ensure that the left ventricle does not distend.
If this happens, the options include cross-clamping and cardioplegic arrest or insertion of a
left ventricular vent through the right superior pulmonary vein or left ventricular apex (our
preference). To arrest the heart, the cross-clamp is applied across the aneurysm with the
pump flows decreased to minimize tension on the dilated aortic wall. Pump flows are then
brought back up, and the heart is arrested with cold blood cardioplegia, first given antegrade
to bring about a satisfactory cardiac arrest and then switching to retrograde coronary sinus
administration. The heart is further protected with a myocardial cooling jacket, and we usually
place a cold laparotomy sponge on the right ventricle to preserve the right ventricle further.
Cardioplegic infusions of 250 to 500 mL are given every 20 minutes throughout the surgical
procedure. We use a myocardial temperature probe placed in the interventricular septum
under the left anterior descending coronary artery to maintain the myocardial temperature
between 10° and 15°C (50°–59°F) throughout the operation.
◆ For patients in whom proximal ascending and aortic root operations are necessary, this cooling
period is the time to resect the ascending aneurysm or perform as much of the root replacement
as possible. However, once desired cooling is achieved, the proximal operation should not
continue but should be deferred for reconstruction of the aortic arch. This avoids unnecessary
time on cardiopulmonary bypass; in addition, sufficient time will be available to complete
the operation as rewarming is performed after the arch replacement is completed.
Cardioplegia
cannula within
Venous aneurysm
cannulation
Coronary
sinus catheter
Figure 25.4
5.0 prolene
10 mm graft
Partial occlusion
clamp
Aortotomy
Innominate artery
Aorta
Figure 25.5
5. Circulatory Arrest and Preparation for Aortic Arch Replacement
◆ When the bladder temperature reaches 18° to 20°C (64.4°–68°F), the pump is discontinued
but the patient is not exsanguinated. A small clamp is placed on the innominate artery
proximally, and flow is initiated to maintain a normal arterial infusion pressure (mean radial
artery pressure ≈ 60 mm Hg). The main cross-clamp is removed, and blood is cleared from
the field with cardiotomy bypass suction.
◆ Once selective antegrade cerebral perfusion is begun, back-bleeding from the remainder of
the great vessel ostia sometimes necessitates placement of small clamps across these vessels.
Once this is achieved, dissection is undertaken, whereby the arch vessels are prepared for
implantation, and a distal anastomotic site is prepared (Fig. 25.6). In the patient with no
connective tissue disorder and good tissue in the aortic arch, it is appropriate to replace the
aortic arch with the great vessels as a single Carrel patch. However, in patients with known
connective tissue disease, the aortic arch should be completely replaced, excluding all aortic
tissue to prevent late aneurysm formation at the island site. For this procedure, special
branched grafts are available for separate implantation of the great vessels.
Figure 25.6
6. Aortic Arch Replacement
◆ Once the distal anastomotic site in the descending thoracic aorta is prepared, a four-branch
graft is brought into the field and invaginated into itself. This is inserted into the distal
descending thoracic aorta, and an anastomosis is performed between the aorta and the cuff,
usually with 3-0 polypropylene sutures (Fig. 25.7A). We do not use felt material for this
anastomosis.
◆ Once the anastomosis is completed, the inside of the graft is evaginated, and a small amount
of surgical adhesive is laid down around the anastomotic site to seal any needle holes. The
side branch of the graft is then cannulated and perfusion to the body is resumed, during
which time the graft is de-aired; a cross-clamp is then placed just proximal to the branch to
allow distal cold perfusion (see Fig. 25.7B).
◆ Anastomoses then proceed with the left subclavian, left common carotid, and innominate
arteries, with sequential moving of the clamp proximally with completion of each anastomosis
to maximize cerebral flow. After completion of all the anastomoses, the clamp is then moved
proximal to the innominate artery graft, thus restoring complete perfusion to the head (see
Fig. 25.7C). At this point, the pump flow is increased as appropriate, and rewarming is begun.
Cuff
anastomosis
Distal descending
thoracic aorta
Invaginated
graft
A B
C
Figure 25.7
7. Closure
◆ During the rewarming procedure, the ascending aorta-to-graft anastomosis is performed, or

proximal aortic work or valve replacement or root replacement can be completed, after which
a graft-to-graft anastomosis is performed. An ascending aortic vent is inserted and, after
appropriate de-airing maneuvers, the cross-clamp is removed and myocardial perfusion is
begun (Fig. 25.8). Atrial and ventricular pacemaker wires are inserted, the heart is allowed
to recover on cardiopulmonary bypass, and ventilation is begun, with continued de-airing.
All suture lines are inspected for bleeding that requires surgical repair, and the axillary artery
graft is tied off and divided.
◆ When the bladder temperature has reached at least 36.5°C (97.7°F), de-airing has been
completed, normal sinus rhythm is restored, and blood gas and laboratory values have normal-
ized, the patient is weaned from cardiopulmonary bypass. The venous cannula is removed,
and protamine is administered through the inflow limb of the arch graft, after which the limb
is ligated and divided close to the arch graft (Fig. 25.9). The innominate graft is ligated with
two no. 2 heavy silk sutures and cut three corrugations above the ties.
◆ After confirmation of complete hemostasis, drains are inserted, usually a flexible drain posteriorly
and one anterior chest tube. The sternum is closed with stainless steel wires, followed by
apposition of soft tissues in layers with absorbable sutures.
Figure 25.8
Figure 25.9
◆ Patients who undergo aortic arch replacement are critically ill. Important postoperative
considerations are maintenance of appropriate hemodynamics and urine output and careful
monitoring for bleeding. Hypertension swings are not uncommon in these patients, and a
single hypertension swing may trigger bleeding from one of the many suture lines used in
this operation.
◆ Careful vigilance regarding the patient’s filling pressures is mandatory to identify any problems
with cardiac tamponade from bleeding. The clinical examination of the patient going into
tamponade shows cold and mottled extremities and an abrupt decline in urine output. Early
reexploration in these patients is mandatory and lifesaving. After an appropriate period of
stability, the patient is weaned from the anesthetic and is allowed to awaken. Extubation then
proceeds by standard criteria, predicated on the patient’s appropriate neurologic recovery.
◆ It is important, especially when a branch replacement of the arch is used, to identify and
preserve the recurrent laryngeal nerves. There is a possibility with this operation that both
nerves can be destroyed, which is irreparably debilitating for the patient.
◆ Orientation of the branch graft is important. When the graft is invaginated, it is advisable to
mark the graft cuff with a marking pencil on the side where the branches will be oriented to
allow appropriate orientation of the cuff in the descending thoracic aorta. This is performed
under circulatory arrest; having to revise this anastomosis because of improper orientation
can have dire consequences.
◆ Another important consideration is suture technique. The vessels being sewn are usually
histologically abnormal (especially if involved with connective tissue disease), and great care
must be taken with each pass of the needle to avoid microtears, which could translate into
troublesome bleeding problems later.
◆ Bleeding can seem unstoppable at times with this operation. The best way to deal with this
is first, to ensure visually that there are no sites of bleeding that require direct surgical repair
while on bypass. Second, make sure that the patient is completely rewarmed (i.e., at least
36.5°C [97.7°F] bladder temperature) before weaning from bypass. Third, reverse anticoagulation
with protamine given slowly, pack all surgical sites, and wait 5 minutes. Have platelets and
fresh-frozen plasma hanging and dripping in during this time. After this period, most needle
holes will seal, and the bleeding will cease or decrease to the point at which sites that need
further attention can be easily identified. From here, if the patient remains coagulopathic,
keep the patient as warm as possible and correct all coagulation abnormalities with blood
products and extra protamine. If bleeding is still troublesome, consider administration of
activated recombinant factor VIIa concentrate.
Bibliography
Hagl C, Khaladj N, Karck M, et al. Hypothermic circulatory arrest during ascending and aortic arch surgery: the theoretical impact of
different cerebral perfusion techniques and other methods of cerebral protection. Eur J Cardiothorac Surg. 2003;24:371–378.
Kamiya H, Klima U, Hagl C, et al. Short moderate hypothermic circulatory arrest without any adjunctive cerebral protection for surgical
repair of the ascending aorta extending into the proximal aortic arch: is it safe? Heart Surg Forum. 2006;9:E759–E761.
Reich DL, Uysal S, Ergin MA, Griepp RB. Retrograde cerebral protection as a method of neuroprotection during thoracic aortic surgery.
Ann Thorac Surg. 2001;72:1774–1782.
Spielvogel D, Lansman SL, Griepp RB. Aortic arch replacement/selective antegrade cerebral perfusion. Op Tech Thorac Cardiovasc Surg.
2005;10:23–44.
Svensson LG, Blackstone EH, Rajeswaran J, et al. Does the arterial cannulation site for circulatory arrest influence stroke risk? Ann Thorac
Surg. 2004;78:1274–1284.
CHAPTER
26
Thoracoabdominal
Aneurysms
Ourania Preventza, Jessica G.Y. Luc, Scott A. LeMaire,
and Joseph S. Coselli
See Video 26.1 on ExpertConsult.com.
◆ Thoracoabdominal aortic aneurysms (TAAAs) are characterized by dilation of the aorta (to at
least 1.5 times its normal diameter) at the diaphragmatic hiatus—the boundary that separates
the descending thoracic and abdominal aortic segments—with varying degrees of extension
into the chest and abdomen.
◆ The normal diameter of the aorta varies by anatomic location and by the patient’s sex, age,
and body size. Average normal aortic diameters for men and women, respectively, are 28 and
26 mm at the level of the mid-descending thoracic aorta, 23 and 20 mm at the celiac axis,
and 19.5 and 16.5 mm at the infrarenal aorta. Body surface area is a better predictor of aortic
size than is height or weight, particularly in patients younger than 50 years.
◆ The Crawford classification of TAAA repairs (Fig. 26.1) enables appropriate risk stratification
and selection of specific treatment modalities based on the extent of the aortic replacement.
Extent I aneurysms involve the descending thoracic aorta and upper abdominal aorta to the
level of the renal arteries. Extent II aneurysms involve the descending thoracic aorta and
infrarenal abdominal aorta to the level of the aortic bifurcation and can involve the iliac
arteries as well. Extent III aneurysms involve the distal half of the descending thoracic aorta
and varying portions of the abdominal aorta. Extent IV aneurysms start from the portion of
the thoracoabdominal aorta where the visceral arteries (celiac and superior mesenteric arteries)
arise and extend into most or all of the remaining abdominal aorta.1
◆ Understanding the anatomy of the spinal cord circulation is necessary to prevent spinal cord
ischemia. The arteria radicularis magna (artery of Adamkiewicz) is the largest of the radicular
medullary arteries supplying the anterior spinal artery and, therefore, is often targeted for
reimplantation during TAAA repair. This artery has a variable origin; it arises from a lower
intercostal artery (T9–T12) in 60% of persons, from a lumbar artery (L1–L4) in approximately
25%, and from an upper intercostal artery (T5–T8) in about 15%. As a principle, we target
large intercostal arteries with slow back-bleeding at the level of T7 to T10.2
438
Chapter 26 • Thoracoabdominal Aneurysms 439
I II III IV
Figure 26.1
◆ Nonoperative management, which consists of strict blood pressure control, cessation of smoking,
and at least yearly surveillance with imaging studies, is appropriate for asymptomatic patients
who have small aneurysms.
◆ Indications for operation in asymptomatic patients include an aortic diameter exceeding 5 to
6 cm or a rate of dilation greater than 1 cm/year. In patients with Marfan syndrome or a
related connective tissue disorder, the threshold for operation is lower for absolute size and
rate of growth. In the case of TAAAs that cause symptoms, especially pain, or that are
complicated by superimposed acute dissection, the risk of impending rupture warrants expedi-
tious evaluation and urgent aneurysm repair, even when the above-mentioned threshold
diameters have not been reached.
◆ With the exception of patients who require emergency surgery, all patients undergo a thorough
preoperative evaluation, with an emphasis on cardiac, pulmonary, and renal function. Patients
who have asymptomatic aneurysms and severe coronary artery occlusive disease undergo
myocardial revascularization before aneurysm repair. If clamping proximal to the left subclavian
artery is anticipated in patients in whom the left internal thoracic artery has been used as
coronary artery bypass graft, a left common carotid to subclavian artery bypass is performed
to prevent cardiac ischemia when the aortic clamp is applied.
◆ Preoperative renal insufficiency has been a major risk factor for early mortality throughout
the history of TAAA repair. The main strategy used to reduce the risk of contrast-induced
nephropathy from preoperative imaging studies is providing intravenous hydration. Peripro-
cedural administration of acetylcysteine can be used as well. Ideally, surgery is delayed for
24 hours or longer after contrast administration. If renal insufficiency occurs or becomes
worse after a patient receives contrast, the surgical procedure is postponed until renal function
recovers or is satisfactorily stabilized.
◆ Pulmonary complications are the most common form of postoperative morbidity in patients
undergoing TAAA repairs. Patients with a forced expiratory volume in 1 second (FEV1) greater
than 1.0 L and a PCO2 less than 45 mm Hg are considered satisfactory surgical candidates.
In suitable patients, borderline pulmonary function frequently is improved by smoking ces-
sation, treatment of bronchitis, weight loss, and a general exercise program that the patient
follows for a period of 1 to 3 months before operation.
◆ An evolving aspect of selecting the appropriate treatment in patients with TAAAs is the choice
between performing a traditional open graft replacement and using an endovascular approach.
Purely endovascular TAAA repairs require the use of fenestrated or branched stent grafts.
These stent grafts are currently custom-made based on the patient’s preoperative computed
tomography (CT) scan and, therefore, are not immediately available. It can take 4 to 6 weeks
for customization. Currently, no stent grafts have been approved by the US Food and Drug
Administration (FDA) for TAAA repairs in the United States. Hybrid repairs entail the use of
open visceral bypass grafting to secure organ perfusion before the entire aneurysm is covered
with a stent graft. Complete endovascular TAAA repair and hybrid repair are used for patients
who have limited physiologic reserve and are poor candidates for open repair. Both techniques
are becoming increasingly popular.3
1. Intraoperative Management Strategy
◆ A cell-saving device is used throughout the procedure to salvage shed blood from the operative
field. The patient’s temperature is allowed to drift down to a nasopharyngeal temperature of
32° to 33°C (89.6°–91.4°F). To prevent acidosis, sodium bicarbonate solution is administered
by continuous infusion at a rate of 2 to 3 mEq/kg/hr while the aorta is clamped.
◆ Left heart bypass (LHB) and cerebral spinal fluid (CSF) drainage are used to optimize organ
protection in patients undergoing Crawford extent I or II TAAA repair and in patients who
are undergoing extent III or IV TAAA repair after a previous descending thoracic aortic
replacement.4-6 Additionally, in patients with poor cardiac function, LHB is used to reduce
cardiac strain and thus to improve the patient’s ability to tolerate aortic clamping. During
aortic clamping, the patient’s blood pressure is controlled primarily by the anesthesia team
with the help of LHB. The target mean pressure is approximately 80 mm Hg. If additional
help is required to control hypertension, nicardipine or nitroglycerin is administered. Enough
CSF is drained to keep the CSF pressure between 8 and 10 mm Hg during the operation.6
◆ Motor-evoked potential monitoring can provide useful information about spinal cord function
and thereby anterior spinal perfusion during aortic repair. This method of spinal cord monitoring,
which precludes complete neuromuscular blockade, requires the use of special anesthetic
techniques.7,8
2. Incisions and Aortic Exposure
◆ The patient is turned to a right lateral decubitus position with the shoulders placed at 60 to
80 degrees and the hips flexed to 30 to 40 degrees from horizontal and stabilized with a
beanbag (Fig. 26.2). For extent I, II (Fig. 26.3), and III TAAAs, the upper portion of the
thoracoabdominal incision is generally made through the sixth intercostal space (see Fig.
26.2A); the upper (more often) or lower ribs may be divided posteriorly to achieve additional
proximal or distal exposure, respectively, as needed. For extent III aneurysms, sometimes we
use the seventh intercostal space. The incision is gently curved as it crosses the costal margin
to reduce the risk of tissue necrosis at the apex of the lower portion of the musculoskeletal
tissue flap. In contrast, to approach extent IV aneurysms, a straight oblique incision is made
through the eighth (most common), ninth, or even tenth interspace; the exact incision site
is chosen based on the patient’s body habitus and specific anatomy (see Fig. 26.2B). In most
cases, the distal extent of the incision is at the level of the umbilicus. The incision is extended
toward the pubis if there are iliac aneurysms to be repaired.1
◆ Fixed metal retractors attached to the operating table provide consistent static exposure. The
diaphragm is divided in a semicurvilinear fashion to protect the phrenic nerve and preserve
a 3- to 4-cm posterolateral rim of diaphragmatic tissue to facilitate closure when the operation
is complete. The abdominal aortic segment is exposed via a transperitoneal approach; the
retroperitoneum is entered lateral to the left colon, where the spleen, left kidney, and ureter
are retracted anteriorly and to the right. The crus of the diaphragm is divided, and the left
renal artery is identified but not circumferentially dissected or encircled with a tape. An open
abdominal approach permits direct inspection of the bowel, abdominal viscera, and visceral
blood supply after aortic reconstruction is completed.
Incision for extent

Incision for extents IV thoracoabdominal
I, II, and III aneurysm
thoracoabdominal
aneurysm
A B
Figure 26.2
Extent II thoracoabdominal
aortic aneurysm extending
from left subclavian artery
to aortic bifurcation
Figure 26.3
◆ When the aneurysm encroaches on the left subclavian artery, the distal aortic arch is mobilized
gently by dividing the remnant of the ductus arteriosus. The vagus and recurrent laryngeal
nerves are identified. Occasionally, the vagus nerve is divided below the recurrent nerve to
provide additional mobility, thereby protecting the recurrent nerve from injury. If clamping
proximal to the left subclavian artery is anticipated, this artery is separately and circumferentially
mobilized to enable placement of a bulldog clamp. After achieving adequate exposure of the
aorta, heparin (1 mg/kg) is administered before aortic clamping or the start of LHB.
3. Graft Replacement of the Aorta
◆ Patients with extensive TAAAs (extents I, II, and often III) are at greatest risk of developing
postoperative paraplegia or paraparesis, and LHB is used to provide distal aortic perfusion
during the proximal portion of the aortic repair.4 This is achieved by using temporary bypass
from the left atrium, via a cannula inserted through the inferior pulmonary vein, to the distal
descending thoracic aorta with a closed circuit in-line centrifugal pump (Fig. 26.4). Carefully
examining CT scans or magnetic resonance images helps the surgeon select an appropriate
site for direct aortic cannulation. Areas with intraluminal thrombus are avoided because
cannulating them can lead to distal embolization (Fig. 26.5).
◆ A clamp is applied to the distal transverse arch, between the left common carotid and left
subclavian arteries, or to the proximal descending thoracic aorta, just distal to the left subclavian
artery. When LHB is used, a distal aortic clamp is placed between T4 and T7 (see Fig. 26.4).
Bypass flows are adjusted to maintain normal proximal arterial and venous filling pressures.
Flows between 1500 and 2500 mL/min are generally required. The aorta is opened, transected
2 to 3 cm beyond the proximal clamp, and dissected from the esophagus. Patent upper
intercostal arteries are oversewn to avoid stealing blood supply from the spinal cord.
◆ The proximal anastomosis is performed between the aorta and a 22-, 24-, or 26-mm Dacron
graft with continuous 3-0 polypropylene sutures. In patients with fragile aortic tissues (e.g.,
those with a connective tissue disorder or complicated acute aortic dissection), 4-0 polypropylene
sutures are often used. Interrupted polypropylene mattress sutures with felt pledgets are used
to reinforce selected portions of the anastomoses. Surgical adhesives are avoided in these
operations.
Hypothermic crystalloid Vagus nerve

perfusion circuit
Normothermic
centrifugal
perfusion circuit
Figure 26.4
Aneurysm
Intraluminal
thrombus
Figure 26.5
◆ After the proximal anastomosis has been completed, LHB is stopped, the aortic cannula from
the descending thoracic aorta is removed, and the entire remaining aneurysm is opened
longitudinally. The origins of the visceral and renal branches are identified, and cold (4°C
[39.2°F]) lactated Ringer’s solution or Custodiol solution is intermittently delivered to the
renal arteries via balloon catheters (Fig. 26.6).9,10 In patients receiving LHB, 9 F balloon-tipped
Pruitt cannulas can be placed in the celiac and superior mesenteric arteries so that selective
visceral perfusion can be delivered from the pump circuit. If the reconstruction is expected
to be complicated and take more time than usual, we choose to perform selective visceral
perfusion.
◆ For most extent I and II repairs, patent lower intercostal arteries are selected and reattached
to an opening cut in the side of the graft (see Fig. 26.6); large arteries with little or no
back-bleeding are considered particularly important. When none of these arteries is patent,
endarterectomy of that aortic wall and removal of calcified intimal disease should be considered
as a means of identifying arteries suitable for reattachment, after which the proximal clamp
is often moved down the graft to restore intercostal perfusion (Fig. 26.7).
Hypothermic
Normothermic centrifugal crystalloid
perfusion circuit perfusion circuit
Figure 26.6
Figure 26.7
◆ In extent I repairs, the reattachment of the visceral arteries is often incorporated into a beveled
distal anastomosis. In extent II and III repairs, the visceral artery origins, usually those of the
celiac, superior mesenteric, and right renal arteries, are reattached to one or more oval openings
in the graft (see Fig. 26.7). Twenty-five percent of the patients have a stenosis at a visceral
artery origin and require endarterectomy, stenting, or interposition bypass grafting.11 In the
majority of cases, the left renal artery requires direct attachment to a separate opening in the
graft (see Fig. 26.7, inset) or is attached via interposition bypass grafting. Usually, for patients
with a connective tissue disorder, a four-branched graft (Fig. 26.8) is used to attach the celiac,
superior mesenteric, and right and left renal arteries separately.12 A four-branched graft is also
used if the origins of the visceral arteries are far apart from each other.13
◆ In extent IV repairs, the proximal anastomosis can be a beveled anastomosis that incorporates
the visceral vessels, or it can be a straight anastomosis between the lower descending thoracic
aorta and Dacron graft, in which case the visceral vessels are attached as described above.
◆ When the aneurysm extends below the renal arteries, a distal anastomosis is performed near
the aortic bifurcation (Fig. 26.9). In patients with iliac artery aneurysms, a bifurcation graft
is sewn onto the end of the straight graft, and routine distal bypass anastomoses are performed.
Care is taken to preserve circulation to at least one of the internal iliac arteries.
Figure 26.8
Proximal end
of graft
Distal end
of graft
Bifurcated
graft Left renal
graft
Figure 26.9
4. Closure
◆ After the cross-clamp has been removed and the patient is hemodynamically stable, protamine
sulfate is administered. Then, meticulous hemostasis is achieved; the renal, visceral, and
peripheral circulations are assessed; and the body is rewarmed with warm water irrigation of
the operative field. Sometimes, if there is enough tissue, the aneurysm wall is then loosely
wrapped around the aortic graft. Two posteriorly located chest tubes and a 19 F closed-suction
retroperitoneal drain are placed before closure. The diaphragm is closed with continuous no.
1 polypropylene sutures, and the thoracotomy is closed with braided polyester sutures and
reinforced with figure-of-eight steel wires.
5. Alternative Techniques: The Reversed Elephant Trunk Technique
◆ The reversed elephant trunk technique is performed as an initial operation in patients who
have extensive aneurysmal disease involving the ascending aorta, transverse aortic arch, and
thoracoabdominal aorta and present with a symptomatic TAAA (back pain), ruptured TAAA
(contained rupture, as shown by CT scan), or a TAAA that is considerably larger in size than
the ascending aorta (Fig. 26.10).14 The TAAA is replaced during the first stage of aortic repair
(Fig. 26.11). A portion of the proximal end of the aortic graft is invaginated into the graft
lumen, and the folded graft edge is used for the proximal anastomosis; this is called the
reversed elephant trunk technique. During the second-stage operation, the suspended section
of the graft is retrieved (Fig. 26.12A) and used to replace the ascending and transverse aortic
arch (see Fig. 26.12B).
7.5-cm
5-cm ascending
thoracoabdominal
aortic aneurysm
aortic aneurysm
Invagination
of graft
A B
Figure 26.12
6. Alternative Techniques: Hypothermic Circulatory Arrest
◆ Hypothermic circulatory arrest is selectively used in cases in which the distal aortic arch
cannot be safely clamped because it is too large (Fig. 26.13) or because the aneurysm has
ruptured. Arterial and venous cannulas are placed via the descending thoracic aorta and the
left common femoral vein. A second venous cannula is placed in the left atrium via the inferior
pulmonary vein to enhance venous drainage and prevent cardiac distension. After the patient
has been cooled to 18° to 20°C (64.4°–68°F) and circulatory arrest has been initiated, the
aneurysm is opened, and the proximal anastomosis to the distal aortic arch is performed.15-17
Then, a Y-limb from the arterial line is connected to a side branch of the graft, the graft is
de-aired and clamped, and pump flow to the upper body is resumed via the Y-limb. The
remainder of the aortic repair is then completed.
1. Early Postoperative Management
◆ Complications that are commonly associated with an increased risk of death include paraplegia,
renal failure, respiratory failure, cardiac events, and bleeding.18
◆ During the first 24 to 48 hours after the procedure, meticulous blood pressure control is
necessary to avoid spinal cord injury. The target mean arterial blood pressure of 80 to 100 mm Hg
is maintained by using dopamine and/or norepinephrine (Levophed) for hypotension. For
hypertensive patients, nicardipine can be used. In patients with particularly fragile aortic
tissue (i.e., those with a connective tissue disorder), a target blood pressure range of 70 to
80 mm Hg is used to help maintain hemostasis. Hypertensive episodes are controlled to
prevent suture line disruption, which can cause severe bleeding or pseudoaneurysm formation.
Hypotensive episodes must also be avoided because they can precipitate ischemic complications,
including paraplegia and renal failure.
◆ Drainage of CSF is usually continued for 2 days postoperatively. Fluid is drained with a closed
collection system, as needed, to keep the CSF pressure between 10 and 12 mm Hg during
the early postoperative period and between 12 and 15 mm Hg after patients have confirmed
that they are able to move their legs.6,19
Enormous thoracoabdominal
aneurysm precludes
aortic clamping
Figure 26.13
◆ For patients in whom paraplegia or paraparesis develops, the first line of treatment is to
increase the blood pressure immediately to at least 100 mm Hg of mean arterial blood pressure.
Other treatments include draining CSF, administering steroids and osmotic diuretics, optimizing
hemodynamics, correcting anemia, and preventing fever.
◆ Vocal cord paralysis can contribute to respiratory complications and should be suspected in
patients with postoperative hoarseness and confirmed by direct examination. Effective treatment
can be provided by direct cord medialization or, in higher-risk patients, by polytetrafluoroethylene
injection.
◆ Infection of a TAAA graft is often fatal; thus, intravenous antibiotics are continued until all
drains, chest tubes, and central venous lines have been removed.
2. Long-Term Surveillance
◆ Patients who have undergone TAAA repair remain at risk for developing new aneurysms in
other aortic segments or in reattachment patches. Lifelong surveillance with annual CT scanning
or magnetic resonance imaging of the chest and abdomen is especially important in patients
with a connective tissue disorder.18,20 Subsequent aortic repairs can be performed with surpris-
ingly low mortality and morbidity, particularly when done electively.21
◆ Beware of the potential presence of a retroaortic left renal vein, which can be injured during
TAAA exposure. When this vein is encountered, it is occasionally possible to mobilize the
intact vessel and work underneath it. More commonly, however, the vein is temporarily ligated
and divided, and after the aortic replacement is completed, the vein is repaired with direct
end-to-end anastomosis or a short interposition graft.
◆ During extent I and II repairs, the aorta at the site of the proximal anastomosis is transected
and carefully dissected off of the esophagus. This enables the placement of full-thickness
aortic sutures while preventing esophageal injury. When the thoracic duct is encountered in
this region, it should be ligated to prevent postoperative chylothorax.
◆ After the aorta is unclamped, intravenous indigo carmine is administered to confirm renal
perfusion. Extravasation of dye into the retroperitoneal field indicates injury of the left ureter,
which can then be repaired.
◆ It is not uncommon to encounter a tear in the splenic capsule during dissection, particularly
during thoracoabdominal reoperations, when one may find that dense adhesions have fused
the spleen and diaphragm. A very low threshold for performing splenectomy is necessary to
prevent dangerous postoperative splenic bleeding and ischemic sequelae.
Acknowledgments
The authors thank Dr. Peter Tsai for his contributions to the 2008 version of this chapter. They also thank
Scott A. Weldon for developing the medical illustrations and Stephen N. Palmer and Heather Leibrecht
for providing editorial support.
References
1. Coselli JS, LeMaire SA. Descending and thoracoabdominal aneurysms. In: Cohn LH, Adams DH, eds. Cardiac Surgery in the Adult.
5th ed. New York: McGraw-Hill; 2017:1075–1099.
2. Brockstein B, Johns L, Gewertz BL. Blood supply to the spinal cord: anatomic and physiologic correlations. Ann Vasc Surg.
1994;8:394–399.
3. Mastracci TM, Greenberg RK, Eagleton MJ, Hernandez AV. Durability of branches in branched and fenestrated endografts. J Vasc Surg.
2013;57:926–933.
4. Coselli JS, LeMaire SA. Left heart bypass reduces paraplegia rates after thoracoabdominal aortic aneurysm repair. Ann Thorac Surg.
1999;67:1931–1934.
5. Coselli JS, LeMaire SA, Koksoy C, et al. Cerebrospinal fluid drainage reduces paraplegia after thoracoabdominal aortic aneurysm
repair: results of a randomized clinical trial. J Vasc Surg. 2002;35:631–639.
6. Preventza O, Coselli JS, LeMaire SA. Technique of cerebrospinal fluid drainage. In: Franco KL, Thourani VH, eds. Cardiothoracic
Surgery Review. Philadelphia: Lippincott Williams & Wilkins; 2012:491–494.
7. Koeppel TA, Mess WH, Jacobs MJ. Motor evoked potentials in thoracoabdominal aortic surgery: PRO. Cardiol Clin. 2010;28:351–360.
8. Mess WH, Jacobs MJ. Regarding “Analysis of motor and somatosensory evoked potentials during thoracic and thoracoabdominal
aortic aneurysm repair”. J Vasc Surg. 2010;51:286–287; author reply 287.
9. Aftab M, Coselli JS. Renal and visceral protection in thoracoabdominal aortic surgery. J Thorac Cardiovasc Surg. 2014;148:2963–2966.
10. LeMaire SA, Jones MM, Conklin LD, et al. Randomized comparison of cold blood and cold crystalloid renal perfusion for renal
protection during thoracoabdominal aortic aneurysm repair. J Vasc Surg. 2009;49:11–19.
11. LeMaire SA, Jamison AL, Carter SA, et al. Deployment of balloon expandable stents during open repair of thoracoabdominal aortic
aneurysms: a new strategy for managing renal and mesenteric artery lesions. Eur J Cardiothorac Surg. 2004;26:599–607.
12. Coselli JS, Green SY, Price MD, et al. Results of open surgical repair in patients with Marfan syndrome and distal aortic dissection.
Ann Thorac Surg. 2016;101:2193–2201.
13. de la Cruz KI, LeMaire SA, Weldon SA, Coselli JS. Thoracoabdominal aortic aneurysm repair with a branched graft. Ann Cardiothorac
Surg. 2012;1:381–393.
14. Coselli JS, LeMaire SA, Carter SA, Conklin LD. The reversed elephant trunk technique used for treatment of complex aneurysms of
the entire thoracic aorta. Ann Thorac Surg. 2005;80:2166–2172.
15. Coselli JS, Bozinovski J, Cheung C. Hypothermic circulatory arrest: safety and efficacy in the operative treatment of descending and
thoracoabdominal aortic aneurysms. Ann Thorac Surg. 2008;85:956–963.
16. Kouchoukos NT, Masetti P, Murphy SF. Hypothermic cardiopulmonary bypass and circulatory arrest in the management of extensive
thoracic and thoracoabdominal aortic aneurysms. Semin Thorac Cardiovasc Surg. 2003;15:333–339.
17. Kouchoukos NT, Kulik A, Castner CF. Open thoracoabdominal aortic repair for chronic type B dissection. J Thorac Cardiovasc Surg.
2015;149:S125–S129.
18. Coselli JS, LeMaire SA, Preventza O, et al. Outcomes of 3309 thoracoabdominal aortic aneurysm repairs. J Thorac Cardiovasc Surg.
2016;151:1323–1338.
19. Wong DR, Coselli JS, Amerman K, et al. Delayed spinal cord deficits after thoracoabdominal aortic aneurysm repair. Ann Thorac Surg.
2007;83:1345–1355.
20. Coselli JS, Amarasekara HS, Green SY, et al. Open repair of thoracoabdominal aortic aneurysm in patients 50 years old and younger.
Ann Thorac Surg. 2017;103:1849–1857.
21. Coselli JS, Rosu C, Amarasekara HS, et al. Reoperative surgery on the thoracoabdominal aorta. J Thorac Cardiovasc Surg. 2017.
CHAPTER
27
Thoracic Endovascular
Aortic Repair for
Descending Thoracic
Aortic and Aortic
Arch Aneurysms
Ibrahim Sultan, Joseph E. Bavaria, and Wilson Y. Szeto
Summary
◆ Thoracic endovascular aortic repair (TEVAR) has become an effective treatment for various
descending thoracic aortic pathologic processes, including aortic aneurysm and dissection.
Although long-term outcome data for this therapy are not available, the short-term and
intermediate results have been promising. Long-term data is accumulating and appears to be
comparable to open surgery.
◆ Multiple devices have been investigated and approved in multicenter trials. Multiple iterations
and advance in endograft design have helped navigate anatomic limitations. With ongoing
improvements in imaging and with the development of branched endografts in particular,
surgeons will be able to offer endovascular therapy for the aortic arch and thoracoabdominal
aorta to an increased population of patients when appropriate.
◆ Beginning distal to the left subclavian artery, the descending thoracic aorta is the continuation
of the aortic arch. As it descends through the posterior mediastinum, the descending thoracic
aorta lies to the left of the vertebral bodies and gradually approaches the midline. At the level
of the 12th vertebra, it passes through the aortic hiatus in the diaphragm and becomes the
abdominal aorta (Fig. 27.1).
◆ Anterior branches of the descending thoracic aorta include bronchial and esophageal arteries.
These branches continue as the segmental arterial supply to their respective structures. Intercostal
arteries are posterior branches along the length of the descending thoracic aorta and provide
segmental arterial blood supply to the spinal cord.
455
Chapter 27 • TEVAR for Descending Thoracic Aortic and Aortic Arch Aneurysms455.e1
Abstract
Thoracic endovascular aortic repair (TEVAR) has become an effective treatment for various
descending thoracic aortic pathologic processes, including aortic aneurysm and dissection.
Although long-term outcome data for this therapy are not available, the short-term and intermediate
results have been promising. Long-term data is accumulating and appears to be comparable to
open surgery.
Keywords
aortic surgery
TEVAR
aorta
endovascular repair of the aorta
Figure 27.1
Chapter 27 • TEVAR for Descending Thoracic Aortic and Aortic Arch Aneurysms 457
◆ In most patients, a dominant anterior medullary artery, the artery of Adamkiewicz, arises
between levels T7 and L1 and provides most of the blood supply to the anterior spinal artery,
perfusing the anterior two-thirds of the spinal cord. Anteriorly, the intercostal arteries continue
along the inferior margins of the ribs and form collaterals with the internal thoracic arteries
located at the anterior chest wall.
◆ There are no major arterial branches in the descending thoracic aorta, enabling the treatment
of the entire descending thoracic aorta with TEVAR. The first major branch is the celiac artery,
which arises in the abdominal aorta to supply the upper gastrointestinal tract. However,
complete coverage of the entire descending thoracic aorta, including the left subclavian artery,
is associated with an increased risk of stroke and spinal cord ischemia.
◆ Careful preoperative planning with appropriate imaging is essential for TEVAR. Preoperative
assessment must address two important issues: anatomic requirements and vascular access.
The gold standard is computed tomography (CT) angiography of the thorax, abdomen, and
pelvis, with distal arterial runoffs. Thin-slice helical CT scanning with 2-mm slices is ideal
to create three-dimensional reconstructions of the aorta. In patients with contraindications
to intravenous contrast, magnetic resonance angiography is an acceptable alternative.
1. Anatomic Requirements
◆ Anatomic requirements center on the suitability of the proximal and distal landing zones.
TEVAR involves the deployment of an intraluminal endoprosthesis resulting in the exclusion
of the thoracic aneurysm. Therefore, the essential requirement is suitable proximal and distal
landing zones to achieve an adequate seal and prevent endoleaks.
◆ The evaluation for the suitability of the landing zones involves two major criteria, the length
of the zone and the aortic diameter. Although device-specific, the length of the landing zone
must be sufficient to achieve adequate exclusion. For most devices, the requirement is 2 cm
of aorta without significant tapering. The aortic diameter must safely accommodate a self-
expanding endovascular device. For aneurysmal disease, the device should be upsized (compared
with the diameter of the landing zone) by 10% to 20% to achieve adequate exclusion. Current
devices allow safe treatment for aortic diameters between 18 and 43 mm.
◆ For nonaneurysmal disease, such as dissection or traumatic transection, less aggressive upsizing
(< 10%) is generally recommended.

◆ Additional factors to consider in the evaluation of the landing zones include the presence of
thrombus, rapid tapering, calcification, tortuosity, and angulation (Fig. 27.2)

◆ Circumferential thrombus and extensive calcification at a landing zone may not allow adequate
seal, resulting in endoleaks.

◆ Minimal tapering of the aortic diameter over the length of the landing zone (< 15%), with
minimal tortuosity and angulation, are also desirable to ensure adequate exclusion.
◆ Angulation is often a proximal landing zone issue at the level of the distal arch. Severe angulation
may result in so-called bird-beaking of the endograft. These and other factors may require
extension of the proximal and distal landing zones. If coverage of the branch vessels is necessary
at the proximal or distal landing zone, an extraanatomic bypass such as a carotid artery–
subclavian artery bypass or mesenteric artery–visceral artery bypass, respectively, may be
necessary. However, branched endografts that are currently undergoing feasibility trials may
be appropriate in these settings in the future.
Straightforward Tortuous Angulated arch
Figure 27.2
2. Vascular Access
◆ A vascular complication is a major component of the morbidity and mortality rates associated
with TEVAR. Current devices require a large-caliber delivery system, typically ranging from
18 to 24 F outer diameter. Several device manufacturers are investigating low-profile devices
that would potentially decrease vascular complications.
◆ Preoperative imaging must include assessment of the iliofemoral vasculature. In addition to
diameter, factors such as excessive calcification, tortuosity, history of peripheral vascular

disease, and previous aortoiliac surgery may prevent safe delivery of the endograft.
◆ If severe peripheral occlusive disease is prohibitive to the safe delivery of the endograft,
endovascular balloon angioplasty may be performed preoperatively or concomitantly during

TEVAR before the introduction of the delivery devices.
◆ If femoral arterial access is inadequate, aortoiliac exposure through a retroperitoneal approach
may be required. Other access alternatives include the subclavian artery, carotid artery, direct
aortic approach, and transapical
3. Intraoperative Monitoring
◆ Patients undergoing TEVAR are at risk for neurologic complications, including stroke and
spinal cord ischemia. Intraoperative neuromonitoring using electroencephalography (EEG),
motor-evoked potentials (MEPs), and somatosensory-evoked potentials (SSEPs) should be
routinely used for patients undergoing TEVAR. Stroke is associated with wire manipulation
in the severely atherosclerotic aortic arch, and systemic heparinization should be attempted
before any wire manipulation in the arch.
◆ Spinal cord ischemia may result in temporary or permanent lower extremity paraplegia.
Factors such as the length of aortic coverage, previous abdominal aortic aneurysm repair,
occlusive aortoiliac disease, and coverage of the left subclavian artery may affect the collateral
arterial supply to the spinal cord and increase the risk of paraplegia.
◆ Intraoperative neuromonitoring may detect early evidence of spinal cord ischemia before a
reliable neurologic examination can be performed. Maneuvers such as volume expansion and
lumbar drainage should be used to prevent permanent paraplegia if intraoperative neuro-
monitoring suggests spinal cord ischemia.
◆ In patients with preoperative risk factors for spinal cord ischemia (i.e., previous abdominal
aortic aneurysm repair, occlusive aortoiliac disease, or total coverage of the descending thoracic
aorta), preemptive lumbar drainage should be considered.
1. Imaging
◆ The primary modality of intraoperative imaging for TEVAR is fluoroscopy. Using a fixed or
portable C-arm, fluoroscopy provides real-time imaging. Additional helpful features include
digital subtraction angiography (DSA) and road mapping.
◆ DSA allows subtraction and removal of background images such as bony structures to enhance
visualization of the object injected with contrast (e.g., descending thoracic aorta).
◆ Road mapping involves the transfer of a reference image superimposed onto a live image for
guidance during deployment of the device (Fig. 27.3A).

◆ Intravascular ultrasonography (IVUS) is an option for patients with renal insufficiency or any
other contraindication to intravenous contrast. Introduced from the femoral artery, IVUS
provides the advantage of direct intraluminal imaging, particularly in cases of dissection,
where the true and false lumens must be identified. Furthermore, intraoperative evaluation
of the aorta, particularly the landing zones, can be performed.
◆ Information regarding the characteristics of the landing zones, such as diameter and
the presence of thrombus, may be obtained and verified with preoperative imaging (see
Fig. 27.3B).
Celiac Superior Inferior

artery mesenteric mesenteric
B artery artery
Figure 27.3
2. Access
◆ For most patients, the common femoral artery provides adequate vascular access for deployment
of the endograft (Fig. 27.4A and B). A transverse incision is made at the level of the inguinal
ligament. The femoral artery is exposed, and proximal and distal control are obtained. An
18-G needle is used for direct puncture of the femoral artery, and a flexible guidewire (0.035-inch
Bentson wire; Boston Scientific, Natick, MA) is introduced retrograde to the aortic arch using
the Seldinger technique under fluoroscopy. Alternatively, percutaneous access of the femoral
artery can be used with percutaneous closure devices, which are becoming increasingly popular
among surgeons.
◆ Because of the angulation and tortuosity of the aortic arch, it is often difficult to deliver the
endograft with a flexible guidewire, and an extra-stiff guidewire (0.035-inch Lunderquist

wire; Cook Medical, Bloomington, IN) is often required. An extra-stiff guidewire should never
be introduced into the arch without a guide catheter because of the risk of rupture or dissection.
Therefore, a wire exchange maneuver is needed.
◆ Under fluoroscopy, a long guide catheter (100-cm MPA [multipurpose angle]; Cordis, Milpitas,
CA) is advanced to the arch over the flexible guidewire. Once in position, the MPA is secured,
and the flexible guidewire is removed. The Lunderquist wire is then advanced within the
MPA to the level of the aortic arch under fluoroscopy. The MPA is removed and the extra-stiff
guidewire is in position for deployment of the endograft.
◆ If the femoral artery is suboptimal for access, the iliac artery may be exposed with a retro-
peritoneal approach (see Fig. 27.4C). The iliac artery can be directly accessed using a technique
similar to that described for the femoral artery. A double purse string of 4-0 polypropylene
sutures is used to secure the vessel and provide hemostasis with the application of two sets
of tourniquets. Alternatively, a 10-mm Dacron graft can be sewn to the iliac artery as a conduit
for delivery of the endograft. The conduit may be brought through a separate counterincision
in the groin to allow for better angulation of the relatively long and stiff deployment device.
◆ A diagnostic catheter (5 F pigtail; Cordis) with multiple side holes is placed percutaneously
in the contralateral femoral artery. Standard percutaneous puncture with the Seldinger technique
is used, and a 5 F or 7 F introducer sheath (Cordis) may be placed for access. The pigtail
catheter is advanced to the aortic arch under fluoroscopy.
◆ Occasionally, brachial access is needed for coil embolization of the left subclavian artery to
create an adequate proximal landing zone if a carotid artery–subclavian artery bypass was
performed. Brachial access is also necessary for patients undergoing branched endograft
deployment. This is because precise deployment of the endograft at the left subclavian artery
or left common carotid artery can be facilitated with placement of the pigtail catheter through
a left brachial artery access.
◆ Brachial access can often be achieved percutaneously using the Seldinger technique with
placement of a 5 F introducer sheath. Systemic heparinization is recommended before any

wire manipulation in the arch.
Inguinal
ligament
Anterior
spine
Skin crease
Common
femoral artery
Profundus
artery
Saphenous
Superficial vein
A femoral artery Femoral vein C
Figure 27.4
3. Deployment of Endograft for Aneurysmal Disease
◆ Preoperative planning will have determined the number, size, and sequence of deployment
of the endografts. The total treatment length (coverage length) of the descending thoracic
aorta determines the length and number of endografts.
◆ The diameter of the endografts is determined by the diameter of the aortic landing zones.
Although there are device-specific variabilities, the endografts are generally deployed in a
proximal to distal sequence. However, if the proximal endograft is larger than the distal device,
or precise deployment is required at the celiac artery, it may be preferable to deploy the
endografts in a distal to proximal sequence.
◆ Under fluoroscopic guidance, the endograft is delivered to the proximal landing zone using
a stiff guidewire (Figs. 27.5 and 27.6)

◆ Devices may come with an introducer sheath or can be deployed directly with access into
the artery
◆ For optimal imaging of the arch and visualization of the brachiocephalic vessels, the C-arm
is placed in a left anterior oblique position of 45 to 50 degrees. Once the endograft is in

place, a diagnostic arteriogram is obtained to confirm the location of the aneurysm and
position of the endograft in relation to the landing zone. If satisfactory, the pigtail catheter is
withdrawn from behind the endograft, and the device is deployed. The mechanism of deploy-
ment is device specific, each with its own advantages and disadvantages. Road mapping may
be used to facilitate precise deployment of the endograft. To deploy a second endograft, it is
exchanged with the first device over the Lunderquist guidewire (Fig. 27.7).
◆ If precise deployment at the celiac artery is necessary, the C-arm is placed in a full lateral
position for optimal imaging, and a second diagnostic angiogram is obtained.

◆ Similar to the proximal device, the distal endograft is advanced to the appropriate landing
zone with the use of angiography and road mapping. Once a satisfactory position has been
achieved, the endograft is deployed. Adequate overlap of the devices is necessary to prevent
junctional, or type III, endoleaks. Although overlaps are device specific, a minimum overlap
of 5 cm is recommended.
◆ Ballooning of the landing zones and the junction between endografts is device specific, but
it is generally recommended that optimal apposition of the endografts be achieved to prevent

endoleaks. Under fluoroscopic guidance, a compliant balloon is advanced to the appropriate
location and inflated. Overly aggressive ballooning may result in aortic dissection or stent
fractures. In general, the ballooning is performed in a proximal to distal sequence, with final
ballooning at the junctions.
Figure 27.5
A B C
Figure 27.6
Celiac
Distal stent
SMA
Figure 27.7
◆ Once all ballooning has been completed, and the positions of the endografts are satisfactory,
a completion angiography is performed (Fig. 27.8). The previously withdrawn diagnostic
pigtail catheter is advanced into the aortic arch under fluoroscopic guidance.
◆ Completion angiography is performed to examine for endograft migration and endoleaks. If
an endoleak is detected, treatment such as ballooning or placement of additional devices

should be performed. If all is satisfactory, the delivery system is withdrawn from the access
vessel. The Lunderquist guidewire is left in place in case of vascular injury or avulsion. By
retaining wire access, an occlusive balloon can be advanced over the Lunderquist wire to
achieve proximal control, if necessary. Once the surgeon is confident that there is no vascular
injury, the Lunderquist guidewire is removed and the access vessel repaired. If there is concern
over iliac rupture or dissection, a retrograde aortoiliac angiogram should be obtained.
◆ If a subclavian artery–carotid artery bypass was previously performed, coil embolization of
the proximal left subclavian artery can be carried out.
4. Subclavian Revascularization
◆ The proximal aorta and the aortic arch is divided into landing zones, as illustrated in Fig.
27.9. Landing zones Z0, Z1, and Z2 involve coverage of brachiocephalic vessels and require
extraanatomic bypasses.
◆ Most commonly, Z2 deployment of the endograft is required to ensure a suitable proximal
landing zone, necessitating a left subclavian transposition or a carotid artery–subclavian artery

bypass before TEVAR.
◆ At our institution, bypass is preferred because transposition requires a more proximal exposure
of the subclavian artery. In the setting of a thoracic aneurysm, the anatomy of the proximal
left subclavian artery can be distorted. However, a left subclavian artery–carotid artery bypass
requires a concomitant coil embolization of the proximal subclavian artery at the time of the
thoracic endografting procedure to prevent the development of a type II endoleak. As described
earlier, this can be accomplished through left brachial access at the time of TEVAR.
◆ The procedure is carried out through a supraclavicular approach to the left subclavian and
common carotid arteries.

◆ An incision is made approximately 1 to 2 cm superior to the clavicle (Fig. 27.10A). Along
with the sternocleidomastoid and omohyoid muscles, the platysma is divided with electrocautery.
The anterior scalene muscle is identified, with the phrenic nerve coursing across the muscle
fibers. Along with the phrenic nerve, the thoracic duct should be identified, and care should
be taken to avoid injury to both structures. The subclavian artery can be found deep to the
anterior scalene muscle. The vertebral and internal mammary arteries are identified.
◆ Proximal and distal dissection are performed; vessel loops may be used for vascular control
(see Fig. 27.10B). With medial retraction of the internal jugular vein, the common carotid
artery is exposed. Vessel loops may also be used for vascular control and to optimize exposure
of the common carotid artery. Systemic heparinization should be achieved before occlusion
of the vessels.
◆ With the clamps in place, arteriotomies are performed in both the common carotid and left
subclavian arteries (see Fig. 27.10C).

◆ It is important to construct the synthetic graft—expanded polytetrafluoroethylene (ePTFE)
or Dacron—with the correct length and configuration to avoid tension or kinking. The
anastomoses are performed using running 5-0 polypropylene sutures.
◆ Once completed, the clamps are removed after de-airing, and the anastomoses are examined
for hemostasis. Once the surgeon is satisfied, the wound is closed in the appropriate anatomic
layers.
Coil embolization
of left subclavian
artery Z1 Z2
Carotid to
subclavian
bypass Z3
Z0
Z4
A B
A B C
Figure 27.10
5. Endograft Deployment in Aortic Dissection
◆ Complicated acute type B aortic dissections (TBAD) can be managed with thoracic endografts.
The goal in these patients is to cover the primary tear site to prevent further malperfusion
and reexpansion of the true lumen (Fig. 27.11). Further use of bare metal stents may be
necessary if malperfusion persists after coverage of the primary tear site (Fig. 27.12). This
can occur because of multiple fenestrations and reentry sites throughout the thoracoabdominal
aorta. Coverage of the left subclavian artery may be necessary in many patients because the
primary tear site typically occurs close to the origin of the left subclavian artery (Fig. 27.13).
Open surgical repair in these patients carries significant morbidity and mortality.
◆ Chronic TBAD, which can be operated on for aneurysmal expansion, can be approached with
open and endovascular repair. Endovascular repair in chronic type B patients can be challenging;
it is important to identify anatomic characteristics on a CT scan that would lead patients to
a successful repair with aortic remodeling.
◆ The use of IVUS is critical in patients with aortic dissection to identify and confirm the true
lumen. IVUS may also help identify mesenteric branches that may be involved in the dissection
(Fig. 27.14).
6. Hybrid Arch Repair and Branched Endografts
◆ Surgical management of aortic arch aneurysms remains a challenge, requiring deep hypothermic
circulatory arrest (DHCA) and a cerebral perfusion strategy. The success of an endovascular
technique in the management of descending thoracic aortic aneurysms has led to the develop-
ment of hybrid procedures for aortic arch aneurysm repair. The hybrid total arch repair
involves open brachiocephalic bypass (debranching procedure) with concomitant endovascular
arch stent grafting. In contrast to traditional open total arch repair, these hybrid procedures
have the advantages of avoiding DHCA and possible cardiopulmonary bypass (CPB).
◆ Midterm outcomes for these procedures have been encouraging.
◆ Hybrid arch repairs can be performed as concomitant or staged procedures. The patient is
placed in a supine position, and a partial upper sternotomy or full sternotomy may be used
for adequate exposure of the arch. Neuromonitoring with continuous EEG is used for the
detection of neurologic events throughout the operation, as per our standard arch protocol.
◆ Based on exposure and the size of the arch aneurysms, CPB and aortic occlusion may be
necessary to perform the proximal anastomosis of the brachiocephalic bypass.

◆ The goal is to create an adequate proximal landing zone in the ascending aorta for the
concomitant arch stent graft deployment. This often requires the proximal anastomosis of the
brachiocephalic bypass to be performed at the level of the sinotubular junction.
◆ Because of the limited length of the ascending aorta, the aortic and cardioplegia cannulae are
placed in full recognition of the location of both the proximal anastomosis of the brachiocephalic
bypass and proximal landing zone of the arch stent graft. If adequate aortic length is present,
a side-biting clamp can be placed at the level of the ascending aorta during the proximal
anastomosis, and CPB may be avoided. A modified trifurcated Dacron graft with an additional
fourth branch for stent graft deployment (Vascutek-Terumo, Ann Arbor, MI) is used for the
brachiocephalic bypass to the great vessels.
Correction
of malperfusion
with bare metal stent
True True
lumen lumen
False False
lumen lumen
Continued
Intimal malperfusion of
tear right common
iliac artery
A B
Left carotid
artery
Left
Proximal subclavian
tear site artery
Thrombus
Carotid to
Stent-graft subclavian
bypass
Perfused
false
lumen
LIMA to LAD

◆ The proximal anastomosis to the ascending aorta is performed as proximally as possible, just
distal to the sinotubular junction, to allow deployment of the stent graft in the ascending
aorta without compromise to the proximal inflow anastomosis. (The average length of the
ascending aorta from the sinotubular junction to the innominate artery is 6 to 7 cm, thus
allowing an optimal 3 to 4 cm proximal landing zone.) The proximal reconstruction of the
brachiocephalic bypass can be performed as an aortic patch or interposition graft. Once the
anastomosis is completed, the distal end-to-end anastomoses of the trifurcated grafts to the
arch vessels are performed from left to right with sequential clamping—first the left subclavian,
then the left common carotid, and finally the innominate artery anastomoses are performed.
The proximal takeoff of each arch vessel is detached.
◆ Deployment of the stent graft is achieved antegrade through the fourth arm of the modified
trifurcated graft or retrograde through the femoral artery. The technical aspects of deployment
of the device are similar to those for TEVAR in the descending thoracic aorta, as described
in the previous section. Fluoroscopic guidance is required for precise deployment of the aortic
stent graft. We have proposed a classification of hybrid arch repairs in the past whereby
brachiocephalic revascularization is followed by endograft deployment in an antegrade or
retrograde fashion (Fig. 27.15).
Endo-
graft
Delivery
sheath
A B C
Arch Hybrid Vascutek Graft
Endograft
Delivery
sheath
D E
Figure 27.15
◆ Feasibility studies for branched endografts began enrolling in the recent past, and the early
results appear to be promising. The advantage of such a procedure is to minimize open
surgery, particularly left subclavian revascularization. This allows the surgeon to deploy the
endograft in zone 2 with left subclavian patency. Alternatively, following left subclavian
revascularization, the endograft can be deployed in zone 1 with the branched graft perfusing
the left carotid artery (Fig. 27.16).
◆ Postoperative care of the patient undergoing TEVAR involves the standard resuscitation protocol
used with any major cardiovascular operation.
◆ Hemodynamic monitoring is recommended in an intensive care unit setting. Because of the
lack of an aortic suture line, higher blood pressure may be tolerated postoperatively to optimize
spinal cord perfusion.
◆ Patients should also be allowed to emerge from anesthesia expeditiously for early neurologic
assessment. If spinal cord ischemia is suspected, immediate salvage maneuvers, including

spinal drainage, hypertension, and volume expansion, should be used.
◆ Success with TEVAR requires extensive preoperative planning, with regard not only to device
selection, but to comprehensive evaluation of vascular access–related issues. Size, tortuosity,
and calcification of the iliofemoral vasculature must be carefully examined.
◆ In the event of iliofemoral injury (Fig. 27.17A), the surgeon must be able to address this
potentially lethal complication expeditiously. The importance of maintaining wire access until
the integrity of the iliofemoral vasculature is ensured cannot be overemphasized.
◆ Device selection as well as the technical considerations of deployment must be carefully
planned. Thorough evaluation of the proximal landing zone is required to prevent bird-beaking
of the device (see Fig. 27.17B).
Zone 2 Zone 1 Zone 0
Figure 27.16
Iliac artery avulsion
Type I endoleak
B C
Figure 27.17
◆ Also, incorrect sizing of the device can have catastrophic consequences. For aneurysms, the
recommendation is upsizing 10% to 20% based on the true diameter on cross-sectional
examination of the aorta. Downsizing may result in inadequate exclusion, predisposing the
patient to endograft migration or endoleak (see Fig. 27.17C). Aggressive upsizing should also
be discouraged because device collapse is a potential complication (Fig. 27.18). Another
possible complication is aortic dissection (Fig. 27.19). Aggressive ballooning may result in
the development of aortic dissection and should also be avoided.
◆ Finally, if multiple devices are deployed, it is crucial to allow adequate overlap to prevent the
development of junctional, or type III, endoleaks (Fig. 27.20).

Retrograde
type A aortic
B dissection
Figure 27.18
C
Figure 27.19
Figure 27.20
Bibliography
1. Appoo JJ, Moser WG, Fairman RM, et al. Thoracic aortic stent grafting: improving results with newer generation investigational
devices. J Thorac Cardiovasc Surg. 2006;131:1087–1094.
2. Bavaria JE, Appoo JJ, Makaroun MS, et al. Endovascular stent grafting versus open surgical repair of descending thoracic aortic
aneurysms in low-risk patients: a multicenter comparative trial. J Thorac Cardiovasc Surg. 2007;133:369–377.
3. Bavaria JE, Vallabhajosyula P, Moeller P, et al. Hybrid approaches in the treatment of aortic arch aneurysms. Postoperative and
midterm outcomes. J Thorac Cardiovasc Surg. 2013;145:S85–S90.
4. Brinkman WT, Szeto WY, Bavaria JE. Stent graft treatment for transverse arch and descending thoracic aorta aneurysms. Curr Opin
Cardiol. 2007;22:510–516.
5. Cheung AT, Pochettino A, McGarvey ML, et al. Strategies to manage paraplegia risk after endovascular stent repair of descending
thoracic aortic aneurysms. Ann Thorac Surg. 2005;80:1280–1288.
6. Chuter TA, Buck DG, Schneider DB, et al. Development of a branched stent-graft for endovascular repair of aortic arch aneurysms. J
Endovasc Ther. 2003;10:940–945.
7. Desai ND, Burtch K, Moser W, et al. Long-term comparison of thoracic endovascular aortic repair (TEVAR) to open surgery for the
treatment of thoracic aortic aneurysms. J Thorac Cardiovasc Surg. 2012;144:604–609.
8. Eggebrecht H, Nienaber CA, Neuhauser M, et al. Endovascular stent-graft placement in aortic dissection: a meta-analysis. Eur Heart J.
2006;27:489–498.
9. Fattori R, Nienaber CA, Rousseau H, et al. Results of endovascular repair of the thoracic aorta with the Talent Thoracic stent graft: the
Talent Thoracic Retrospective Registry. J Thorac Cardiovasc Surg. 2006;132:332–339.
10. Gutsche JT, Cheung AT, McGarvey ML, et al. Risk factors for perioperative stroke following thoracic endovascular aortic repair. Ann
Thorac Surg. 2007;84:1195–1200.
11. Leshnower BG, Szeto WY, Pochettino A, et al. Thoracic endografting reduces morbidity and remodels the thoracic aorta in Debakey
III aneurysms. Ann Thorac Surg. 2013;95:914–921.
12. Mitchell RS, Miller DC, Dake MD, et al. Thoracic aortic aneurysm repair with an endovascular stent graft: the “first generation.”. Ann
Thorac Surg. 1999;67:1971–1974.
13. Sultan I, Atluri P. Total endovascular arch replacement: are we there yet? Are we there yet?… J Thorac Cardiovasc Surg.
2016;151:1213–1214.
14. Suzuki T, Mehta RH, Ince H, et al. Clinical profiles and outcomes of acute type B aortic dissection in the current era: Lessons from
the International Registry of Aortic Dissection (IRAD). Circulation. 2003;108(suppl 1):II312–II317.
15. Szeto WY, Bavaria JE, Bowen FW, et al. The hybrid total arch repair: brachiocephalic bypass and concomitant endovascular aortic
arch stent graft placement. J Card Surg. 2007;22:97–102.
16. Szeto WY, Bavaria JE. Hybrid repair of aortic arch aneurysms: combined open arch reconstruction and endovascular repair. Semin
17. Vallabhajoysula P, Szeto WY. Current paradigms in aortic arch repair: Striking the balance between open surgery and endovascular
repair. J Thorac Cardiovasc Surg. 2015;150:1399–1400.
18. Wheatley GH 3rd, Gurbuz AT, Rodriguez-Lopez JA, et al. Midterm outcome in 158 consecutive Gore TAG thoracic endoprostheses:
single-center experience. Ann Thorac Surg. 2006;81:1570–1577.
V·
'
SECTION
Miscellaneous
Operations
CHAPTER
28
Surgery for Atrial

Fibrillation
Hoda Javadikasgari, Edward G. Soltesz, and A. Marc Gillinov
Atrial Fibrillation
◆ Atrial fibrillation (AF) is a supraventricular tachyarrhythmia that is projected to affect 12

million patients in the United States by 2050; prevalence is increased in older people and in
patients with hypertension, heart failure, coronary artery disease (CAD), valvular heart disease,
obesity, diabetes mellitus, and chronic kidney disease (CKD).1 AF is present in up to 50% of
patients undergoing mitral valve surgery and also in 1% to 6% of patients presenting for
coronary artery bypass graft (CABG) surgery.2
◆ Hemodynamic consequences of AF result from uncoordinated atrial contraction, suboptimal
ventricular filling, and sympathetic activation.3 The mechanisms of AF vary among affected
individuals and so, too, do clinical presentations.4 In patients with mitral stenosis, hypertension,
hypertrophic cardiomyopathy (HCM), or restrictive cardiomyopathy, diastolic ventricular filling
is already impaired, and loss of atrial contraction caused by concomitant AF may markedly
decrease cardiac output.5 AF is an independent risk factor for cardiac mortality and morbidity
and is associated with reduced early and long-term survival and a fivefold increased risk of
stroke.2
◆ Although left atrial enlargement, longer duration of AF, and advanced age have been associated
with reduced success, they do not contraindicate surgical ablation.6 The 2012 Expert Consensus
Statement on Catheter and Surgical Ablation of Atrial Fibrillation has recommended consideration
of AF ablation in all patients with symptomatic AF undergoing other cardiac surgery (Class
IIa, level of evidence C). The guidelines also suggest consideration of stand-alone AF surgery
for symptomatic AF patients who prefer a surgical approach, who have failed one or more
attempts at catheter ablation, or who are not candidates for catheter ablation (Class IIb, level
of evidence C).7
479
Chapter 28 • Surgery for Atrial Fibrillation479.e1
Abstract
Untreated atrial fibrillation is associated with increased morbidity and decreased early and late
survival. Biatrial lesion set of the Cox-Maze procedures, including wide pulmonary vein isolation,
a mitral isthmus lesion, and right atrial lesions is the most successful approach. In addition,
surgical ablation includes exclusion of the left atrial appendage. Herein, we discuss the current
status of atrial fibrillation surgery as a concomitant or standalone procedure.
Keywords
atrial fibrillation
Cox-Maze
left atrial appendage
480 Section V • Miscellaneous Operations
◆ The pulmonary veins and posterior left atrium are the critical anatomic sites in patients with
isolated AF. However, some patients also manifest right atrial focal or reentrant activation.
Around 60% of AF is paroxysmal AF, which is initiated by focal pulmonary vein or atrial
triggers. The remaining 40% of AF is classified as persistent or long-standing persistent AF
and is due to well-established, self-perpetuating, macroreentrant circuits that generally have
little or nothing to do with these focal atrial or pulmonary vein triggers.8 Data from the Society
of Thoracic Surgeons (STS) database have demonstrated that preoperative AF is present in
11% of patients presenting for nonemergent, first-time cardiac surgery.9 In patients with
concomitant AF secondary to left heart pathology (e.g., mitral valve disease, aortic valve
disease, CAD), the mechanism of concomitant persistent and long-standing persistent AF
may not be due to pulmonary vein triggers alone, and simple pulmonary vein isolation may
not be adequate. Although controversial, most authorities have agreed that persistent and
long-standing persistent AF, whether stand-alone or concomitant, requires additional linear
lesions to accompany pulmonary vein isolation to attain long-term freedom from AF.8
◆ Routine real-time intraoperative mapping is currently not available to guide AF ablation in
cardiac surgery patients. Therefore, an anatomic approach is the foundation for the surgical
ablation of AF.
◆ The two settings in which cardiac surgeons encounter patients seeking ablation of AF are AF
in patients undergoing concomitant cardiac surgery and isolated AF as an indication for a
stand-alone procedure.
◆ In the concomitant setting, ablation is usually performed in patients with mitral valve disease
and AF. Almost all such patients should have a combined procedure that includes correction
of the mitral valve dysfunction and ablation of AF. An exception might be made in a very
high-risk patient undergoing a complex and lengthy reoperative procedure; in that case, it
might be prudent to close the left atrial appendage (LAA) but forgo ablation to minimize
cross-clamp time.
◆ Stand-alone surgical ablation is uncommon, and there are few data documenting long-term
results of newer, less invasive procedures. Stand-alone surgical ablation is indicated in the
following cases: (1) patients who fail medical therapy and catheter ablation; (2) patients who
fail medical therapy and have contraindications to catheter ablation (e.g., left atrial thrombus,
discontinuous inferior vena cava, contraindication to warfarin); and (3) selected highly
symptomatic individuals who desire the procedure with the highest probability of success.
Surgical approaches in these patients include the full Cox-Maze IV procedure performed on
cardiopulmonary bypass or an off-pump procedure centered on bilateral pulmonary vein
isolation, generally incorporating additional lesions. Long-term results of the Cox-Maze IV
operation suggest 2-year freedom from AF of 65% to 85%.10-12 In patients with left atrial
thrombus, the Cox-Maze IV procedure with cardiopulmonary bypass is indicated because
less invasive, off-pump approaches may result in the dislodgment of thrombus.
Chapter 28 • Surgery for Atrial Fibrillation 481
◆ The Maze procedure is the gold standard for the surgical treatment of AF and is the most
effective curative therapy for AF yet devised.13,14 This procedure includes isolation of the
pulmonary veins and multiple left and right lesions to interrupt the reentrant circuits of AF,
as well as excision or exclusion of the LAA to reduce the risk of thromboembolism. A left
atrium-based procedure that includes an encircling lesion around all four pulmonary veins
with a lesion to the mitral annulus eliminates AF in 60% to 90% of mitral valve patients.15
The addition of right atrial lesions in these patients is simple and likely increases the rate of
cure while simultaneously decreasing the risk of typical right atrial flutter.16,17 Therefore, AF
ablation should probably entail treatment of both atria whenever feasible.15
1. Isolation of Pulmonary Veins
◆ Pulmonary vein isolation is most easily performed on the arrested decompressed heart. After
establishing cardiopulmonary bypass via bicaval cannulation, the aorta is cross-clamped and
the heart is arrested. The posterior surface of the right and left pulmonary veins is bluntly
dissected. Beginning from the right pulmonary veins, a bipolar radiofrequency (RF) clamp
(AtriCure, West Chester, OH) is positioned around the pulmonary veins and advanced toward
the left atrium to isolate as much atrial tissue as possible (Fig. 28.1A). Four overlapping
ablation lines are created on the left atrium proximal to the left atrium–pulmonary vein
junction.
◆ The heart is retracted to the right to expose the left pulmonary veins. The same procedure
is performed using the bipolar RF clamp (see Fig. 28.1B). As before, four overlapping lesions
are created on the left atrial tissue proximal to the pulmonary vein orifice to avoid pulmonary
vein stenosis.
2. Left Atrial Lesions
◆ The procedure for left-sided lesions is performed on the arrested heart through a standard
left atriotomy anterior to the right pulmonary veins. To complete the so-called box lesion in
the posterior left atrium, connecting lesions between the right and left pulmonary veins are
created with the RF clamp (see Fig. 28.1C and D). For each connecting lesion, one jaw of
the clamp is placed inside the heart, and one jaw rests on the epicardial surface of the atrium.
Each of these lesions entails the creation of two overlapping lesions, which generally suffices
for the relatively thin atrium in these regions.
C D
Figure 28.1
Figure 28.1 Box lesions in left atrium. (A) Isolation of right pulmonary veins. (B) Isolation of left pulmonary veins. (C) Connection
lesions between inferior pulmonary veins. (D) Connection lesions between superior pulmonary veins.
◆ The left atrial isthmus lesion is then created using both a bipolar RF clamp and a cryoprobe.
This is a connecting lesion from the right inferior pulmonary vein to the P3 region of the
mitral annulus. The first part of the lesion is created with bipolar RF, with the clamp angled
toward the P3 segment of the mitral valve (Fig. 28.2A). At the mitral annulus, the lesion is
completed with a cryoprobe. The coronary sinus and mitral annulus are sandwiched by creating
overlapping cryolesions on the endocardial and epicardial aspects, thereby ensuring a transmural
lesion (see Fig. 28.2B).
3. Right Atrial Lesions
◆ The right atrial lesion set includes an intercaval lesion, T lesion to the tricuspid annulus, and
lateral right atrial lesion from this T lesion to the tip of the right atrial appendage. The
intercaval lesion is created between the superior vena cava and inferior vena cava, avoiding
the sinoatrial node. The lesions to the tricuspid annulus are created with a cryoprobe. Care
is taken at this point to avoid contact between the cryoprobe and phrenic nerve (Fig. 28.3).
These three lesions can be placed in a matter of minutes during the rewarming phase of the
operation with the patient still on cardiopulmonary bypass and the cross-clamp removed.
4. Left Atrial Appendage
◆ Between 60% and 90% of strokes in AF patients originate from the LAA. Therefore, management
of the LAA is mandatory and requires its complete isolation. If the LAA is excised, the residual
stump must be less than 1 cm in length. New epicardial occlusion devices enable safe, rapid,
and complete LAA exclusion. Suture exclusion of the LAA is generally less successful because
recurrent communication between the LAA and left atrium is frequent.18
A B
Figure 28.2
Figure 28.3
Figure 28.2 Left atrial isthmus lesion. (A) Radiofrequency. (B) Cryoablation.
Figure 28.3 Right atrial lesions.

Step 4. Choice of Lesion Set
◆ The discussion about the correct surgical approach for each patient with AF begins with the
lesion set. Although we do not have the ability to tailor the AF ablation strategy for each
individual, recent studies have suggested that the biatrial Cox-Maze IV procedure for all
patients with AF in the concomitant setting is the most successful technique.19-21
1. Mitral Valve Surgery
◆ Because the left atrium is opened for mitral valve procedures, the full Maze procedure should
be performed for all mitral valve patients, regardless of the type of AF. In patients with left
atrial enlargement (> 6 cm), widely placed lesions or left atrial reduction may increase the
chance of sinus rhythm restoration.22
2. Coronary Artery Bypass Graft
◆ Many surgeons are reluctant to open the left atrium when performing AF ablation in patients
undergoing an isolated CABG procedure. Several reports have documented good results with
left atrial lesions alone.21,23 However, a subsequent meta-analysis of 5885 patients has dem-
onstrated superior long-term freedom from AF in patients receiving lesions in both atria.16
◆ It is important to remember that adding a Maze procedure only minimally increases cross-
clamp and cardiopulmonary bypass times and does not increase morbidity or mortality in
patients undergoing a CABG procedure.24 The consensus is that isolation of the pulmonary
veins with LAA management is recommended for high-risk patients or patients with paroxysmal
AF. A complete biatrial Maze procedure and LAA treatment are recommended for CABG
patients with persistent or long-standing persistent AF.
3. Aortic Valve Surgery
◆ These patients should be handled in exactly the same manner as those undergoing a CABG
procedure and concomitant AF surgery. If the patient has concomitant paroxysmal AF, pulmonary
vein isolation with LAA management is sufficient. If the patient has concomitant persistent
or long-standing persistent AF, the surgeon is faced with the same dilemma as mentioned
previously in regard to whether or not to open the left atrium to perform a full Maze procedure,
which is the strategy most likely to treat AF successfully.
4. Stand-Alone Atrial Fibrillation
◆ When the surgeon performs ablation of AF as a stand-alone procedure, options range from
the Cox-Maze IV procedure to a variety of minimally invasive procedures. Minimally invasive
procedures may include unilateral or bilateral thoracoscopic approaches, or unilateral or
bilateral minithoracotomies.15
◆ A full Cox-Maze IV lesion set can be created through a 6-cm right thoracotomy (Fig. 28.4A),
with the heart arrested after establishing cardiopulmonary bypass through peripheral bicaval
cannulation (see Fig. 28.4B). The approach is endocardial and biatrial and may use one of
several different alternative energy sources.
◆ Common early postoperative arrhythmias include AF, atrial flutter, and junctional bradycardia.
Postablation AF occurs in 30% to 60% of patients; however, by 3 months after surgery, up
to 85% of these patients have returned to normal sinus rhythm. When AF or flutter develops,
an in-hospital trial of antiarrhythmic agents or electrical cardioversion is indicated. Permanent
pacemakers should not be placed for bradycardia until at least 1 week after ablation because
the return of sinus node function may take several days.
◆ Preoperative beta blockers should be continued in all patients who do not have a contraindica-
tion. Additional antiarrhythmic medication is recommended for patients with postablation

AF for 4 to 6 weeks. All patients are discharged on warfarin for 3 months with a target
international normalized ratio (INR) of 2.0. If a patient has no AF on a long-term monitor
determined at 3 months, no left atrial spontaneous echocardiographic contrast (or “smoke”)
on echocardiography, a well-controlled LAA, and no other indication for anticoagulation, we
believe that it is reasonable to discontinue warfarin. Electrical cardioversion is attempted at
3 months postoperatively for patients who remain in AF.
◆ A biatrial lesion set has the greatest probability of success in AF treatment. The LAA should
be removed or carefully excluded in all patients undergoing surgical ablation. Early postoperative
arrhythmias are common and do not indicate failure. Advances necessary to improve AF
ablation in cardiac surgical patients include the use of uniform definitions and methodology
for reporting results, improved technology to facilitate ablation and its intraoperative assessment,
and refinement of minimally invasive procedures.
B
Figure 28.4
Figure 28.4 (A) Right thoracotomy. (B) The heart is arrested after establishing cardiopulmonary bypass through peripheral bicaval cannulation.
References
1. Go AS, Mozaffarian D, Roger VL, et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart
disease and stroke statistics—2014 update: a report from the American Heart Association. Circulation. 2014;129:e28–e292.
2. Gillinov AM, Gelijns AC, Parides MK, et al; CTSN Investigators. Surgical ablation of atrial fibrillation during mitral-valve surgery. N
Engl J Med. 2015;37:1399–1409.
3. Hsu L-F, Jais P, Sanders P, Garrigue S, et al. Catheter ablation for atrial fibrillation in congestive heart failure. N Engl J Med.
2004;351:2373–2383.
4. Nabauer M, Gerth A, Limbourg T, et al. The Registry of the German Competence NETwork on Atrial Fibrillation: patient
characteristics and initial management. Europace. 2009;11:423–434.
5. Williams L, Frenneaux M. Syncope in hypertrophic cardiomyopathy: mechanisms and consequences for treatment. Europace.
2007;9:817–822.
6. Gillinov M, Soltesz E. Surgical treatment of atrial fibrillation: today’s questions and answers. Semin Thorac Cardiovasc Surg.
2013;25:197–205.
7. Calkins H, Kuck KH, Cappato R, et al. 2012 HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of
Atrial Fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions,
endpoints, and research trial design. Europace. 2012;14:528–606.
8. Cox JL. A brief overview of surgery for atrial fibrillation. Ann Cardiothorac Surg. 2014;3(1):80–88.
9. Ad N, Suri RM, Gammie JS, et al. Surgical ablation of atrial fibrillation trends and outcomes in North America. J Thorac Cardiovasc
Surg. 2012;144:1051–1060.
10. Weimar T, Bailey MS, Watanabe Y, et al. The Cox-maze IV procedure for lone atrial fibrillation: a single center experience in 100
consecutive patients. J Interv Card Electrophysiol. 2011;31:47–54.
11. Ad N, Henry L, Hunt S. Current role for surgery in treatment of lone atrial fibrillation. Semin Thorac Cardiovasc Surg. 2012;24:42–50.
12. Gillinov M, Moskowitz AJ, Argenziano M. Surgical ablation for atrial fibrillation. N Engl J Med. 2015;373:484.
13. Cox JL, Schuessler RB, Boineau JP. The development of the Maze procedure for the treatment of atrial fibrillation. Semin Thorac
14. McCarthy PM, Gillinov AM, Castle L, et al. The Cox-maze procedure: the Cleveland Clinic experience. Semin Thorac Cardiovasc Surg.
2000;12:25–29.
15. Saltman AE, Gillinov AM. Ablation of atrial fibrillation with cardiac surgery. Semin Thorac Cardiovasc Surg. 2007;191:25–32.
16. Barnett SD, Ad N. Surgical ablation as treatment for the elimination of atrial fibrillation: a meta-analysis. J Thorac Cardiovasc Surg.
2006;131:1029–1035.
17. Calò L, Lamberti F, Loricchio ML, et al. Left atrial ablation versus biatrial ablation for persistent and permanent atrial fibrillation: a
prospective and randomized study. J Am Coll Cardiol. 2006;47:2504–2512.
18. Lee R, Vassallo P, Kruse J, et al. A randomized, prospective pilot comparison of 3 atrial appendage elimination techniques: internal
ligation, stapled excision, and surgical excision. J Thorac Cardiovasc Surg. 2016;152:1075–1080.
19. Tilz RR, Rillig A, Thum A-M, et al. Catheter ablation of long-standing persistent atrial fibrillation: 5-year outcomes of the Hamburg
Sequential Ablation Strategy. J Am Coll Cardiol. 2012;60:1921–1929.
20. Gillinov AM. Choice of surgical lesion set: answers from the data. Ann Thorac Surg. 2007;84:1786–1792.
21. Gillinov AM, Bhavani S, Blackstone EH, et al. Surgery for permanent atrial fibrillation: impact of patient factors and lesion set. Ann
Thorac Surg. 2006;82:502–514.
22. Scherer M, Dzemali O, Aybek T, et al. Impact of left atrial size reduction on chronic atrial fibrillation in mitral valve surgery. J Heart
Valve Dis. 2003;12:469–474.
23. Gaita F, Riccardi R, Caponi D, et al. Linear cryoablation of the left atrium versus pulmonary vein cryoisolation in patients with
permanent atrial fibrillation and valvular heart disease correlation of electroanatomic mapping and long-term clinical results.
Circulation. 2005;111:136–142.
24. Gammie JS, Haddad M, Milford-Beland S, et al. Atrial fibrillation correction surgery: lessons from the Society of Thoracic Surgeons
National Cardiac Database. Ann Thorac Surg. 2008;85:909–914.
CHAPTER
29
Surgery for Hypertrophic

Cardiomyopathy
Dustin Hang and Hartzell V. Schaff
◆ Knowledge of the anatomy involved with hypertrophic cardiomyopathy (HCM) is paramount

in understanding the pathophysiology that ultimately contributes to dynamic subaortic
obstruction.
◆ HCM is defined as left ventricular (LV) hypertrophy in the absence of another underlying
cause, such as aortic valve stenosis, systemic hypertension, or metabolic disorders, such as
Fabry disease or amyloidosis.1
◆ Septal hypertrophy and systolic anterior motion (SAM) of the anterior mitral leaflet combine
to produce LV outflow obstruction, as well as mitral valve regurgitation in varying degrees.

Previously, LV outflow tract (LVOT) obstruction was thought to be present in a minority of
patients, but it is common in symptomatic patients with HCM.
◆ Patients display varying degrees and distribution of LV hypertrophy, ranging from the anterior
basal septum (most common) to the apex (Fig. 29.1). Midventricular obstruction may occur
if the hypertrophied septum comes into contact with the papillary muscles.
◆ Dynamic SAM of the mitral leaflets contributes to obstruction by narrowing the LVOT. The
mechanism is thought to be due to the Venturi effect in the LVOT.2 In addition, one study
has documented increased lengths of the mitral leaflets in HCM; a ratio of anterior mitral
leaflet length to LVOT diameter more than 2.0 was found to be associated with obstruction.3
An added consequence of SAM is varying degrees of mitral regurgitation, which contributes
to the patient’s symptoms of dyspnea and fatigability.
◆ Abnormalities of mitral valve chordae and papillary muscles are present in 15% to 20% of
patients, but these do not always contribute to outflow tract obstruction or mitral valve
dysfunction (e.g., false chords). Direct insertion of the papillary muscle to the body of the
anterior mitral valve leaflet may contribute to outflow tract obstruction.4
◆ In obstructive HCM, the aortic valve is usually normal, in contrast to congenital subaortic
stenosis, in which turbulence due to a subaortic membrane and muscular obstruction often
leads to cusp retraction and aortic valve regurgitation.
489
Chapter 29 • Surgery for Hypertrophic Cardiomyopathy489.e1
Abstract
Hypertrophic cardiomyopathy is a debilitating disease that can produce significant symptoms

that affect the quality of life, and most symptomatic patients have left ventricular outflow tract
obstruction. Understanding the anatomy and physiology of the disease is critically important
in planning surgical relief of subaortic and/or midventricular obstruction to minimize procedural
risk and obtain the best late outcomes. This chapter summarizes our experience and approach
to surgical repair, as well as postoperative management.
Keywords
Hypertrophic cardiomyopathy
transaortic septal myectomy
transapical septal myectomy
A B
C D
Figure 29.1 Redrawn and recolored by Elsevier with permission of Mayo Foundation for Medical Education and
Research; all rights reserved.
Figure 29.1 Patterns of hypertrophy in patients with hypertrophic cardiomyopathy. (A) Normal ventricular morphology. (B) Basal septal
hypertrophy, a pattern that is ideal for septal myectomy. (C) Septal hypertrophy extends from the subaortic area to the midventricle. (D)
Apical hypertrophic cardiomyopathy.
Chapter 29 • Surgery for Hypertrophic Cardiomyopathy 491
1. Diagnosis and Imaging
◆ As seen by echocardiography or cardiac magnetic resonance imaging (MRI), the most common
pattern of hypertrophy is diffuse involvement of the ventricular septum. LV wall thickness
typically ranges from 20 to 22 mm; however, 5% to 10% of patients have a wall thickness
ranging from 30 to 50 mm,5 and some patients have SAM with a septal thickness of less than
29 mm.
◆ LVOT obstruction is characterized on Doppler echocardiography by a high-velocity, late-peaking
signal, sometimes described as dagger-shaped. Patients with no resting obstruction may reveal
latent obstruction with provocative maneuvers, as described in the following.
◆ The surgeon should identify the level of LVOT obstruction relative to SAM because this will
ultimately guide the surgical approach. At times, the white endocardial fibrous scar on the
septum demarcating the area of contact between the septum and the anterior mitral leaflet
can be identified on an echocardiogram.
◆ Transthoracic echocardiography is also used to identify any primary mitral valve pathologies
that need to be addressed intraoperatively, including abnormal papillary muscles and their
insertion.
2. Indications for Septal Myectomy
◆ Septal myectomy is recommended for patients who have symptoms and diminished functional
capacity refractory to initial medical therapy (e.g., beta blockers, calcium channel blockers,
and/or disopyramide).6,7
◆ Patients with a resting LVOT gradient of 30 mm Hg or more have reduced late survival rates
compared to those with HCM without obstruction.6

◆ For those patients with latent obstruction, septal myectomy is indicated because relief of
latent obstruction results in similar symptom relief, as does myectomy in patients with resting
obstructive HCM.8
◆ Midventricular obstruction can cause symptoms similar to those occurring with subaortic
obstruction.9 With isolated midventricular obstruction, there is no SAM of the mitral leaflet;
rather, the site of obstruction is the contact point between the anterolateral papillary muscle
and the midventricular septum.
◆ Patients with apical HCM and diastolic heart failure may benefit from apical myectomy to
enlarge the LV cavity.10,11

3. Preoperative Planning
◆ Documentation of the severity of the LVOT gradient is made by transthoracic Doppler echo-
cardiography. Many symptomatic patients will have minimal resting outflow tract gradients,
and it is important in the preoperative evaluation to perform provocative maneuvers to elicit
a gradient. These maneuvers include simple Valsalva maneuver, inhalation of amyl nitrite,
exercise echocardiography, and infusion of isoproterenol during a hemodynamic study.12
◆ Cardiac MRI may be useful in identifying details of the ventricular anatomy, but it is not
necessary for planning the operation in patients with isolated subaortic obstruction. This
study is commonly performed, however, to determine LV wall thickness more precisely and
the presence or absence of delayed enhancement, which may influence decision making for
implantation of a defibrillator to prevent sudden cardiac death.13,14
◆ The level of ventricular outflow obstruction should be determined based on the transthoracic
echocardiogram, which will reveal SAM of the mitral valve and the bright endocardial scar
of the septal contact area.
◆ It is important to identify midventricular or multilevel obstruction in patients with LVOT
obstruction because a simple subaortic septal myectomy may not be adequate to relieve
obstruction and the resulting symptoms.15
◆ If chest pain is a presenting symptom, coronary angiography or computed tomography (CT)
angiography of the coronaries is warranted to assess for the need for concomitant coronary
artery bypass surgery if the patient has fixed coronary obstruction or unroofing of intramyocardial
vessels, where bridging is thought to produce obstruction.16
◆ Depending on the location of the obstruction, a transaortic or transapical approach can be

used. Both approaches will be covered in this chapter.
◆ Intraoperative transesophageal echocardiography (TEE) is essential in confirming the preoperative
findings and to assess the mitral valve for associated pathology.
1. Transaortic Approach
◆ A median sternotomy is performed with the institution of normothermic cardiopulmonary

bypass in the usual fashion, with a single two-staged venous cannula through the right atrium.
Before placing the patient on bypass, intracardiac pressures should be measured to ascertain
the LV to aortic gradient to help confirm a successful myectomy at the end of the case.17 This
is done by using a 2.5-inch, 22-G spinal needle that is placed into the aorta near the inflow
cannula, as well as a 3.5-inch, 22-G spinal needle in the left ventricle through the right
ventricular free wall and septum. By measuring pressures from both needles at the same time,
the gradient can be calculated. To assess dynamic LVOT gradients, a premature ventricular
contraction (PVC) can be induced by tapping the heart, and the gradient in the next beat is
recorded (Fig. 29.2).
240
120
PRE BYPASS
PRE PVC POST PVC
AO = 78/47 AO = 68/39
LV = 202/12 LV = 264/10 HR = 62 CO = 4.63
GRAD = 124 GRAD = 196
Figure 29.2 Redrawn and recolored by Elsevier with permission of Mayo Foundation for Medical
Education and Research; all rights reserved.
Figure 29.2 Direct intraoperative measurement of the left ventricle outflow tract (LVOT) pressure gradient. As shown on the top, a 2.5-inch,
22-G spinal needle is inserted into the aorta near the inflow cannula; a 3.5-inch, 22-G spinal needle is inserted into the left ventricle through
the right ventricular free wall and septum. The pressure gradient can be calculated in real time by measuring pressures from both needles
simultaneously. On the bottom, dynamic LVOT gradients can be elicited by tapping the heart to induce a premature ventricular contraction
(PVC) and recording the gradient in the next beat.
◆ Cardiac arrest is achieved with antegrade cold blood cardioplegia after the ascending aorta
is cross-clamped. An initial dose of 1000 mL is used due to associated LV hypertrophy.
◆ A transverse-oblique (hockey stick) aortotomy is made, beginning cephalad to the commissure
between the right and noncoronary sinuses, continuing rightward and inferiorly toward the
base of the noncoronary sinus. At the base of the incision, 1 cm should be left between the
incision and the aortic annulus. Of note, this incision is lower than that of a typical aortic
valve replacement and is closer to the sinotubular junction (Fig. 29.3).
◆ Several maneuvers are used to facilitate exposure of the subaortic area. One can use pericardial
stitches only on the right side to elevate the right heart and allow the ventricular apex to fall
posteriorly. The inferior edge of the aortotomy can be retracted anteriorly with stay sutures.
The assistant then places the cardiotomy sucker through the aortic valve, against the commissure
between the noncoronary and left aortic sinuses into the left ventricle, thereby displacing the
anterior leaflet of the mitral valve posteriorly as well as removing blood from the operative
field (Fig. 29.4). A sponge stick can be used to depress the right ventricle to orient the LVOT
tract more anteriorly. Elevating and tilting the operating table to the left will also help to align
the surgeon’s view with the plane of the subaortic septum.
Figure 29.3 The aortotomy. A transverse-oblique (hockey stick) incision is made, beginning cephalad to the right aortic sinus, continuing
rightward and inferiorly toward the base of the noncoronary sinus (dashed line). Of note, 1 cm should be left between the incision and the
aortic annulus.
Figure 29.4 Exposure. The aortotomy can be retracted with stay sutures to facilitate exposure. The cardiotomy sucker can be placed into
the left ventricle through the aortic valve, against the commissure between the noncoronary and left aortic valve cusps. This displaces the
anterior leaflet of the mitral valve posteriorly and removes blood from the operative field.
◆ After identifying the area of septal and mitral contact (usually demarcated by white fibrous
tissue), a no. 10 blade on a long handle is used to make an incision in the septum, beginning
just to the right of the nadir of the right aortic sinus. This incision is carried upward initially
and then leftward toward the anterior leaflet of the mitral valve. To assess for the correct
incisional depth, the width of the no. 10 blade is a good reference. Scissors can be used to
complete the excision (Fig. 29.5).
2
1
Figure 29.5 Myectomy. With a no. 10 blade on a long handle, an incision is made in the septum, beginning just to the right of the nadir
of the right aortic sinus. This incision is carried upward initially and then leftward toward the anterior leaflet of the mitral valve (dashed
line).
◆ This initial excision is deepened and carried further toward the apex of the left ventricle.
Hypertrophied septum beyond the endocardial scar is excised, as well as any trabeculations.
Pituitary rongeurs can be used to facilitate excision. At the end of the excision, 3 to 12 g of
muscle is considered an adequate amount of tissue (Figs. 29.6 and 29.7).
◆ In regard to the mitral valve, papillary muscles that insert directly into the body of the anterior
leaflet can contribute to LVOT obstruction. By excising these anomalous papillary muscles,
LVOT obstruction may be alleviated further.
◆ The left ventricle is irrigated for any residual debris. It is important to inspect the aortic and
mitral valves to rule out any inadvertent injury.

◆ The aortotomy is clo1sed in two layers with 4-0 polypropylene sutures. The patient is weaned
off cardiopulmonary bypass in the usual fashion. Atrial and ventricular pacing wires are placed
before closing the chest.
2. Transapical Approach
◆ This approach is beneficial when the obstruction is at or below the level of the papillary
muscles. The incision is also used for surgery to enlarge the left ventricle in patients with the
nonobstructive apical variant; in this condition, the small size of the LV cavity contributes to
diastolic dysfunction. The transapical incision is used for patients with isolated midventricular
obstruction that would be difficult to reach through a transaortic approach.8,10
◆ As in the transaortic approach, a median sternotomy is used and the patient is put on car-
diopulmonary bypass in the usual fashion.

◆ To elevate the ventricular apex, moist laparotomy pads are placed behind the left ventricle.
2nd
1st
Figure 29.6 Redrawn and recolored by Elsevier with permission of Mayo Foundation for Medical Education and Research;
all rights reserved.
Figure 29.6 Extension of myectomy. The initial excision is carried further toward the apex of the left ventricle. Hypertrophied septum
beyond the endocardial scar is excised (along the dashed line), as well as any trabeculations. Note the use of a sponge stick to depress the
right ventricle to orient the left ventricular outflow tract more anteriorly.
Figure 29.7 Completed excision. Pituitary rongeurs can be used to facilitate excision toward the apex.
◆ For midventricular obstruction:

◆ A small apical ventriculotomy (≈ 5 cm) is made parallel and lateral to the left anterior
descending coronary artery. This incision should be located over the apical dimple
(Fig. 29.8).
◆ Papillary muscles and chordae are retracted away from the septum with the cardiotomy
sucker, and the white endocardial scar is identified.

◆ Myectomy of the myocardial scar and the muscle below is performed. Significantly enlarged
papillary muscles, as well as excess muscle on the free wall, can be shaved (Fig. 29.9).
Figure 29.8 Apical ventriculotomy. An incision of approximately 5 cm is made parallel and lateral to the left anterior descending (LAD)
coronary artery, over the apical dimple.
Figure 29.9 Apical septal myectomy. The papillary muscles and chordae are retracted leftward, and the septal muscle is excised, beginning
at the apex and progressing to the subaortic area to enlarge the left ventricular cavity (along the dashed line). The apical incision is also
used to approach midventricular obstruction.
◆ For apical HCM:

◆ Due to the obliteration of the apex with hypertrophied muscle, papillary muscles are
displaced apically. Particular attention is made to the protection of the papillary muscles
on entering the ventricle.
◆ Septal myectomy is performed first to increase the LV cavity size, followed by LV free wall
myectomy.
◆ Inspection and digital palpation confirm the extent of the myectomy.
◆ The ventriculotomy is closed in two layers with Teflon strips of felt (Fig. 29.10).
Step 4. Postoperative Management
◆ Maintaining adequate afterload is of utmost importance in the postoperative setting. Vasodilating

drugs are avoided, and vasopressors (e.g., vasopressin, norepinephrine) are commonly used
to maintain peripheral vascular resistance.
◆ Atrioventricular synchrony is particularly important to maintain adequate filling of a hyper-
trophied ventricle. Atrial fibrillation (AF) may be poorly tolerated; amiodarone is used to treat
AF. It is used prophylactically in patients with a history of atrial arrhythmias and in patients
with prodromic arrhythmias, such as premature atrial contractions.
◆ If hypotension due to supraventricular tachycardia develops, early direct current (DC) car-
dioversion is warranted.
◆ Beta blockade is reinstituted after the immediate intensive care period. Typically, half the
preoperative dose is used.

◆ All patients undergo transthoracic Doppler echocardiography before discharge to evaluate for
residual LVOT obstruction, cardiac valve function, and any pericardial effusion.
◆ The most common reason for residual LVOT gradients after myectomy is inadequate length
(toward the apex) of septal excision. The other important cause of residual gradients and
symptoms is residual midventricular obstruction due to contact of the anterolateral papillary
muscle and septum. In patients undergoing myectomy for LVOT obstruction who have long
segment septal hypertrophy, we often combine transapical midventricular myectomy with the
subaortic myectomy.
◆ The LV to aortic gradient should be remeasured after discontinuing cardiopulmonary bypass,
both by direct intracardiac measures and TEE. If the provoked LVOT gradient is greater than
15 to 20 mm Hg, bypass should be reinitiated for additional resection, depending on the
level of obstruction.
◆ Significant residual SAM or mitral regurgitation is usually a consequence of inadequate muscle
resection, rather than the lack of a mitral valve procedure. Of note, hypovolemia or anemia
can be causes of residual SAM, even after adequate myectomy.
◆ If there are no primary abnormalities of the mitral valve, an additional mitral valve procedure
is typically not needed to alleviate the patient’s mitral regurgitation.

Figure 29.10 Redrawn and recolored by Elsevier with permission of Mayo Foundation for
Medical Education and Research; all rights reserved.
Figure 29.10 Closure of ventriculotomy. The ventriculotomy is closed in two layers with Teflon strips of felt.
◆ If an anomalous papillary muscle inserts into the free edge of the anterior leaflet, caution
should be exercised if one proceeds with excision because the muscle could be contributing
to the leaflet’s support. Excision may lead to prolapse and actually worsen regurgitation. In
contrast, anomalous papillary muscles that insert into the body of the anterior leaflet should
be excised to enlarge the LVOT area.
◆ If the patient has complete right bundle branch block preoperatively, transaortic septal myectomy
often leads to left bundle branch block and the need for a permanent pacemaker. At particular
risk are patients who have previously had alcohol septal ablation, which commonly causes
right bundle branch block.
References
1. Richardson P, McKenna W, Bristow M, et al. Report of the 1995 World Health Organization/International Society and Federation of
Cardiology Task Force on the Definition and Classification of cardiomyopathies. Circulation. 1996;93:841–842.
2. Wigle ED, Rakowski H, Kimball BP, Williams WG. Hypertrophic cardiomyopathy. Clinical spectrum and treatment. Circulation.
1995;92:1680–1692.
3. Maron MS, Olivotto I, Harrigan C, et al. Mitral valve abnormalities identified by cardiovascular magnetic resonance represent a
primary phenotypic expression of hypertrophic cardiomyopathy. Circulation. 2011;124:40–47.
4. Kadkhodayan A, Schaff HV, Eleid MF. Anomalous papillary muscle insertion in hypertrophic cardiomyopathy. Eur Heart J Cardiovasc
Imaging. 2016;17:588.
5. Ommen SR, Nishimura RA. Hypertrophic cardiomyopathy. Curr Probl Cardiol. 2004;29:239–291.
6. Maron BJ, Dearani JA, Ommen SR, et al. The case for surgery in obstructive hypertrophic cardiomyopathy. J Am Coll Cardiol.
2004;44:2044–2053.
7. Gersh BJ, Maron BJ, Bonow RO, American College of Cardiology Foundation/American Heart Association Task Force on Practice
Guidelines, et al. 2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy: a report of the
American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Developed in
collaboration with the American Association for Thoracic Surgery, American Society of Echocardiography, American Society of Nuclear
Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, and
Society of Thoracic Surgeons. J Am Coll Cardiol. 2011;58:e212–e260.
8. Schaff HV, Dearani JA, Ommen SR, et al. Expanding the indications for septal myectomy in patients with hypertrophic
cardiomyopathy: results of operation in patients with latent obstruction. J Thorac Cardiovasc Surg. 2012;143:303–309.
9. Kunkala MR, Schaff HV, Nishimura RA, et al. Transapical approach to myectomy for midventricular obstruction in hypertrophic
cardiomyopathy. Ann Thorac Surg. 2013;96:564–570.
10. Said SM, Schaff HV, Abel MD, Dearani JA. Transapical approach for apical myectomy and relief of midventricular obstruction in
hypertrophic cardiomyopathy. J Card Surg. 2012;27:443–448.
11. Schaff HV, Brown ML, Dearani JA, et al. Apical myectomy: a new surgical technique for management of severely symptomatic patients
with apical hypertrophic cardiomyopathy. J Thorac Cardiovasc Surg. 2010;139:634–640.
12. Prasad M, Geske JB, Sorajja P, et al. Hemodynamic changes in systolic and diastolic function during isoproterenol challenge predicts
symptomatic response to myectomy in hypertrophic cardiomyopathy with labile obstruction. Catheter Cardiovasc Interv.
2016;88:962–970.
13. Maron MS, Maron BJ. Clinical impact of contemporary cardiovascular magnetic resonance imaging in hypertrophic cardiomyopathy.
Circulation. 2015;132:292–298.
14. Chan RH, Maron BJ, Olivotto I, et al. Prognostic value of quantitative contrast-enhanced cardiovascular magnetic resonance for the
evaluation of sudden death risk in patients with hypertrophic cardiomyopathy. Circulation. 2014;130:484–495.
15. Cho YH, Quintana E, Schaff HV, et al. Residual and recurrent gradients after septal myectomy for hypertrophic cardiomyopathy—
mechanisms of obstruction and outcomes of reoperation. J Thorac Cardiovasc Surg. 2014;148:909–915.
16. Kunkala MR, Schaff HV, Burkhart H, et al. Outcome of repair of myocardial bridging at the time of septal myectomy. Ann Thorac Surg.
2014;97:118–123.
17. Ashikhmina EA, Schaff HV, Ommen SR, et al. Intraoperative direct measurement of left ventricular outflow tract gradients to guide
surgical myectomy for hypertrophic cardiomyopathy. J Thorac Cardiovasc Surg. 2011;142:53–59.
CHAPTER
30
Surgery for Left

Ventricular Aneurysm
and Remodeling
Ravi K. Ghanta and Irving L. Kron
◆ Amelioration of left ventricular (LV) remodeling is an appealing target for medical and surgical
therapies for heart failure. Remodeling is a complex process that leads to maladaptive ventricular
dilation, hypertrophy, and altered ventricular wall stress and may occur after large myocardial
infarction, chronic ischemia, or chronic valvular heart disease.
◆ The most distinct sequela of remodeling is aneurysm formation at the site of infarction.
Transmural infarcts result in full-thickness necrosis and scar formation, with subsequent
thinning and infarct expansion secondary to mechanical stretch. Nontransmural infarcts alter
regional compliance resulting in infarct area bulging and expansion. The net result is formation
of a ventricular aneurysm and increased LV volume.
◆ Consequently, surgical ventricular reconstruction (SVR) primarily involves aneurysmectomy
and LV volume reduction. These operations are almost always done concomitantly with coronary
artery bypass grafting or mitral valve surgery.
◆ LV aneurysms occur at the site of infarction, most frequently anterior apical (90%) after left
anterior descending (LAD) and posterior (10%) after circumflex (Cx) infarcts.
◆ Important anatomic considerations are the location of major coronary arteries, such as the
LAD and Cx relative to the proposed ventriculotomy (Fig. 30.1; arrow indicates LAD).
◆ Indications for operation include:

◆ congestive heart failure
◆ angina
◆ aneurysm expansion and rupture
◆ arrhythmia
◆ embolism
505
Chapter 30 • Surgery for Left Ventricular Aneurysm and Remodeling505.e1
Abstract
Left ventricular (LV) aneurysms most frequently occur as a consequence of maladaptive remodeling
after a large infarction. Surgical ventricular restoration involves aneurysmectomy and LV volume
reduction. Patient selection, appropriate placement of the endoventricular circular Fontan suture,
and concomitant revascularization or valve repair is essential for success.
Keywords
heart failure
left ventricular aneurysm
ventricular remodeling
surgery
A B
Figure 30.1
Chapter 30 • Surgery for Left Ventricular Aneurysm and Remodeling 507
◆ Preoperative left heart catheterization is mandatory. Complete revascularization should be

performed to viable myocardial territories. An LV aneurysm can be well delineated on the
ventriculogram during catheterization, as demonstrated in Fig. 30.2 (highlighted by red arrows).
◆ The size of the ventricle and location of the akinetic or dyskinetic portion are critical and
require additional diagnostic imaging, such as via echocardiography or cardiac magnetic resonance
imaging (MRI). There are no established size criteria for SVR; however, SVR can be considered
when the LV end-systolic volume index is more than 80 mL/m2 or the end-diastolic volume
index is more than 120 mL/m2.
◆ The degree of mitral regurgitation should be quantified before surgery by echocardiography.
Mitral valve annuloplasty and/or replacement should be performed if severe. Fig. 30.3 shows
an apical aneurysm in the four-chamber view.
◆ Cardiac MRI can measure aneurysm size, ventricular morphology, and myocardial viability.
Cardiac MRI can aid in planning revascularization strategy and extent of the scar. Fig. 30.4
is an MRI scan of an apical infarction. Note the thinning of the anterior wall and apex (red
arrows), delineating the extent of the aneurysm.
◆ If ventricular arrhythmia is an issue, preoperative endocardial mapping is useful for possible
concomitant ablation during SVR.

Figure 30.2

◆ A median sternotomy and central cannulation for cardiopulmonary bypass are performed. If
mitral valve surgery is planned, bicaval cannulation is performed. Cardiopulmonary bypass
is initiated. To prevent potential embolization from a small LV thrombus, care is taken to
prevent manipulation of the heart.
◆ The akinetic or dyskinetic segment of the left ventricle can be identified intraoperatively by
the characteristic dimpling or flattening of the anterior wall after the aortic cross-clamp is
applied and the LV vent is on (Fig. 30.5).
◆ Aortic cross-clamp is applied, and cardiac arrest is achieved with antegrade and possibly
retrograde cardioplegia.
◆ Complete coronary revascularization, including the LAD, is performed.
◆ The heart is elevated in the pericardial well to allow for visualization. The ventricle is opened
(Fig. 30.6) with an incision (dashed line) approximately 1 to 2 cm lateral to the LAD and in
a direction parallel to the LAD (arrow). This places the incision parallel to the septum. The
myocardial thinning and endocardial scar should be visible through the ventriculotomy.
Figure 30.5
A B
Figure 30.6
◆ After stay sutures are placed, the intraventricular cavity is cleared of thrombus, and the
anatomy is identified. The scarred region has a white coloration (Fig. 30.7; yellow arrow). The
papillary muscles are located (blue arrow).
◆ Multiple techniques are used to determine the location of the endoventricular circular suture,
also known as the Fontan suture. Some surgeons have suggested placement of an intraventricular
balloon (expanded to 50 mL/m2) to guide the placement of the Fontan suture and subsequent
reduction of the LV cavity, as demonstrated in Fig. 30.8. With the intraventricular balloon in
situ, placement of the Fontan suture allows for the ventricular volume to be reduced, primarily
in the anterior and septal regions of the left ventricle.
◆ We use preoperative transesophageal echocardiography to determine heart size and Fontan
suture placement relative to the ventricular walls and papillary muscles of the mitral valve,
aiming for a postoperative end-diastolic ventricular volume of approximately 50 mL/m2. An
alternative technique involves identifying the transition zone between viable myocardium and
scar tissue by grasping the ventricular wall between the thumb and forefinger and identifying
where the transition point occurs, indicated by the thinning of the ventricle between the
finger and thumb.
Figure 30.7
Figure 30.8
◆ A 2-0 polypropylene monofilament suture is passed through the endocardium at the transition
between the scarred and normal myocardium in a circular fashion (Fontan stitch). Care is
taken not to include the papillary muscles in this circular suture (Figs. 30.9 and 30.10).
A B
Figure 30.9
A B
Figure 30.10
◆ In cinching the Fontan suture (Fig. 30.11), care is taken to tighten the suture to define the
new wall, not to close the opening. This reduces the ventricular cavity volume.
◆ A Dacron patch is then fashioned to close the opening; care is taken to make the patch large
enough that it can be readily sutured over the defect. If the residual opening is less than 1 cm
wide, the defect may be closed primarily with a second suture line of 2-0 or running 3-0
polypropylene monofilament sutures (Fig. 30.12).
Figure 30.11
A B
Figure 30.12
◆ The patch is sutured into place with running 3-0 polypropylene monofilament sutures
(Fig. 30.13).
◆ Once the patch is placed, the ventriculotomy is closed in a two-layer fashion, using first a
horizontal mattress suture and then a running over and over–type closure (Fig. 30.14).
◆ Note that some surgeons prefer to reinforce the ventriculotomy closure with Teflon strips, as
demonstrated; however, this may conceal the sources of any residual hemorrhage (Fig. 30.15).
◆ If severe mitral regurgitation is present, the mitral valve must be repaired. Usually, the mitral
leaflet morphology is normal, and the mechanism of regurgitation is secondary to papillary

muscle displacement or annular enlargement from a dilated ventricle. These mechanisms are
addressed by placement of an annuloplasty ring. The repair is performed through a standard
left atrial incision. Interrupted braided 2-0 sutures are placed in a horizontal mattress fashion
around the annulus, and the annuloplasty ring is seated to these.
◆ Inferior aneurysms are treated using the same principles. However, the defect is often smaller,
and the neck can be closed primarily.
◆ Patients may require intraaortic balloon counterpulsation in the initial postoperative period,
especially if there is an element of right ventricular dysfunction or a poor preoperative LV
ejection fraction (< 25%).
◆ Postoperative care is focused on managing heart failure. We use Swan-Ganz catheters in all
these cases.
◆ Incomplete revascularization, especially of the septum, prevents optimal contractility and

recovery of function.
◆ Embolism from a ventricular thrombus secondary to ventricular manipulation before the
aortic cross-clamp can be placed.

◆ Lack of regional basal contraction of the left ventricle portends a poor outcome and should
be considered a relative contraindication.

◆ The residual ventricular cavity may be too small, resulting in inadequate stroke volume and
cardiac output.
◆ Severe right ventricular dysfunction is a relative contraindication to the procedure.
◆ Significant residual mitral regurgitation portends a poor outcome.
◆ Areas of ventricular calcification must be removed.
◆ The ejection fraction should be evaluated at 3 months and the need for an automated implant-
able cardioverter-defibrillator assessed, based on recognized guidelines.

◆ The use of carbon dioxide should be considered to decrease the amount of air introduced
into the ventricular cavity and decrease residual air bubbles after the cross-clamp is removed.
A B
Figure 30.13

Bibliography
Athanasuleas CL, Buckberg GD, Stanley AW, et al; RESTORE Group. Surgical ventricular restoration in the treatment of congestive heart
failure due to post-infarction ventricular dilation. J Am Coll Cardiol. 2004;44:1439–1445.
Athanasuleas CL, Stanley AW Jr, Buckberg GD, et al. Surgical anterior ventricular endocardial restoration (SAVER) in the dilated
remodeled ventricle after anterior myocardial infarction. RESTORE Group. Reconstructive Endoventricular Surgery, returning Torsion
Original Radius Elliptical Shape to the LV. J Am Coll Cardiol. 2001;37:1199–1209.
Athanasuleas CL, Stanley AW Jr, Buckberg GD, et al; RESTORE Group. Surgical anterior ventricular endocardial restoration (SAVER) for
dilated ischemic cardiomyopathy. Semin Thorac Cardiovasc Surg. 2001;13:448–458.
Bolling SF, Smolens IA, Pagani FD. Surgical alternatives for heart failure. J Heart Lung Transplant. 2001;20:729–733.
Buckberg GD. Defining the relationship between akinesia and dyskinesia and the cause of left ventricular failure after anterior infarction
and reversal of remodeling to restoration. J Thorac Cardiovasc Surg. 1998;116:47–49.
Kron IL, Kern JA, Theodore P, et al. Does a posterior aneurysm increase the risk of endocardial resection? Ann Thorac Surg.
1992;54:617–620.
Lundblad R, Abdelnoor M, Svennevig JL. Surgery for left ventricular aneurysm: early and late survival after simple linear repair and
endoventricular patch plasty. J Thorac Cardiovasc Surg. 2004;128:449–456.
Maxey TS, Serfontein SJ, Reece TB, Rheuban KS, Kron IL. The beating heart approach is not necessary for the Dor procedure. Ann Thorac
Surg. 2003;76:1571–1574.
Menicanti L, Castelvecchio S. Left ventricular reconstruction concomitant to coronary artery bypass grafting: when and how? Curr Opin
Cardiol. 2011;26:523–527.
Menicanti L, Di Donato M. The Dor procedure: what has changed after fifteen years of clinical practice? J Thorac Cardiovasc Surg.
2002;124:886–890.
Mickleborough LL, Merchant N, Ivanov J, et al. Left ventricular reconstruction: early and late results. J Thorac Cardiovasc Surg.
2004;128:27–37.
White HD, Norris RM, Brown MA, et al. Left ventricular end-systolic volume as the major determinant of survival after recovery from
myocardial infarction. Circulation. 1987;76:44–51.
CHAPTER
31
Approaches and Techniques

for Extracorporeal
Membrane Oxygenation
Hadi Toeg, David Glineur, and Sophie De Roock
◆ Extracorporeal membrane oxygenation (ECMO) pertains to prolonged extracorporeal cardio-

pulmonary bypass using intrathoracic or extrathoracic vascular cannulation. The bypass circuit
includes a distensible venous blood reservoir receiving deoxygenated blood from the patient
passing through a nonocclusive centrifugal pump toward the membrane oxygenator and
countercurrent heat exchanger to be delivered finally to the patient via an arterial or venous
cannula (Fig. 31.1). To prevent thrombosis within the ECMO circuit from blood tubing
contact interactions, patients are generally anticoagulated with heparin or bivalrudin.1
◆ Providing full or partial circulatory support with adequate gas exchange is the primary objective
of ECMO. Broad indications for initiating ECMO include isolated cardiac failure, respiratory
failure, and cardiorespiratory failure. The arrangement of the cannulae and ECMO circuit can
be varied, depending on the indication for extracorporeal life support. Generally, patients
with isolated respiratory failure can be supported with venovenous ECMO, whereas patients
with cardiac or cardiorespiratory failure will require venoarterial ECMO.
◆ ECMO was first used in the early 1970s and, although several studies have demonstrated
poor clinical outcomes, successes were individually dramatic. In an effort to evaluate, improve,
and innovate ECMO therapy, the Extracorporeal Life Support Organization (ELSO) was
established in 1989. This international multicenter registry reports clinical outcomes in adult
and children who are undergoing various forms of ECMO therapy.2
520
Chapter 31 • Approaches and Techniques for Extracorporeal Membrane Oxygenation 520.e1
Keywords
extracorporeal membrane oxygenation

Chapter 31 • Approaches and Techniques for Extracorporeal Membrane Oxygenation 521
Right internal
jugular vein
Oxygen blender Oxygenator
Centrifugal
pump
Console
Right femoral
vein
Figure 31.1
Figure 31.1 Veno-venous ECMO circuit.

1. Femoral Vessels
◆ The key for successful ECMO cannula placement is understanding the anatomy of the common
femoral artery, with emphasis on its branches and its relationship to the inguinal ligament
and common femoral vein (Fig. 31.2). When performing a surgical cutdown for ECMO
placement, it is critical to identify and dissect out the superficial femoral and profunda femoris
arteries to ensure cannulation of the common femoral artery proper and to consider placement
of an antegrade perfusion catheter in the superficial femoral artery.
◆ To provide safe control of the proximal aspect of the common femoral artery, part of the
inguinal ligament may need to be divided.
2. Axillary Artery
◆ Cardiac surgeons should also be familiar with the pertinent anatomy of the axillary and
subclavian arteries. In particular, the axillary vein is anterosuperior to the artery, and the
brachial plexus is posterolateral (Fig. 31.3).
◆ It is imperative to determine whether a patient requiring ECMO has a potentially reversible

underlying pathologic process or has plans for longer term therapy (e.g., left ventricular assist
device, heart or lung transplantation). General indications include acute reversible respiratory
or cardiac failure unresponsive to optimal medical therapy for which recovery can be expected
within a sensible time frame. Contraindications include patients with active bleeding, conditions
incompatible with a normal quality of life after cardiac or lung recovery (e.g., major brain
injury) and mechanical ventilation for more than 10 days.
◆ After deciding which type of ECMO circuit would provide maximal oxygenation and/or circula-
tory support, the surgeon will need to devise a cannulation strategy. This can be divided into
central (thoracic) or peripheral (extrathoracic) cannulation. Venovenous ECMO in the setting
of respiratory failure will typically be performed via peripheral cannulation—the femoral and/
or jugular vein). Although most venoarterial ECMO procedures are performed via peripheral
cannulation, a central cannulation strategy (i.e., right atrium and ascending aorta) may be
considered in the setting of post–cardiopulmonary bypass patients or for those who require
effective left ventricular venting. Finally, appropriately sized arterial and venous cannulae
must be chosen to provide adequate flow.
◆ Percutaneous peripheral ECMO cannulation can now be performed in both the venovenous
and venoarterial ECMO settings. A single double-lumen cannula for venovenous ECMO can
be placed under guidance by transesophageal echocardiography (TEE) and/or fluoroscopy.
◆ After establishing full cardiorespiratory support, the team must routinely assess for distal limb
perfusion in the setting of peripheral arterial cannulation, the need for left ventricular venting
and, finally, preventing upper body hypoxia. The latter situation can occur when a venoarterial
ECMO patient ejects deoxygenated blood from the left ventricle and the oxygenated femoral
arterial cannula flow is prevented from reaching the upper body. In this setting, an additional
peripheral venous cannula can be placed to provide oxygenated blood from the ECMO circuit.3
Common
iliac artery
Femoral
nerve Internal
iliac artery
Inguinal
ligament
Common
femoral
artery
Superfi-
cial
femoral
Profunda
femoris
artery
Figure 31.2
Brachial plexus
Axillary artery
Axillary vein
Pectoralis
minor muscle
Figure 31.3
Figure 31.2 Femoral artery anatomy.
Figure 31.3 Axillary artery anatomy.

1. Venoarterial Extracorporeal Membrane Oxygenation: Peripheral Cannulation
Femoral Artery Cannulation
◆ For femoral artery cannulation, a vertical incision overlying and just slightly medial to the
femoral pulse can be made (Fig. 31.4). Alternatively, a slightly oblique incision aligned with
the inguinal ligament to facilitate healing can be made.
◆ Proximal and distal control of the femoral artery should be obtained. A noncalcified site for
the arteriotomy should be chosen after considering where the proximal clamp may be safely
placed and how the repair will be accomplished when the cannula is removed. The distal
vessels may be occluded with separate clamps or tapes. Purse-string sutures (5-0 polypropylene)
can be placed in a diamond shape overlying the area of insertion.
◆ A transverse arteriotomy should be made and the femoral cannula gently introduced while
an assistant releases the proximal clamp. The cannula is then secured by tying it to the
proximal snare, with a second suture securing the tubing to the surface of the thigh.
◆ Percutaneous femoral arterial cannulation can be achieved via an ultrasound-guided Seldinger
technique in the common femoral artery. A 15 F or 17 F arterial cannula should be used to

allow some distal limb perfusion. Alternatively, one can perform a hybrid cannulation (e.g.,
percutaneous after a femoral cutdown; see Fig. 31.4).
◆ To ensure adequate distal limb perfusion, an antegrade catheter can be placed in the superficial
femoral artery open or percutaneously, or a small retrograde catheter can be placed in the
posterior tibial artery via cutdown (Fig. 31.5).4
Axillary Artery Cannulation
◆ A 6-cm transverse incision is made 2 cm below the clavicle overlying the deltopectoral groove
(see Fig. 31.3). The dissection is continued between the fibers of the pectoralis major. The
exposure is aided by two self-retaining retractors.
◆ The cephalic vein can be identified in this space, where it penetrates the fascia to join the
axillary vein. The clavipectoral fascia is incised, and the pectoralis minor muscle is retracted
laterally or partially dissected. The axillary vein should be encircled with loops and gently
retracted cephalad.
◆ The artery, which lies superior and deep to the vein, can be identified by palpation and then
exposed and controlled proximally and distally with vessel loops. Care must be taken to avoid
injuring the medial and lateral brachial plexus cords.
◆ After heparin is administered, the artery can be controlled with clamps and an 8-mm tube
graft should be anastomosed to this site (see Fig. 31.4), and the arterial cannula should be
inserted into the tube graft. The cannula is not advanced into the axillary artery proper, but
rather perfuses from within the graft.
◆ After eventual decannulation, the stump can be controlled with several large hemoclips applied
transversely and then oversewn with 4-0 polypropylene sutures.

Site of
arteriotomy
Femoral
vein
Femoral
artery
A B
Figure 31.4
Figure 31.5
Figure 31.4 Femoral artery purse-string and cannulation.
Figure 31.5 Axillary artery tubegraft anastomosis.

Femoral Venous Cannulation
◆ We prefer to use a multistage venous cannula because it may be used for definitive venous
drainage. One or two purse-string sutures (4-0 polypropylene) are placed around the common
femoral vein, and a 14-G needle is inserted followed by guidewire advancement to the superior
vena cava (SVC; see Fig. 31.4). The cannula is inserted over the wire, with further minor
opening of the vein wall with a scalpel superiorly up to 3 mm from the apex of the diamond
or via progressive dilation. Further advancement of the cannula is guided by TEE to ensure
that the tip is just inside the SVC. The cannula is anchored to the leg with several heavy silk
sutures.
◆ Once the patient is weaned from ECMO, the purse strings can be gently snared as the cannula
is removed and then tied, with little compromise of the femoral vein lumen. Although jugular
venous cannulation can be used in adult peripheral venoarterial ECMO, it is generally used
in the pediatric population.
2. Venoarterial Extracorporeal Membrane Oxygenation: Central Cannulation
Ascending Aortic Arterial Cannulation
◆ The most important factor for central arterial cannulation is securing the cannula and ensuring
hemostasis. After an appropriate cannulation site in the distal ascending aorta has been chosen,
two 4-0 large pledgeted polypropylene sutures are used to create two diamond-shaped purse-
string sutures (Fig. 31.6). Two snare snuggers are placed around these sutures. A subcostal
tunnel is made to allow the arterial tubing to reach the arterial cannula once it has been
placed. The ascending aorta is cannulated with a one-piece arterial cannula, an elongated
one-piece arterial cannula, and the snare snuggers are tightened (see Fig. 31.6). The arterial
cannula is attached to the tunneled arterial tubing. If hemostasis is achieved, the purse-string
sutures are tied in place onto the snare snugger with an extra piece of rubber tubing or a
plastic button. Heavy silk ties are used to secure the cannula to the snare snuggers. Additional
purse-string sutures can be placed if adventitial bleeding is noted. See Chapter 2 for details
regarding general techniques for central cannulation.
◆ Depending on the clinical scenario, the patient’s sternum can be closed with the arterial
cannula arising subcostally. Chest tubes should be placed to monitor bleeding from the
pericardial well.
Snare
snugger
One piece Snare

arterial snugger
cannula
Figure 31.6
Figure 31.6 Central aortic cannulation with multiple pledgets.

Venous Cannulation
◆ See Chapter 2 for details and information regarding central venous cannulation. This can be
performed with a two-stage venous cannula through the right atrial appendage. Achieving
hemostasis can be difficult due to friable atrial tissue. This can be reinforced with large
pledgeted sutures.
◆ An alternative approach for venous cannulation is placing a multistage venous cannula through
the femoral vein. This can be achieved by a percutaneous method (see next section).
◆ Left ventricular and left atrial venting can be achieved by placing a 20 F multistage cannula
through the left atrial wall, just adjacent to the right superior pulmonary vein. Alternatively,
a larger single-stage venous cannula could be placed and connected to the venous return
tubing. Once again, placing several large, pledgeted, purse-string sutures and securing with
snare snuggers is needed to attain acceptable hemostasis. See Chapter 2 for principles for
placing a left ventricular vent.
3. Venovenous Extracorporeal Membrane Oxygenation:

Peripheral Percutaneous Cannulation
◆ Prior to performing venovenous ECMO, appropriately sized vessels and ECMO configuration
(e.g., femoral-femoral, femoral-jugular) must be chosen to achieve maximum flow to support
the patient.
◆ The femoral vein is punctured with an 18-G needle by palpating the femoral artery and
directing the needle just medial to the artery or via ultrasound. A J-tipped guidewire is
advanced through the needle and should be visualized in the right atrium–inferior vena cava
(IVC) junction. A series of graduated dilators are used, and the venous cannula is placed over
the guidewire (see Fig. 31.4). A similar approach is carried out for the jugular vein. Recirculation
can occur if the drainage catheter is in close proximity with the outflow cannula, leading to
decreased efficiency in the ECMO circuit. This can occur in the femoral-femoral and femoral-
jugular configuration.
◆ To minimize recirculation and ease of implantation, a novel method of achieving venovenous
ECMO is via a double-lumen catheter, which can be placed in the right internal jugular vein.
Ultrasound-guided venous puncture of the right internal jugular vein is achieved with an
18-G needle; a stiff J-tipped guidewire is placed and should be anchored deep into the IVC.
TEE is essential; however, to minimize complications, fluoroscopy should be considered.5 A
series of graduated dilators are used, and the double-lumen catheter is placed such that the
upper and lower drainage holes are located at the SVC and IVC, respectively (Fig. 31.7A).
The return (oxygenated blood) port is found in the mid–right atrium and the oxygenated
blood is directed toward the tricuspid valve (see Fig. 31.7B). Adjustments can be made based
on oxygenated flow using TEE Doppler.
Avalon
catheter
A B
Figure 31.7
Figure 31.7 (A) Avalon double catheter cannulation. (B) Close up/internal view of the double lumen Avalon catheter.
◆ Daily assessment for organ recovery and consideration for ECMO weaning should be done
because major complications, including bleeding, thromboembolism, limb ischemia, and
infection, are common.6 If a patient is initially placed on venoarterial ECMO for cardiorespiratory
support, and cardiac function improves, the surgeon should consider switching to venovenous
ECMO because this approach has a lower risk of bleeding, seizures, and infections. Alternatively,
if a patient is placed on venovenous ECMO for respiratory support and has further deterioration
of cardiac function, using an arterial cannula should be considered.7
◆ Systemic anticoagulation during ECMO is recommended to prevent thromboembolic events.
However, in the case of a patient with ongoing bleeding or coagulopathy, lowering the anti-
coagulation targets, using heparin-bonded circuits, or even holding anticoagulation for a short
period of time can be considered.8,9
◆ Sites of arterial and venous cannulation should be chosen with consideration to the vessel to
cannula size match and how the site of vascular entrance can be repaired should complications
such as bleeding or dissection occur.
◆ Communication between the surgeon and perfusionist is paramount, especially in regard to
sizing and understanding which acceptable flows can be achieved through various cannulae.
Due to the extensive potential cannulation and ECMO circuit strategies, the surgical team
should be well prepared. The appropriate equipment should be available in the room, including
TEE and/or fluoroscopy.
◆ Careful femoral arterial cannulation should be performed to avoid life-threatening complications
such as iliac artery puncture or rupture. Patients with coronary artery disease are at particular
risk due to ubiquitous atherosclerosis.7
◆ Recirculation can occur during venovenous ECMO if the inflow drainage catheter is in close
proximity with the outflow/oxygenated cannula, thereby resulting in lack of oxygenation to

the right ventricle and systemic circulation. This also decreases efficiency in the ECMO circuit.
This can be avoided by using a single double-stage cannula in the jugular vein (see Fig. 31.7)
or ensuring that the drainage femoral cannula is placed in the IVC, below the diaphragm and
above the renal veins, while the outflow femoral cannula enters the right atrium.10,11
References
1. Tramm R, Ilic D, Davies AR, et al. Extracorporeal membrane oxygenation for critically ill adults. Cochrane Database Syst Rev.
2015;(1):CD010381.
2. Lawson DS, Lawson AF, Walczak R, et al. North American neonatal extracorporeal membrane oxygenation (ECMO) devices and team
roles: 2008 survey results of Extracorporeal Life Support Organization (ELSO) centers. J Extra Corpor Technol. 2008;40:166–174.
3. Choi JH, Kim SW, Kim YU, et al. Application of veno-arterial-venous extracorporeal membrane oxygenation in differential hypoxia.
Multidiscip Respir Med. 2014;9:55.
4. Rupprecht L, Lunz D, Philipp A, et al. Pitfalls in percutaneous ECMO cannulation. Heart Lung Vessel. 2015;7:320–356.
5. Rubino A, Vuylsteke A, Jenkins DP, et al. Direct complications of the Avalon bicaval dual-lumen cannula in respiratory extracorporeal
membrane oxygenation (ECMO): single-center experience. Int J Artif Organs. 2014;37:741–747.
6. Zangrillo A, Landoni G, Biondi-Zoccai G, et al. A meta-analysis of complications and mortality of extracorporeal membrane
oxygenation. Crit Care Resusc. 2013;15:172–178.
7. Abrams D, Combes A, Brodie D. Extracorporeal membrane oxygenation in cardiopulmonary disease in adults. J Am Coll Cardiol.
2014;63:2769–2778.
8. Yeo HJ, Kim do H, Jeon D, et al. Low-dose heparin during extracorporeal membrane oxygenation treatment in adults. Intensive Care
Med. 2015;41:2020–2021.
9. Lawler PR, Silver DA, Scirica BM, et al. Extracorporeal membrane oxygenation in adults with cardiogenic shock. Circulation.
2015;131:676–680.
10. Xie A, Yan TD, Forrest P. Recirculation in venovenous extracorporeal membrane oxygenation. J Crit Care. 2016;36:107–110.
11. Abrams D, Bacchetta M, Brodie D. Recirculation in venovenous extracorporeal membrane oxygenation. ASAIO J. 2015;61:115–121.
CHAPTER
32
Ventricular Assistance
and Support
Garrett Coyan and Christopher Sciortino
See Video 32.1 on ExpertConsult.com.
◆ Since the first implantation of a left ventricular assist device (LVAD) by Dr. Michael DeBakey
in 1966, the search for durable short- and long-term mechanical support has resulted in a
myriad of devices and expanded indications. Targeted funding by the National Institutes of
Health (NIH) and industry has resulted in several innovative technologies with which the
surgeon must be familiar in order to recommend appropriate mechanical support therapy,
when indicated.
◆ As waiting times for transplantation lengthened, clinical experience was gained with various
devices. Today, pulsatile and nonpulsatile mechanical circulatory support devices are increasingly
being used as bridges to transplantation and as destination therapy. The ReMATCH trial has
shown that LVADs have a permanent place as destination therapy in end-stage heart failure.1
In this chapter, we describe techniques used for the implantation of various common devices
for temporary and durable ventricular support in heart failure.
◆ The anatomy of pump insertion is similar for most devices discussed in this chapter. The
inlet cannula of both externally and internally placed LVADs is usually implanted in the left
ventricular apex. The diaphragmatic surface of the left ventricle between the ventricular
septum and the origin of the papillary muscles for the inlet cannula or pump can also be
used (Fig. 32.1). This convenient flat space is particularly suited for implantation of small
centrifugal force pumps and intraabdominally placed axial flow pumps.
531
Chapter 32 • Ventricular Assistance and Support531.e1
Keywords
LVAD
left ventricular assist device
RVAD
right ventricular assist device
Centrimag
impella
ventricular assist
heart failure
Figure 32.1
Figure 32.1 Diaphragmatic surface anatomy of the left ventricle.
Chapter 32 • Ventricular Assistance and Support 533
1. Indications for Use of Various Ventricular Assist Devices
◆ Temporary ventricular assist devices are typically used in the setting of acute left or right
ventricular dysfunction or for univentricular support for interventional procedures. Devices
are available that can be placed percutaneously via open vascular exposure or via mediastinal
access. Temporary ventricular assist devices can be deployed rapidly in various clinical locations
(e.g., intensive care unit [ICU], operating room [OR], or catheterization laboratory). A variety
of devices are commercially available, including the Impella (Abiomed, Danvers, MA) series
of left and right ventricular assist devices that provides temporary axial flow support in a
low-profile device. The Impella 2.5 and Impella CP (Fig. 32.2) can be inserted percutaneously,
or the higher flow Impella 5.0 (Fig. 32.3) can be inserted via right axillary or femoral cut-down
for higher flows. The newly released Impella RP (Fig. 32.4) is intended for right heart support
via percutaneous venous access.2 Numerous extracorporeal centrifugal pumps (e.g., CentriMag
[Thoratec, Pleasanton, CA] or Tandem heart) are available for left and/or right ventricular
support (Fig. 32.5). We currently prefer to use the CentriMag in our institution because of
its relative ease of use and the ability to splice in cardiotomy reservoirs for transfusion,
oxygenators, and renal replacement devices.3 There is an ever-increasing number of patients
who present with acute, acute on chronic, or chronic heart failure that require temporary or
durable mechanical circulatory support. This chapter provides an overview of the major
temporary and durable ventricular assist devices that are currently available. Descriptions of
the indications and implantation techniques are outlined.
Figure 32.2 © 2017 Abiomed, Inc. All rights reserved. Figure 32.3 © 2017 Abiomed, Inc. All rights reserved.
Figure 32.5 Reproduced with permission of St. Jude Medical,

Figure 32.4 © 2017 Abiomed, Inc. All rights reserved. © 2017. All rights reserved.
Figure 32.2 Impella CP® device.
Figure 32.3 Impella 5.0® device.
Figure 32.4 Impella RP® device.
Figure 32.5 CentriMag® blood pump.

◆ For long-term implantable support, the HeartMate II (Thoratec) and HeartWare HVAD
(HeartWare, Framingham, MA) are the two current continuous-flow devices that are most
commonly used. The HeartMate II (Fig. 32.6) is an axial flow pump requiring implantation
in the abdomen, whereas the HeartWare HVAD (Fig. 32.7) is a centrifugal pump that is
implanted within the pericardium itself. Other implantable LVADs are also available either
commercially or on a trial basis.
1. External Temporary Devices
Impella
◆ The Impella 2.5 and Impella CP devices are regularly inserted using a percutaneous access
technique either in the cardiac catheterization laboratory or the OR. Femoral arterial access
is obtained using the Seldinger technique, the artery is dilated up, and a tear-away sheath is
placed. The Impella device is then inserted after priming, guided into the left ventricle, and
positioned across the aortic valve under fluoroscopic and/or echocardiographic guidance.
After adequate positioning is obtained, the automated controller is activated, and an appropriate
power level is selected for the desired cardiac output.
Figure 32.6 Reproduced with permission of St. Jude Medical, Figure 32.7 Reproduced with permission of Medtronic, Inc.
© 2017. All rights reserved.
Figure 32.6 Heartmate II® left ventricular assist device.
Figure 32.7 Heartware™ HVAD™ left ventricular assist device.

◆ Insertion of the Impella 5.0 is performed via either a femoral cut-down technique with direct
arterial cannulation or, more commonly at our institution, an axillary artery cut-down technique
(Fig. 32.8).4 We prefer to place an 8- to 10-mm tube graft on the axillary artery with 4-0
polypropylene sutures and cannulate the graft with the Impella 5.0 device. The device is then
advanced and positioned as previously described using intraoperative fluoroscopy and echo-
cardiography. We prefer to close the cut-down site with layers of interrupted sutures to help
prevent bleeding and infection while the device is in place.
◆ If short-term temporary right ventricular assist is needed, the new Impella RP device can be
placed percutaneously for right ventricular assistance. The device is advanced from the femoral
vein up through the inferior vena cava (IVC) and positioned with the tip of the device in the
main pulmonary artery under fluoroscopic and echocardiographic guidance.
CentriMag
◆ The CentriMag is a versatile temporary support device that lends itself to several cannulation
configurations, depending on the clinical circumstances. For left ventricular support, we
prefer to cannulate the left ventricular apex for the inflow portion. For postcardiotomy support
(or for those undergoing sternotomy for implantation), we graft the ascending aorta for the
outflow. For patients requiring LVAD support for cardiogenic shock who otherwise do not
require sternotomy, we routinely perform a left thoracotomy for cannulation of the apex; the
outflow graft is constructed using a right axillary artery cut-down. For the inflow in either
circumstance, the apex of the left ventricle is elevated, and two circumferential purse-string
sutures of 2-0 Teflon polypropylene are placed. In general, a site should be chosen that will
center the cannula tip coaxial to and in the center of the left ventricular cavity. The size of
the drainage cannula should be chosen based on the patient’s size. The cannula is tunneled
out of the chest through a subcutaneous tunnel, ensuring that there is no kinking of the
tubing. The cannula tip is inserted into the left ventricle through a cruciate incision and
secured by purse-string sutures to the cannula. Securing the inlet cannula in position is critical
to prevent cannula dislodgment, which can result in bleeding and the development of a cata-
strophic air embolus during pumping. Transesophageal echocardiography is used to confirm
acceptable inlet cannula position.
◆ For patients undergoing sternotomy, a partial aortic clamp is applied to the aorta in a location
devoid of calcifications and plaques. A 10-mm tube graft is placed in an end-to-side fashion.
The anastomosis is performed to the ascending aorta with 4-0 polypropylene sutures.
◆ If the left thoracotomy approach is used for inflow cannulation, the right axillary artery is
exposed for outflow grafting. After isolating the axillary artery, a 10-mm graft is sewn to the
artery in an end-to-side fashion, and the CentriMag circuit is attached directly to the graft
and secured with several silk ties and sutures. The graft is either tunneled via a separate
incision or through the cut-down incision, depending on the orientation of the graft to avoid
kinking. To limit overflow to the ipsilateral arm, a snare is adjusted to maintain a mean arterial
pressure (MAP) of 70 mm Hg in the ipsilateral arterial line. We then close the incision in
layers temporarily to limit bleeding and infection risks.
Axillary vein
Axillary artery
Dacron graft
Figure 32.8
Figure 32.8 Right axillary artery exposure with tube graft anastomosis for ventricular assist device implantation.
◆ If right ventricular assist is needed, we prefer to use a percutaneous dual-stage venous cannula
placed via the femoral vein under echocardiographic guidance. This provides excellent drainage
of the right atrium; if additional drainage is needed, a percutaneous superior vena cava (SVC)
cannula can be placed via the right internal jugular vein. We perform a sternotomy and place
a 10-mm tube graft on the right pulmonary artery, directly between the SVC and the aorta,
using 4-0 polypropylene sutures (Fig. 32.9). We have found that this position of the outflow
graft provides good flow dynamics bilaterally and minimizes pulmonary regurgitation. It is
also readily exposed via this approach.
◆ Removal of the device is straightforward in each of the previous approaches. For the graft
sites, we simply use a GIA stapler to staple off the grafts and then oversew using 4-0 poly-
propylene sutures.
2. Internal Axial Flow Pump
◆ The HeartMate II is implanted through a median sternotomy with the patient supported by
cardiopulmonary bypass (CPB). A cylindric blade is used to excise a circular plug of myocardium
near the ventricular apex. Horizontal mattressed 2-0 pledgetted Ti-Cron sutures are placed
circumferentially around the ventricular opening. These sutures are used to secure the HeartMate
II sewing ring to the margins of the opening (Fig. 32.10). The ventricular cavity should be
inspected digitally and visually to ensure that no ventricular muscle or clot could embolize
or interfere with device placement. The ventricular assist device (VAD) is placed within the
sewing cuff and secured with heavy braided sutures.5
◆ The body of the pump is typically placed in a supradiaphragmatic pocket in the left chest.
The location of the pocket can be patient-dependent based on factors such as body habitus
and previous abdominal surgeries. The pocket is created by lysing the anterior attachments
of the diaphragm, which can be accomplished with electrocautery or endothoracic staples.
Careful attention to hemostasis is necessary to minimize the risk of postoperative bleeding.
It is imperative that the pocket is large enough for the VAD to sit without tension or risk of
movement with chest closure. A plastic model of the VAD profile is available to check for
pocket size.
◆ The driveline is tunneled from the middle mediastinum and brought through the anterior
fascia and subcutaneous space to a predetermined exit site in the left or right upper quadrant
of the abdomen. The tract is created and the driveline tunneled with a tunneling device
specific for the HeartMate II. The velour of the driveline is tunneled to the skin exit site.
◆ The outflow graft is attached to the pump and sutured to the ascending aorta with 3-0 or
4-0 polypropylene sutures and positioned on the anterior or arterial lateral surface of the
ascending aorta. A partial aortic cross-clamp is used to isolate this area of the ascending aorta.
The outflow graft is de-aired prior to initiation of the VAD. This can be accomplished either
with a needle de-airing site or a formal de-airing cannula.
◆ The left ventricle should be well filled before pump flow is initiated. The pump is started at
6000 rpm, and the speed is gradually increased until the patient is weaned from CPB. Appropriate
inotropic support is initiated for right ventricular support, as necessary. Final VAD speed is
set based on the desired output and biventricular (septal) geometry.
10 mm graft to right main Aorta
pulmonary artery
Right
pulmonary
artery
Figure 32.9
Figure 32.10 Reproduced with permission of St. Jude Medical,

© 2017. All rights reserved.
Figure 32.9 Tube graft anastomosis to right main pulmonary artery for right ventricular assist device support.
Figure 32.10 Heartmate II® LVAD implantation.

3. Internal Centrifugal Flow Pump
HeartWare HVAD
◆ The HeartWare HVAD is a continuous-flow LVAD that is implantable within the pericardium
itself (Fig. 32.11).6 The inflow cannula is contained within the housing of the device to
accomplish this. The sewing ring is secured to the left ventricle either with a technique
described with the HeartMate II or with a felt strip–reinforced, running 3-0 Prolene technique.
A spring-loaded coring device packaged with the HVAD is used to core the left ventricle in
the center of the sewing ring. The left ventricle is inspected for clot and obstructive trabeculae,
which are removed. The head of the VAD is placed within the sewing ring and locked into
place by tightening the bolt on the sewing ring with a torque driver. The driveline is tunneled
and the outflow graft anastomosed in a manner similar to that for the HeartMate II. After
implantation, the device is initiated at 1800 rpm and increased as CPB is weaned. The final
VAD speed (≈ 3000 rpm) is set based on desired pump flow and biventricular geometry and
function.
4. Explantation Procedures for Cardiac Transplantation
HeartWare HVAD and HeartMate II
◆ VAD explantation typically occurs at the time of orthotopic heart transplantation, VAD exchange,
or left ventricular recovery. For patients who undergo LVAD implantation as a bridge to
transplantation, we cover the VAD, right ventricle, and right atrium with a double layer of
preclude Gore-Tex membrane (WL Gore, Newark, DE) to facilitate redo mediastinal dissection.
The outflow graft is covered with a ringed Gore-Tex tube graft that is cut longitudinally to
facilitate placement and prevent outflow graft compression. Redo sternotomy is performed
in the standard fashion and the mediastinum exposed. The double-layer Gore-Tex membrane
technique provides a nice plane to initiate the LVAD and cardiac mobilization. We place a
double layer of Gore-Tex between the right atrium and the right-sided pericardium for rapid
exposure to the SVC, right atrium, and IVC. Adhesions are lysed, and the aorta, SVC, and
IVC are exposed and cannulated. Once CPB is initiated, the outflow graft is clamped and the
pump turned off. It is imperative to clamp the outflow graft to prevent recirculation. The
SVC and IVC are isolated and snared, and the aorta is cross-clamped. The cardiectomy is
performed in the standard fashion, with simultaneous removal of the LVAD. The driveline is
cut with wire cutters, and the internal portion of the driveline is mobilized to the level of the
fascia. Once the heart transplantation is completed and the chest is closed, we remove the
remaining portion of the driveline from the exit site. We attempt to remove all remnants of
the LVAD outflow graft; however, there are times where the aortic transection is performed
at the outflow graft site due to anatomic limitations, and a small portion of the graft is left
in situ. For the Heartmate II, it is imperative that meticulous hemostasis of the abdominal
pocket be obtained. Another technique for the HeartMate II is to leave the pump in situ and
come back to remove the pump posttransplantation after some recovery of coagulation and
function has been realized.
Figure 32.11 Image provided courtesy of Heartware Inc.

Figure 32.11 Heartware™ HVAD™ implantation.
5. Ventricular Assist Device Removal or Replacement
◆ Both devices can be removed by redo sternotomy or a subcostal approach. The VAD is
explanted, and the apical site is closed with a patch closure or mechanical plug placement.
Alternatively, the VAD can be functionally excluded. This is accomplished by outflow graft
obstruction with an Amplatzer plug and discontinuing the VAD.
◆ Both the HeartMate II and HVAD can be replaced via a subcostal approach.7 This technique
is used mainly for LVAD failure (e.g., not outflow graft thrombus or VAD malposition). This
can be performed either on or off CPB. The technique involves LVAD, proximal outflow graft,
and driveline exposure. Outflow graft is clamped at the time of exchange. The VAD is removed
and replaced with the new pump. The HeartMate II outflow graft is resecured with the screw
mechanism, whereas the HVAD requires a graft to graft anastomosis. The new driveline is
tunneled and secured. Once the new VAD is functional, the incision is closed in multiple
layers.
1. Extracorporeal Ventricular Assist Devices
◆ Bleeding often occurs in the immediate postoperative period, particularly when CPB has been
used. Mediastinal drainage tubes should be used liberally to ensure complete drainage of the
mediastinum. Open chest techniques are used at my institution when exceptionally coagulopathic
patients undergo these procedures, with washouts as needed.
◆ No anticoagulant should be given while a patient is bleeding; when the patient is stable,
intravenous heparin is initiated using a specific VAD protocol to maintain the prothrombin
time between 60 and 70 seconds. Alternatively, direct thrombin inhibitors such as bivalirudin
can be used. Impella devices can be run with anticoagulation through the sheath only. It is
important in these devices to monitor for hemolysis because prolonged device time with high
power usage can result in significant hemolysis.
2. HeartMate II and HeartWare HVAD
◆ Care should be taken to avoid overdriving this pump and excessively unloading the ventricle
in the postoperative period, which can induce ventricular arrhythmias, suck-down events,
or septal distortion (right ventricular distortion leading to right ventricular dysfunction).
Patients can be particularly volume-responsive during this period and may benefit from
crystalloid or blood transfusion. Right heart failure is a concern in select patients, and proper
inotropic therapy and even temporary right ventricular assist device (RVAD) support may be
required.
1. Impella Devices
◆ Arterial injury may result from the percutaneous placement of these devices. After discontinu-
ation, one must follow up to ensure that no arterial injury or pseudoaneurysm has developed.8
◆ Ensure the security of these devices to the skin as well as to the vasculature if a cut-down is
used. Slight movements can result in malpositioning of the cannula, damage to valve structures,
and decreased support.
2. CentriMag
◆ These devices can have cardiotomy reservoirs and dialysis filters spliced inline, which can be
extraordinarily useful. However, one must be extremely vigilant to ensure that air is not
introduced into the system using one of these adjuncts.
3. Continuous-Flow Pumps
◆ The aortic anastomoses and graft anastomoses for continuous-flow pumps have a tendency
to bleed. The needle point for de-airing must also be carefully closed because this can serve
as a site of postoperative bleeding. The area can be wrapped with Surgicel (Johnson & Johnson,
Somerville, NJ) or with a circumferential graft.
4. Explantation
◆ When either the HeartWare HVAD or HeartMate II is removed, the pump should be stopped
at the time of institution of CPB, or the low pressure in the ventricle may allow the pump to
entrain air. Clamping the outflow graft at the time of CPB initiation prevents recirculation
into the left ventricle.
References
1. Rose EA, Gelijns AC, Moskowitz AJ, et al. Long-term use of a left ventricular assist device for end-stage heart failure. N Engl J Med.
2001;345:1435–1443.
2. Anderson MB, Goldstein J, Milano C, et al. Benefits of a novel percutaneous ventricular assist device for right heart failure: the
prospective RECOVER RIGHT study of the Impella RP device. J Heart Lung Transplant. 2015;34:1549–1560.
3. Loforte A, Montalto A, Lilla Della Monica P, Musumeci F. Simultaneous temporary CentriMag right ventricular assist device placement
in HeartMate II left ventricular assist system recipients at high risk of right ventricular failure. Interact Cardiovasc Thorac Surg.
2010;10:847–850.
4. Sassard T, Scalabre A, Bonnefoy E, et al. The right axillary artery approach for the Impella Recover LP 5.0 microaxial pump. Ann
Thorac Surg. 2008;85:1468–1470.
5. Adamson RM, Mangi AA, Kormos RL, et al. Principles of HeartMate II implantation to avoid pump malposition and migration. J Card
Surg. 2015;30:296–299.
6. Whitson BA. Surgical implant techniques of left ventricular assist devices: an overview of acute and durable devices. J Thorac Dis.
2015;7:2097–2101.
7. Popov AF, Mohite PN, Sabashnikov A, et al. Minimally invasive HeartWare LVAD implantation through single left thoracotomy. J Artif
Organs. 2015;18:170–172.
8. Abaunza M, Kabbani LS, Nypaver T, et al. Incidence and prognosis of vascular complications after percutaneous placement of left
ventricular assist device. J Vasc Surg. 2015;62:417–423.
CHAPTER
33
Heart Transplantation
Vivek Rao
Donor
Step 1. Surgical Anatomy and Exposure
◆ The potential donor is placed supine on the operating room table. The standard incision for
the multiorgan donor is a midline sternotomy incision extended into a midline abdominal
incision to expose the liver, kidneys, small bowel, and pancreas (Fig. 33.1).
◆ The superior vena cava (SVC) lies partly outside the pericardium. It is anterior and to the
right of the trachea and its surrounding nodal tissue. The arch of the azygos vein is noted
posteriorly as the only branch of the SVC. This is an important landmark because the SVC
should be harvested beyond the insertion of the azygos vein and, if possible, to the origin of
the innominate vein.
◆ Nine vessels are exposed during retrieval—the two cavae, four pulmonary veins, the aorta,
and the right and left pulmonary arteries. If the heart is retrieved as the sole thoracic organ,
the pulmonary veins are divided, and the pulmonary artery is divided at the level of the
bifurcation. The inferior vena cava (IVC) is usually left with the hepatic resection because
the inferior anastomosis is donor right atrium to recipient IVC.
◆ If the lungs are being simultaneously harvested with the heart, the transverse pericardial sinus
is explored in situ. The lung team usually cannulates the distal pulmonary artery at the level
of the bifurcation to facilitate organ flushing and the administration of preservative solution.
The left atrium is divided halfway between the coronary sinus and the insertion of the pulmonary
veins.
546
Chapter 33 • Heart Transplantation546.e1
Abstract
As we celebrate the 50th anniversary of the first human heart transplant in December 1967, we
marvel at the tremendous medical advances that have taken place. Surprisingly few modifications
have occurred since the original surgical technique was described by Shumway and Lower. The
following chapter describes the surgical conduct of both the donor procurement and recipient
implant for modern cardiac transplantation.
Keywords
heart transplant
surgical technique
donor management
Chapter 33 • Heart Transplantation 547
Figure 33.1
Figure 33.1 Midline incision (dotted line) to expose the organs to be retrieved.
1. Selection and Management
◆ Risk matching between donor characteristics and recipient needs ensures maximal utilization
of the potential donor pool and minimizes the risks associated with longer waiting lists.1-3
For example, a heart from a higher risk donor may be used in an older recipient with previous
surgery, but not in a younger recipient who is a good candidate for an assist device. The
typical risk factors for donor hearts include advanced age, prolonged ischemic time, preexisting
ventricular dysfunction and/or coronary disease, and the need for inotropic support.4 Fur-
thermore, it is unwise to compound risk (e.g., use an older donor subjected to a prolonged
ischemic time).
◆ Common causes of brain death include trauma and intracranial bleeding. Suicide remains a
common cause, with the mode of death incorporating both anoxic and traumatic brain injuries.
Opioid intoxication is an increasingly frequent cause of donor death. Cardiac donations after
circulatory arrest have been recently reported and are likely to increase in the future.5
◆ Screening for a given recipient begins with confirming blood type compatibility and the
approximate size, height, and weight for the patient, as well as gender. Ensuring an appropriate-
sized donor (> 0.8 of the recipient’s size) remains a key component in the selection of
donor-recipient matches. The size match guideline may be adjusted if the donor is female
and the recipient is male (closer height to weight match). It may be widened if the donor is
a younger male or if there is a shorter anticipated ischemia time. Recipient pulmonary vascular
resistance (PVR) must also be taken into account, and a larger older donor is usually preferred.
Some surgeons contend that an 80-kg male donor is adequate for any size of recipient.2
◆ The female donor older than 35 years with an intracranial bleed must be evaluated carefully.
This cause of death is frequently associated with hypertensive disease and left ventricular
hypertrophy (LVH). LVH as assessed by echocardiographic measurement of septal and posterior
wall thickness and electrocardiographic criteria should be judged in the context of the patient’s
body surface area. The use of hypertrophied hearts can significantly affect graft survival,
particularly in the presence of electrocardiographic criteria that reflect a long-standing history.6
However, LVH can be overestimated in donors who are hypovolemic.
◆ The ideal donor should have excellent cardiac function with appropriate filling pressure and
normal anatomy. He or she should not require any inotropic support; however, pressor support
to overcome low systemic vascular resistance is usually acceptable. Many centers will accept
a heart with a low filling pressure (<10 mm Hg) and no inotropic support, even in the absence
of echocardiographic assessment.
◆ As donor age increases, the depth of evaluation increases as well. Cardiac catheterization is
recommended in all males older than 45 or females older than 50 years.3 Donors with known
risk factors for coronary disease should also undergo angiography. These risk factors include
diabetes, hypertension, hyperlipidemia, smoking history, and a history of cocaine abuse.
◆ The presence of any coronary artery disease is usually a contraindication to utilization for a
standard donor. However, in extenuating circumstances for a recipient at high risk for imminent
death, simultaneous coronary bypass surgery can be performed.
◆ Hepatitis C has traditionally been a contraindication to heart donation because it may predispose
the recipient to liver dysfunction and coronary graft disease. However, newer antivirals are
now permitting the successful use of hepatitis C positive donors.7 Similarly, hepatitis B core
antibody immunoglobulin G (IgG)–positive donors may be used for high-status recipients if
immunoglobulin M (IgM) is negative. In such cases, the risk of transmission is considered
low (< 5%–10%).
2. Donor Management
◆ The ideal management of the multiorgan donor has been previously published.3 β-Adrenergic
inotropic support should be avoided if possible. Hormone replacement with thyroxine (T4)
infusion, vasopressin, and methylprednisolone should be administered routinely, regardless
of baseline LV function. Systemic blood pressure should be titrated to less than 120 mm Hg
after appropriate volume resuscitation. Anemia should be corrected because this will cause
hypotension. A PCO2 of 30 to 35 mm Hg should be sought to decrease PVR. In the common
presentation of systemic hypertension, therapy should consist of sodium nitroprusside or
short-acting beta blockers such as esmolol.
◆ The retrieval team should strive to keep the donor heart relaxed and undistended. Intraoperative
management of the donor includes inhaled anesthetic agents for blood pressure control and
judicious volume resuscitation to maintain a central venous pressure (CVP) of 8 to 12 mm Hg.
Right ventricular (RV) distention or stress is often noted when the systemic blood pressure
rises above 110 to 120 mm Hg.
1. Visualization
◆ On arrival, the retrieval team checks donor blood type against that of the recipient, as well
as donor consent, certification of brain death, and other pertinent data.
◆ Communication between the donor and recipient surgical teams is essential. A nonscrubbed
assistant is preferred who can keep the recipient team apprised as to expected cross-clamp
and travel times.
◆ A generous median sternotomy is performed and extended into a midline abdominal incision.
A short retractor is placed, with the cross bar at the superior aspect of the incision so as not
to disturb exposure for the liver transplantation team.
◆ A pericardial cradle is created with stay sutures. The lung transplantation team may choose
to secure these with clamps so that access to the pleural spaces is maintained.
◆ The heart is visualized and inspected for adequate function. The right ventricle is readily
visible. One should note a relaxed right atrium, as well as a relaxed outflow tract. The heart
should be displaced gently to assess left ventricular (LV) function and to look for a left SVC.
When examining the posterolateral wall, hypotension commonly occurs. The rate of return
to normal hemodynamics is a good indicator of myocardial function.
◆ In older donors, the coronary arteries should be palpated. Usually, a cardiac catheterization
study will have been done. Diffuse coronary artery disease may not be obstructive but would
still preclude donation. Extensive calcifications, although not necessarily stenotic, also preclude
use of the organ. The donor heart is examined for signs of long-standing hypertension such
as increased epicardial fat, tortuous coronary arteries, and a shortened ascending aorta with
effacement of the sinotubular junction.
◆ An estimate of heparin and clamp time is determined with the other organ retrieval teams.
The timing of recipient and donor operations is individualized secondary to reoperative status,
ventricular assist device (VAD) excision, and anticipated travel times. My team usually allocates
2 hours for sternal reentry and explantation of an implantable VAD. I would time the donor
cross-clamp so that arrival of the allograft in the recipient operating room would coincide
with the initiation of cardiopulmonary bypass. In cases for which total ischemic time is
expected to be prolonged, cardiopulmonary bypass is often initiated 10 to 20 minutes prior
to anticipated allograft arrival to allow for recipient cardiectomy.
◆ The aorta and pulmonary artery are separated to allow for aortic cross-clamping without
interfering with pulmonary artery cannulation by the lung team. The SVC is mobilized from
the right pulmonary artery. I usually isolate the SVC with a silk tie, which is subsequently
tied after the aortic cross-clamp is applied.
◆ A back table setup is prepared and checked at this time to allow efficient preparation and
packaging. The packing plastic bag is prepared in a large basin filled with iced saline slurry.
The bag is filled with 1 L of the same solution that is used for flush cooling. This setup keeps
the storage solution cold and prevents ice from coming into direct contact with the heart.
An aortic cross-clamp is also selected.
2. Organ Recovery
◆ Preparation is made to allow adequate suction and venting into the right chest. The pericardium
adjacent to the IVC is divided to allow drainage into the right chest. This drainage can be
collected with a pool suction. Another pool suction is prepared for insertion into the IVC,
which will be incised.
◆ The cardioplegia bag should be kept in a cooler until just before heparin is given. An assistant
or preservationist hangs and administers the cardioplegia. Heparin (300 U/kg) is administered
intravenously. A cardioplegia cannula is inserted into the ascending aorta, just distal to the
fat pad. After securing the cardioplegia cannula, the tubing is passed off to be connected to
the preservative solution bag. The line is de-aired, clamped, and connected. Cardioplegic
administration can be performed with either a pressure monitoring line or a pressurized
infuser. Care should be taken to avoid pressures higher than 200 mm Hg. Measuring cardioplegia
pressure is particularly important for pediatric and adolescent donors in whom the aorta is
small, and pressure estimation by palpation is unreliable. Flush cooling at supraphysiologic
pressures may cause edema of the donor organ, potentially leading to dysfunction.
◆ The flush cooling sequence is initiated by the cardiac team in coordination with the abdominal
team. The aortic clamp is applied and cardioplegic solution administered. The SVC is ligated
and the IVC is hemisected anteriorly to vent the right heart. The left heart is similarly vented
by an incision into the left atrial appendage. A suction catheter is placed inside the IVC and
in the right pleural space (Fig. 33.2).
◆ I usually infuse 3 L of cold Celsior solution (Genzyme, Cambridge, MA) and then store the
explanted heart in 500 mL of cold Celsior solution. I avoid topical ice because it can lead to
crystallization of epicardial fat and occasional hemorrhage of epicardial microvessels. The
heart is usually cooled to a temperature of 4° to 10°C (39.2°–50°F).
◆ It usually takes 6 to 8 minutes to flush-cool the heart. During this time, blood is observed
clearing from the coronary arteries, and the surgeon ensures that there is no right or LV
distention.
◆ Once the cardioplegia is given, the aorta should be transected if pneumoplegia is still being
given, as is usually the case. This should help further to vent the left-sided cardiac chambers
and to prevent the pneumoplegia from washing out the cardioplegia.
◆ The IVC is then divided. I usually have the abdominal team provide caudal traction to the
liver. As described previously, most of the suprahepatic IVC is kept with the liver resection.
The heart is elevated and retracted to the left to expose the right pulmonary veins for division
at the pericardial reflection. The heart is then retracted superiorly and to the right to expose
the left pulmonary veins. As described previously, if the heart is the sole thoracic organ being
procured, the pulmonary veins are divided at the pericardial reflection. If the lungs are also
being harvested, a left atrial incision is made between the coronary sinus and the insertion
of the pulmonary veins (Fig. 33.3).
Venting of
inferior
vena cava
Venting of left
atrial appendage
Figure 33.2
Coronary sinus
Figure 33.3
Figure 33.2 Venting of the left and right heart immediately after aortic cross-clamping.
Figure 33.3 Incision lines for combined heart and lung retrieval.
◆ The main pulmonary artery is divided proximal to the pneumoplegia cannula site at the
bifurcation. Again, the surgeon should look inside to follow the contour of the bifurcation
and protect the pulmonary valve. I prefer to separate the heart from the lung block in situ
(vs. on the back table).
◆ Downward traction is applied to the aorta, and it is divided beyond the clamp site. The azygos
vein is divided, as is the SVC above the site of ligation. The heart is then delivered to the
back table and placed in the cold preservation solution.
Step 4. Postretrieval Care
◆ Donor pericardium and paratracheal lymph nodes are harvested at this point, if this was not
done previously. The pericardium is packaged with the donor heart. If needed, this can be
used for patches or pledgets during the recipient operation. In congenital cases, this pericardium
is also useful for augmentation of native, recipient pulmonary arteries or other great vessels.
◆ A rapid assessment is performed to assess surgical damage, valve competency, and the presence
of a patent foramen ovale, which should be closed. I inspect the ostia of the coronary arteries
to rule out undetected disease or abnormal takeoffs, which may predispose to sudden cardiac
death. Finally, the junction of the IVC and right atrium are inspected to ensure that an
adequate rim of atrial tissue is present next to the coronary sinus.
◆ The remaining back table dissection may be performed before packaging. This dissection
includes preparing the left atrial cuff for anastomosis by dividing the pulmonary veins from
superior to inferior on either side and incising the posterior left atrium (in case of solitary
heart retrieval). The mitral valve is inspected carefully. The pulmonary artery is splayed open
and dissected away from the left atrium and SVC on the right. This will already have been
done in situ when lung retrieval has been carried out.
◆ The heart is placed in 500 mL of preservation solution inside a plastic jar. This jar is then
placed into two separate sterile bags. The outer bag is subsequently contaminated during
transport, allowing for subsequent retrieval of the inner sterile bag and jar. The jar and overlying
bags are then placed in a cooler surrounded by ice.
◆ Frequent communication is necessary with the recipient team to convey adjustments in time
to optimize donor ischemic time. I instruct the donor team to notify us just prior to anticipated
cross-clamping, on departure from the donor operating room, on flight departure and arrival
(or estimated ground travel time) and, finally, when they are approximately 10 minutes away
from the recipient operating room.
◆ Donor blood pressure will rise with stimulation. Inhaled anesthetic agents should be used to
keep systolic blood pressure at a maximum of 120 mm Hg. Transfusion of the donor with
packed red blood cells should be encouraged to avoid anemia (hemoglobin < 8 g/dL).
◆ Often, the initial donor incision is performed by the abdominal retrieval teams because they
generally require 1.5 to 3 hours to prepare their organs for retrieval. Careful inspection for
hemostasis—particularly thymic and phrenic vessels—can avoid anemia. In general, discourage
the abdominal team from contaminating the thorax with intraabdominal contents (e.g., omentum,
small bowel). Particularly in cases of trauma, these structures may no longer be sterile and
could potentially lead to life-threatening infection in the cardiac allograft.
◆ Focused communication with the lung harvest team is needed to avoid cardiac distention,
which can be extremely deleterious to the posttransplantation function of the donor heart.
It is important to wait until the left atrial appendage is vented and the heart is arrested before
starting lung perfusion. This also prevents the lung perfusate from displacing the cardioplegia
solution from the aortic root. If the cardioplegia has finished infusing before the pneumoplegia,
the aorta must be transected and suction carefully advanced toward the aortic valve to prevent
the pneumoplegia from washing out the cardioplegia. Pneumoplegia may be toxic to the heart
and coronary arteries.
◆ In severe chest or abdominal trauma, the surgeon must always be alert to the possibility of
hematomas around the aorta or innominate vein, which may be a source of important blood
loss on opening the chest.
◆ Excessive manipulation of the donor heart during flush cooling may cause transient aortic
valve incompetence, with ensuing right and LV distention, and therefore should be avoided.
◆ On excision, it is crucial to avoid damage to the coronary sinus during division of the IVC
and left atrium. Suboptimal length of the SVC can lead to sinoatrial node damage.
Adult Recipient
◆ The recipient’s pericardial space is often enlarged, making it prone to postoperative effusions
because of the relatively smaller donor heart size.
◆ Even during a planned bicaval anastomosis, the SVC and IVC do not need to be mobilized
away from adjacent structures. Although I favor transecting the SVC, necessitating separation
from the right pulmonary artery posteriorly, many surgeons preserve the posterior wall of the
right atrium. Preserving the posterior wall provides greater flexibility in sizing the length of
the donor to recipient SVC anastomosis.
◆ The right pulmonary artery is often enlarged, thin, and friable owing to heart failure. It is
posterior to the aorta and may be injured during aortic clamping or excision of the recipient
native heart.
1. Recipient Selection
◆ The revised listing criteria have recently been updated by the International Society for Heart
and Lung Transplantation (ISHLT).8 In general, there are few absolute contraindications to
heart transplant, and many prior absolute contraindications are now relative. Psychosocial
factors increasingly have been recognized as important determinants of long-term outcome,
and a history of noncompliance and persistent substance abuse should raise concerns about
the recipient’s willingness to adhere to the prescribed regimen following transplantation. A
recent history of potentially metastatic cancer is perhaps the only other absolute contraindication
to transplantation. Many other relative contraindications can be overcome by bridging with
a durable VAD, including obesity, pulmonary hypertension, and renal insufficiency.9
◆ It is important to perform a right heart catheterization immediately prior to transplantation
to verify that the PVR is less than 4 Wood units. The absolute value of the pulmonary artery
pressure itself can be misleading with regard to pulmonary hypertension because it may be
elevated passively secondary to a high left atrial pressure. I generally target a transpulmonary
gradient (TPG—mean pulmonary artery pressure minus pulmonary capillary wedge pressure)
of less than 12 mm Hg. When this is found to be elevated pretransplantation, I attempt
vasodilator therapy with sodium nitroprusside and diuretic therapy with intravenous (IV)
furosemide. If the TPG remains higher than 15 mm Hg, I will consider canceling the planned
transplantation. This is particularly important in the setting of valvular cardiomyopathy, in
adults with congenital heart disease, or in those with hypertrophic cardiomyopathy.
◆ Due to their disease process, a recipient’s heart and pericardial cavity are usually significantly
dilated. Therefore, apart from acute fulminant myocarditis or acute massive myocardial infarc-
tion, oversizing a donor to recipient is rarely problematic. Caution should be exercised with
extreme height mismatches because an extended donor SVC-IVC length can lead to obstruction
when the recipient is significantly shorter.
◆ Due to current organ allocation criteria, most transplant recipients are deemed as high status
and inpatients at the time of being offered an organ. It is increasingly rare to admit an outpatient
for transplantation unless she or he is supported by a VAD. The most recent ISHLT registry
report has suggested that almost 50% of transplant recipients are currently bridged with a
mechanical circulatory support device.4
2. Preparation, Timing, and Coordination With Donor Operation
◆ If the recipient is anticoagulated, warfarin may be reversed with vitamin K, 2 mg, given
intravenously as a slow infusion. Although central venous lines (permitting the insertion of
a Swan-Ganz catheter for the assessment of PVR) are routinely inserted preoperatively, the
recipient does not undergo induction of anesthesia until the donor heart has been found to
be satisfactory.
◆ Inotropic agent infusions are continued until cardiopulmonary bypass is initiated. Automatic
defibrillators are usually adjusted after entry into the operating room. I favor maintaining
pacing and antitachycardiac pacing therapies while deactivating shock therapies. In pacer-
dependent patients, the device is set to dual chamber sense, dual chamber pace, and 0
response to sensing (DDO) mode to permit the use of electrocautery.
◆ I usually allow 1 hour from skin incision to arrival of the donor heart in recipients who have
not undergone a previous sternotomy. In patients with a prior sternotomy, this period is
extended to 2 hours to allow adequate time for complete dissection of the native heart before
heparin administration. In patients with a prior sternotomy, patent internal mammary artery
grafts, biventricular failure (with high RV pressure), or assist device, the surgeon may consider
exposure of the femoral artery and vein.
◆ Most multiorgan donor procedures require 1 to 3 hours from visualization to cross-clamping.
An additional 30 minutes is needed for organ perfusion, excision, and back table dissection
and packaging. It is advisable to err on the side of the recipient team’s being ahead of the
donor team. Again, frequent communication between the retrieval and implantation teams
is essential
1. Initiation of Cardiopulmonary Bypass and Native Heart Excision
◆ As with any redo cardiac surgical procedure, after safe sternal reentry, the ascending aorta is
mobilized to permit arterial cannulation and subsequent transfusion, if required. I then normally
expose the right atrial free wall to again permit urgent cannulation should the need arise. At
this point, the IVC and SVC are dissected and prepared for direct cannulation. As mentioned
previously, in high-risk redo cases, consideration is given to percutaneous femoral cannulation
for arterial and/or venous access. The heart is manipulated minimally owing to extreme irritability
and possible dislodgment of a left atrial or ventricular thrombus.
◆ Ideally, cardiac dissection is completed prior to the administration of heparin. Time permitting,
I favor packing the pericardium for 5 minutes to allow for normal coagulation. Heparin is
then given when the donor heart is about 30 minutes away. Direct vena cava cannulation is
accomplished with low-profile, high-flow cannulae. Cardiopulmonary bypass can be initiated
10 to 20 minutes before the donor heart arrives. VADs are deactivated, and the cannulae and
grafts are clamped before cardiopulmonary bypass is initiated. Sometimes it is safer to cannulate
the IVC after the initiation of cardiopulmonary bypass. The donor heart is kept in its transport
cooler during native heart excision. Carbon dioxide is insufflated into the pericardial well at
a rate of 4 L/min. Ultrafiltration is routinely used during cardiopulmonary bypass, and the
hematocrit is maintained at 28%.
◆ The recipient is allowed to drift to 33°C (91.4°F) and the SVC and IVC are snared to isolate
the right heart. Cardiopulmonary bypass flow is maintained at an index of 2.4 L/min/m2.

I then routinely clamp the ascending aorta. The recipient heart does not require cardioplegia.
◆ The first incision is usually at the superior junction of the SVC and right atrium. This incision
is extended inferiorly to approximately 3 to 4 cm from the IVC cannula. This incision allows
visualization of the interatrial septum, which is then incised to enter the left atrium.
◆ Automated implantable cardioverter defibrillator and pacing leads are cut flush with the SVC
after gentle traction is applied so the remnant may retract out of the field. I usually excise
the pulse generator at the end of the procedure while waiting for hemostasis to occur.
◆ Once the left atrium is entered, the incision is carried superiorly into the dome. At this point,
the aorta and pulmonary artery are transected as close to the valves as possible to allow for
maximal length. From an immunologic perspective, it is preferable to have more recipient
tissue than donor tissue.
◆ Once the aorta and pulmonary artery have been transected, the incision in the dome of the
left atrium is extended to the left atrial appendage. At this point, I visualize all four pulmonary
veins draining into the left atrium. The lateral left atrial incision is then carried down, maintaining
an adequate rim of tissue above the orifice of the pulmonary veins. At the inferior border of
the left atrium, I focus on the right side and visualize the coronary sinus. The native heart is
then excised along the atrioventricular groove, maintaining the coronary sinus with the explanted
heart. The edges of the left atrial cuff are cauterized, as is the exposed area of the interatrial
septum. Large thebesian veins require suture ligation.
◆ If an assist device pump is present, the aorta is excised just caudal to the outflow graft
anastomosis. The LV apex can be particularly challenging to mobilize and, if time constraints
are worrisome, I will transect the LV apex and explant the VAD following donor heart implant.
◆ A small (14 F) vent catheter is placed in the right superior pulmonary vein and advanced
into the left inferior pulmonary vein to collect the bronchial return. The most proximal
opening must be in the most dependent part of the field. This helps exposure and prevents
rewarming of the donor heart after completion of the left atrial anastomosis. Just prior to
completion of the LA anastomosis, this vent is repositioned across the mitral valve to decompress
the left ventricle.
◆ As described previously, I favor transection of the SVC at its junction with the right atrium.
The SVC is mobilized away from the right pulmonary artery to provide an adequate sewing
cuff. Some surgeons favor retaining the posterior wall of the right atrium (Fig. 33.4) and
sewing the donor SVC and IVC directly to the posterior wall of the right atrium.
◆ At this point, the donor heart is removed from the cooler and brought into the operating
field. If the donor surgeon has not done so, the pulmonary artery, left atrial, and aortic cuffs
are prepared. The atrial septum is inspected for a patent foramen ovale, which must be closed
to prevent right to left shunting in case of transiently elevated pulmonary artery pressures
postoperatively.
Left atrium
Right lateral Right atrial

atrial wall appendage
Fossa ovalis
Coronary sinus
A
B
Figure 33.4
Figure 33.4 Incision lines for native heart excision (A) and proper placement of a left atrial vent (B).
2. Donor Heart Implantation
◆ The traditional order of anastomoses is the left atrium, IVC, SVC, pulmonary artery, and
aorta. Many surgeons will do the left atrium and then aortic anastomoses first to allow for
aortic cross-clamp removal and reperfusion. This is particularly useful in cases of prolonged
ischemic times. The following description refers to the traditional order of anastomoses.10
◆ The use of cardioplegia during donor heart implant is variable. Many surgeons prefer a cut
and sew technique and simply reperfuse the heart by removing the aortic cross-clamp at the
end of the procedure. In most cases, and particularly those with prolonged cold ischemic
times, I favor using intermittent cold blood cardioplegia. I usually give a dose prior to
implantation, following the left atrial anastomosis, just prior to the pulmonary artery anastomosis,
and a so-called hot shot just prior to removing the aortic cross-clamp.11
◆ Immunotherapy varies considerably among centers. At my center, I use 1 g of IV methyl-
prednisolone prior to recipient incision and an additional 500 mg IV at the removal of the
aortic cross-clamp.
◆ The key to donor implantation starts with the correct orientation of the left atrial anastomosis.
The donor heart is wrapped in a large, cold, saline-soaked gauze and placed in a small basin,
with the left atrium exposed and oriented superiorly. I routinely mark the orientation by
placing a long 3-0 polypropylene suture at the apex of the remnant left atrial appendage and
another at the junction between the IVC and inferior aspect of the left atrium. These sutures
are passed through the same locations in the donor heart so that the orientation of the posterior
left atrium anastomosis is now fixed in the correct manner.
◆ I begin the posterior left atrial anastomosis with forehand suturing patterns from the left atrial
appendage caudally to the previously placed IVC marking suture. Usually, after three or four
passes of the superior marking suture, the heart must be lowered into the pericardial cavity. It
is useful to have a second assistant place traction on the inferior marking suture while placing a
suction catheter into the donor’s left atrium, exposing the anastomotic line. The inferior marking
suture is tied and one arm tied to the suture that closed the posterior wall of the left atrium.
One arm is then passed internally to create a mattressed second layer closure travelling back to
the left atrial appendage. The advantages of this second layer include hemostasis and burying
of the raw cut edges of the left atria. The mattress suture provides endothelial apposition that
is less thrombogenic. The mattress suture then exits the left atrium at the level of the left atrial
appendage marker and tied to the original arm (Fig. 33.5).
◆ I then use the longer suture of these two arms to begin closure of the dome and anterior left
atrium. At approximately the midportion of the interatrial septum, the inferior suture is
brought forward to complete the anastomosis. As noted previously, during the transition from
the superior to inferior suture, the left atrial vent is repositioned across the mitral valve into
the left ventricle.
◆ The use of a bicaval technique is now nearly universally adopted because it has been associated
with improved RV function and less tricuspid valve regurgitation.12 Many surgeons find it
easier to perform the IVC anastomosis immediately after the left atrial anastomosis. This
ensures a tension-free connection that remains relaxed as the aorta and pulmonary artery
lengths are adjusted accordingly. The biatrial technique is rarely used in my adult practice.
It may be required in cases of congenital anomaly, such as a persistent left SVC. In such a
case, I still attempt to perform a direct SVC anastomosis in addition to a right atrial cuff
anastomosis.
◆ The posterior wall of the IVC is anastomosed first, starting with the medial (assistant) side
and finishing on the lateral (surgeon) side. I then bring the second arm of the initial suture
to complete the anterior wall of the IVC (Fig. 33.6).
Aorta
Pulmonary
artery
Superior
vena cava Aorta
Pulmonary
artery
Superior
vena cava
Right Inferior
atrium vena cava
A B
Figure 33.5
Figure 33.6
Figure 33.5 The start (A) and completion (B) of the left atrial suture line.
Figure 33.6 The inferior vena cava anastomosis.

◆ The length of the recipient’s native SVC is preserved. Nevertheless, the donor SVC up to the
azygos branch point is usually required to produce a tension-free anastomosis. This is because
the dome of the recipient native left atrium is usually enlarged, causing the donor SVC to be
displaced medially after completion of the left atrial anastomosis. In case of size mismatch,
the donor right atrium can be incised at the superior aspect of the IVC and extended appro-
priately to match the recipient IVC (Fig. 33.7).
◆ The donor pulmonary artery is separated from the aorta. The location of the left main coronary
artery, which can be seen posteriorly, is noted.

◆ The donor pulmonary artery is trimmed so that there is about 1.5 cm of tissue beyond the
pulmonary valve. A double-loaded 4-0 polypropylene suture on an SH or SH-1 needle is

used for this anastomosis. It is constructed as described previously. Size mismatch is corrected
both posteriorly and anteriorly. If the tissue appears friable, a strip of treated pericardium is
incorporated into the suture line (Fig. 33.8).
◆ At the completion of the pulmonary arterial anastomosis, systemic rewarming is initiated.
The recipient aorta is trimmed 1 to 1.5 cm proximal to the aortic clamp. The donor aorta is
gently pulled superiorly to the right of the recipient’s aorta so that the edges overlap. The
donor aorta is usually trimmed distal to the aortic fat pad with an anterior to posterior bevel
to enlarge the diameter available for the anastomosis. It is common for the donor aorta to be
significantly smaller than the recipient aorta. It must be kept in mind that the lesser curve
of the aorta is shorter than the greater curve. A 0.5-cm margin is maintained on both the
donor and recipient sides to allow for a secure suture line. The surgeon must note the location
of the left main ostium, this time by looking into the donor aortic root. A 1-cm margin is
needed to avoid distortion of the left main coronary artery.
Figure 33.7
Strip of pericardium
Recipient’s pulmonary Donor’s pulmonary

artery artery
Figure 33.8
Figure 33.7 The superior vena cava anastomosis.
Figure 33.8 The reinforced pulmonary artery anastomosis.

◆ This suture line is constructed in the same way as that of the pulmonary artery. Size mismatch
is corrected mostly anteriorly. Fig. 33.9 demonstrates the completed transplantation, with
IVC augmentation of the donor right atrium.
3. Reperfusion
◆ The LV vent is initially placed on suction, and the heart is filled by partially clamping the
venous lines. I also place a de-airing hole in the ascending aorta. Alternatively, a cardioplegia
catheter can be inserted into the root to administer the terminal hot shot, as described previ-
ously. This then becomes useful as a root vent. The anesthesiologist is instructed to place
positive pressure on the lungs (Valsalva maneuver). This maneuver also effectively de-airs the
pulmonary veins, which frequently trap air. The aortic cross-clamp is then removed to reperfuse
the heart.
◆ Once a siphon is established with the aortic root and/or LV vent, they are placed on gravity
to prevent air entrainment through the suture holes.

◆ During reperfusion, I inspect all anastomotic lines for hemostasis. Filling the heart facilitates
inspection of the IVC and SVC anastomoses. This is also the best time to retract the heart
and inspect the left atrial suture line.
◆ Electrical activity usually returns spontaneously in good donor hearts. Nevertheless, temporary
epicardial atrial and ventricular pacing wires are inserted in all patients. Inotropic support is
now initiated because it is better to wean from cardiopulmonary bypass with a hyperdynamic
state than with a dysfunctional heart that further exacerbates poor RV function. I favor an
initial infusion of epinephrine (0.05 µg/kg/min) and milrinone (0.5 µg/kg/min). Although
the epinephrine can be titrated based on hemodynamics, I usually maintain the milrinone
infusion until the patient is extubated, at which point the right ventricle is no longer stressed
by positive-pressure ventilation.
◆ It is not unusual for transplant recipients to come to the operating room on amiodarone and/
or angiotensin-converting enzyme inhibitors. Both these agents have been shown to increase
the risk of perioperative vasoplegia.13 When vasoplegia has been problematic during cardio-
pulmonary bypass, I avoid the use of milrinone due to its vasodilatory properties. Arginine
vasopressin and/or methylene blue can be used aggressively in the treatment of profound
vasoplegia.14
4. Separating From Cardiopulmonary Bypass
◆ Once an adequate heart rate, higher than 90 beats/min, is achieved (either spontaneous or
with pacing) and inotropic infusions are in place, ventilation is initiated. The root vent and
LV vent remain on gravity drainage to aid in de-airing, which is verified by transesophageal
monitoring. The perfusionist is instructed to decrease forward flow slowly while simultaneously
filling the heart to a CVP of 5 mm Hg. At this point, if de-airing is adequate, as verified by
transesophageal echocardiography (TEE), the LV vent is removed. I keep the aortic vent in
situ until the patient has been completely weaned from cardiopulmonary bypass to reduce
the risk of air embolizing from the LV cavity to the right coronary artery.
Recipient’s superior
vena cava
Aorta
Pulmonary
artery
Donor right atrium

Donor right
ventricle
Left ventricular vent
Donor left
ventricle
Recipient’s inferior vena cava
Figure 33.9
Figure 33.9 The completed transplantation.
◆ It is important to maintain an adequate mean arterial pressure (MAP; > 65 mm Hg) to optimize
RV perfusion. Norepinephrine and vasopressin infusions can be titrated as needed. As described
previously, if the MAP is higher than 80 mm Hg, epinephrine can be weaned but the milrinone
infusion should be maintained. Arterial and/or venous vasodilators are used for persistent
hypertension.
◆ If RV function is suboptimal, despite high-dose inotropic support (> 0.5 µg/kg/min of milrinone
or > 0.1 µg/kg/min of epinephrine), then I usually initiate inhaled nitric oxide or epoprostenol
(Flolan) therapy. Many centers routinely use inhalational agents in all transplant recipients
in the early postoperative period.15
◆ If hemodynamics remain poor, despite maximal medical therapy, consideration should be
given to short-term mechanical circulatory support. It is often difficult (even with TEE guidance)
to differentiate primary RV dysfunction from secondary RV dysfunction due to a hypokinetic
left ventricle. A hypokinetic right ventricle leads to underfilling of the left ventricle, which
may mask underlying LV dysfunction. Therefore, the device of choice in this situation is either
central or peripheral extracorporeal membrane oxygen (ECMO) support.16
5. Closure
◆ All foreign bodies from assist devices are removed at this time. In the case of paracorporeal
devices, the exit sites of the IVC and SVC are excised and closed primarily. The closure may
require retention sutures. In the case of an implantable device, the driveline exit site is similarly
closed. Peritoneal defects should be repaired because blood is a significant abdominal irritant.
All nonbiologic material must be removed.
◆ As described previously, during the reperfusion period I routinely pack the pericardial cavity
and suture lines with surgical sponges. While protamine is being administered to fully reverse
heparinization (even if extracorporeal life support [ECLS] has been used), the pulse generator
is removed from its subclavicular location.
◆ The mediastinum is drained with a tube anterior to the heart that is positioned along the
right pericardial edge to avoid RV compression. An additional drain is used behind the heart.
◆ I explore both pleura with small incisions in the apex to drain any preexisting effusions.
Usually, the anterior mediastinal tube is adequate to drain air from both spaces.
◆ I routinely close the native pericardium (even in cases of redo sternotomy) to achieve two
goals.17 First, mediastinal bleeding is compartmentalized into the anterior and pericardial
spaces. Bleeding from the pericardial tube necessitates reexploration, but bleeding from the
anterior mediastinal tubes usually reflects sternal and chest wall bleeding and can observed
carefully. Second, in the event of subsequent reoperation (for aortic or valvular pathology),
sternal reentry is facilitated.18
◆ The sternal edges are covered with vancomycin paste to minimize the risk of infection. Sternal
closure is routine as per any cardiac procedure using a median sternotomy.
◆ Postoperative immunosuppression varies among centers. Some prefer an induction strategy

with antilymphocyte therapy, whereas others proceed directly to triple therapy consisting of
steroids, a calcineurin inhibitor (cyclosporine or tacrolimus), and mycophenolate mofetil.19
◆ Routine intensive care monitoring is required for all cardiac transplant recipients. In contrast
to other patients, transplant recipients should have cautious volume replacement and avoid
blood products that may cause subsequent antibody sensitization. The CVP must be monitored
closely because it may be the first clue of underlying RV dysfunction. A rising systolic pulmonary
artery pressure in the setting of a stable or falling CVP is a sign of RV recovery and should
not be cause for concern.
◆ Oliguria and a rising serum creatinine level is not uncommon and may prompt the use of a
calcineurin-free immune strategy during the early postoperative period.20 Again, in the setting
of worsening renal function, one must pay close attention to volume status because an
accumulated positive balance can lead to worsening RV performance and further exacerbation
of renal function.
◆ If hemodynamics are acceptable, inhalational therapies are weaned to facilitate endotracheal
extubation. Often, the best treatment for marginal RV function is extubation, which converts
positive-pressure ventilation to negative pressure. If extubation is not possible, switching from
positive pressure to negative pressure (pressure support) is preferred.
◆ Communication between the donor and recipient teams is essential for optimizing both cold
and warm ischemic times. In addition, the donor team needs to be aware of any need for
donor pericardium, extended aorta (for aneurysmal recipient aorta), branch pulmonary arteries
(for congenital cases requiring reconstruction), or a long SVC. When necessary, donor cross-
clamping is delayed to allow the recipient team to catch up. It is preferable to have the
recipient cannulated and heparinized awaiting donor arrival than to have the donor organ
remain in storage during recipient dissection.
◆ Implanting the donor heart usually takes about 45 to 60 minutes. This is considered warm
ischemia time.
◆ RV dysfunction is the most common pitfall because of recipient PVR. In addition to the
aforementioned treatment plan, one should consider pacing to a rate of 90 to 110 beats/min.
This increases cardiac output and helps prevent overdistention of the right ventricle. The
latter causes decreased coronary perfusion and poor function.
◆ Postoperative bleeding is a major concern because extensive transfusions will cause a transient
rise in PVR and secondary RV dysfunction. Along these lines, cardiopulmonary bypass time
should be minimized. In recipients with previous surgery, bypass should be delayed until as
much of the dissection as possible has been carried out. This must be weighed against the
risk of prolonging cold ischemia time, which may be acceptable.
◆ Adults with congenital heart disease often present the challenge of pulmonary artery or other
great vessel reconstruction at the time of transplantation. This may require the use of additional
donor conduit or pericardial patches or polytetrafluoroethylene graft material. Many of these
recipients also have a greatly increased bronchial collateral circulation. They may require
moderate to deep hypothermia (22°–28°C; 71.6°–82.4°F) to reduce this flow and minimize
potential warm ischemia of the donor heart. The increased return to the left-sided chambers
also requires a larger donor size than usual, usually 20% greater than the recipient.
◆ When performing transplantation in a recipient who has been bridged with a biventricular
assist device, removal of the right VAD before cannulation for cardiopulmonary bypass should
be considered. This is usually well tolerated and allows for a more extensive dissection before
anticoagulation.
◆ The presence of a left SVC without an innominate bridge warrants preservation of the recipient
coronary sinus and performance of a biatrial anastomosis. The SVC should also be cannulated
during cardiopulmonary bypass. Alternatively (in cases of redo), a drop vent can be placed
in the recipient coronary sinus to return left SVC effluent to the pump circuit.
◆ The pulmonary anastomosis is rarely too short and commonly too long, causing kinking and
right ventricular outflow tract (RVOT) obstruction.21 When sizing the pulmonary arteries, err
on the side of being too short. It is possible to sew the sinotubular junction of the donor to
the pericardial reflection of the recipient and still be adequate in length.
◆ In patients with high preoperative PVR, donor size mismatch, or prolonged ischemic times,
some surgeons advocate a back table tricuspid valve repair. This is achieved via the IVC
incision and consists of a DeVega-type annuloplasty.22
◆ Most postoperative surgical bleeding comes from the aorta because of size mismatch and
friable recipient tissue. Trimming the donor aorta with a bevel that accentuates the natural
curve of the ascending aorta, as described previously, helps adjust the size mismatch. The
surgeon should observe the left main orifice inside the donor aorta to keep at least 1 cm of
tissue distal to this on the posterior aspect. There should be a low threshold for performing
a double suture line for the aortic anastomosis; it adds very little time to the warm ischemia
and provides great benefit with regard to bleeding.
◆ Due to common size mismatch between the donor and recipient vessels, a so-called pseudo-SVC
obstruction can occur, as manifested by turbulent flow across the SVC anastomosis. A direct
pressure gradient should be determined intraoperatively with a needle transducer. A gradient
over 7 mm Hg should prompt revision of the SVC anastomosis, usually requiring pericardial
patch augmentation. A percutaneous approach is also possible to correct this problem.23
◆ Recently, there has been a trend toward earlier institution of mechanical circulatory support
in patients with primary graft dysfunction. This strategy avoids persistent hypotension, which
aggravates RV dysfunction and also prevents end-organ injury to the liver and kidney.24
References
1. Marelli D, Laks H, Kobashigawa J, et al. Seventeen-year experience with 1083 heart transplants at a single institution. Ann Thorac
Surg. 2002;74:1558–1567.
2. Zaroff JG, Rosengard BR, Armstrong WF, et al. Consensus conference report: maximizing use of organs recovered from the cadaver
donor: cardiac recommendations, March 28-29, 2001, Crystal City, Va. Circulation. 2002;106:836–841.
3. Shemie SD, Ross HJ, Pagliarello J, et al. Canadian Council for Donation and Transplantation. Organ donor management in Canada:
recommendations of the forum on Medical Management to Optimize Donor Organ Potential. CMAJ. 2006;174:S13–S32.
4. Lund LH, Edwards LB, Dipchand AI, et al. The International Society for Heart and Lung Transplantation: thirty-third official Heart
Transplant Report. J Heart Lung Transplant. 2016;35:1170–1184.
5. Dhital KK, Iyer A, Connellan M, et al. Adult heart transplantation with distant procurement and ex-vivo preservation of donor hearts
after circulatory death: a case series. Lancet. 2015;385:2585–2591.
6. Marelli D, Laks H, Fazio D, et al. The use of donor hearts with left ventricular hypertrophy. J Heart Lung Transplant.
2000;19:496–503.
7. Khan B, Singer LG, Lilly LB, et al. Successful lung transplantation from hepatitis C positive donor to seronegative recipient. Am J
Transplant. 2017;17:1129–1131.
8. Mehra MR, Canter CE, Hannan MM, et al. The 2016 International Society for Heart and Lung Transplantation listing criteria for heart
transplantation: a 10-year update. J Heart Lung Transplant. 2016;35:1–234.
9. Elhenawy AM, Algarni KD, Rodger M, et al. Mechanical circulatory support as a bridge to transplant candidacy. J Card Surg.
2011;26:542–547.
10. Wolfsohn AL, Walley VM, Masters RG, et al. The surgical anastomoses after orthotopic heart transplantation: clinical complications
and morphologic observations. J Heart Lung Transplant. 1994;13:455–465.
11. Teoh KH, Christakis GT, Weisel RD, et al. Accelerated myocardial metabolic recovery with terminal warm blood cardioplegia. J Thorac
12. Aziz T, Burgess M, Khafagy R, et al. Bicaval and standard techniques in orthotopic heart transplantation: medium-term experience in
cardiac performance and survival. J Thorac Cardiovasc Surg. 1999;118:115–122.
13. Leyh RG, Kofidis T, Struber M, et al. Methylene blue: the drug of choice for catecholamine-refractory vasoplegia after
cardiopulmonary bypass. J Thorac Cardiovasc Surg. 2003;125:1426–1431.
14. Argenziano M, Chen JM, Cullinane S, et al. Arginine vasopressin in the management of vasodilatory hypotension after cardiac
transplantation. J Heart Lung Transplant. 1999;18:814–817.
15. Ardehali A, Hughes K, Sadeghi A, et al. Inhaled nitric oxide for pulmonary hypertension after heart transplantation. Transplantation.
2001;72:638–641.
16. Rao V. Resurgence of extracorporeal support for the primary management of cardiogenic shock. J Thorac Cardiovasc Surg.
2015;150:341–342.
17. Rao V, Komeda M, Weisel RD, et al. Should the pericardium be routinely closed after heart operations? Ann Thorac Surg.
1999;67:484–488.
18. Elhenawy AM, Feindel CM, Ross H, et al. Valve-sparing root and ascending aortic replacement after heart transplantation. Ann Thorac
Surg. 2012;94:2114–2115.
19. Ruan V, Czer LS, Awad M, et al. Use of anti-thymocyte globulin for induction therapy in cardiac transplantation: a review. Transplant
Proc. 2017;49:253–259.
20. Nelson LM, Andreassen AK, Andersson B, et al. Effect of calcineurin-inhibitor free Everolimus-based immunosuppressive regimen on
albuminuria and glomerular filtration rate after heart transplantation. Transplantation. 2017;101:2793–2800.
21. Dreyfus G, Jebara VA, Couetil JP, Carpentier A. Kinking of the pulmonary artery: a treatable cause of acute right ventricular failure
after heart transplantation. J Heart Transplant. 1990;9:575–576.
22. Jeevanandam V, Russell H, Mather P, et al. A one-year comparison of prophylactic donor tricuspid annuloplasty in heart
transplantation. Ann Thorac Surg. 2004;78:759–766.
23. Sze DY, Robbins RC, Semba CP, et al. Superior vena cava syndrome after heart transplantation: percutaneous treatment of a
complication of bicaval anastomoses. J Thorac Cardiovasc Surg. 1998;116:253–261.
24. Takeda K, Li B, Garan AR, et al. Improved outcomes from extracorporeal membrane oxygenation versus ventricular assist device
temporary support of primary graft dysfunction in heart transplant. J Heart Lung Transplant. 2017;36:650–656.
CHAPTER
34
Chronic Thromboembolic
Pulmonary Hypertension
Gus J. Vlahakes and Cameron D. Wright
◆ Chronic thromboembolic pulmonary hypertension (CTEPH) is an increasingly recognized

clinical entity. Pulmonary embolism (PE) is a common disease, with an annual incidence of
about 100/100,000 in the United States. Many episodes of PE, however, are silent; from 30%
to 50% of patients with CTEPH have no history of a PE. Patients with a prior PE who do
not have complete fibrinolysis of their clot may go on to have the residual clot remodel into
a scar, which can occlude or narrow segmental, lobar, and even main pulmonary arteries with
a fibrous plug, leading to pulmonary hypertension. The incidence of CTEPH after a documented
PE has been reported in several studies, and a reasonable estimate is in the 4% to 5% range.
The classic study by Pengo and colleagues has suggested a 3.8% incidence of CTEPH after a
PE.1 A more recent study has suggested a 4.8% incidence of CTEPH after a PE.2 Risk factors
for CTEPH are listed in Table 34.1.3 Although many hypercoagulable states have been docu-
mented in CTEPH patients (e.g., antithrombin III deficiency, protein C, protein S, factor V
Leiden, prothrombin gene mutation), they are not more prevalent than in patients with
primary pulmonary hypertension. However, antiphospholipid antibody syndrome is more
prevalent in CTEPH patients.
◆ The diagnostic evaluation process is relatively straightforward; the most important factor is
to consider this process when a patient presents with unexplained dyspnea with a clear chest
radiograph and no obvious cardiopulmonary disease.4,5 Common presenting symptoms include
dyspnea on exertion, atypical exertional chest discomfort, exercise intolerance, exertional
presyncope or syncope, and hemoptysis. Common signs include signs of right heart failure
with lower extremity edema, hypoxemia, and occasionally pulmonary artery (PA) flow murmurs.
◆ A ventilation-perfusion (V̇ /Q̇ ) scan will show substantial segmental defects in CTEPH, whereas
a normal V̇ /Q̇ scan essentially eliminates CTEPH from further diagnostic consideration
(Fig. 34.1). An echocardiogram can then confirm significant pulmonary hypertension and
screen for other cardiac disease. Complete pulmonary function tests are usually performed
in older patients to screen for other pulmonary disease. In the United States, contrast-enhanced,
pulmonary embolism (PE) protocol, chest computed tomography angiography (PE-CTA) is
also performed to screen for other pulmonary disease and to demonstrate the PA anatomy.
Findings on CT suggestive of CTEPH include a mosaic perfusion pattern, peripheral infarcts,
a clot within the PA, narrowed pulmonary arteries, webs, and PA cutoffs. Dual-energy CTA
is a promising imaging modality that may help better identify good operative candidates and
can potentially offer a quantitative estimate of the degree of PA obstruction. Magnetic resonance
angiography (MRA) is often used in European centers instead of CTA to evaluate CTEPH
patients.
566
Chapter 34 • Chronic Thromboembolic Pulmonary Hypertension566.e1
Abstract
Chronic thromboembolic pulmonary hypertension is an uncommon but increasingly recognized

surgically treatable cause of pulmonary hypertension. Diagnosis is often delayed when patients
present with unexplained exertional dyspnea in the absence of obvious cardiopulmonary disease.
The standard evaluation process includes an echocardiogram, a ventilation perfusion scan, chest
computed tomography angiography, and a right heart catheterization with a pulmonary angiogram.
Most patients have surgically accessible disease when evaluated by an experienced hypertension
team. The operation is standardized and performed through a median sternotomy, with standard
bicaval and aortic cannulation. Hypothermic circulatory arrest is used to ensure a bloodless
field. The key to the operation is selecting the proper dissection plane between the intima and
the media, which allows the surgeon to dissect the specimen far out into the segmental and
subsegmental pulmonary artery vessels. Anticoagulation is started early postoperatively as soon
as mediastinal chest tube output is minimal. Most patients have a good result and operative
mortality is now under 5% in most centers.
Keywords
chronic thromboembolic pulmonary hypertension

pulmonary thromboendarterectomy
Chapter 34 • Chronic Thromboembolic Pulmonary Hypertension 567
Table 34.1 Risk factors for chronic thromboembolic pulmonary hypertension

RISK FACTOR ODDS RATIO
Previous PE 19
Younger age 1.8/decade
Larger defect on perfusion scan 2.2/decile decrease in perfusion
Unprovoked PE 5.7
Splenectomy 18
VA shunt or infected pacemaker 76
Chronic inflammation Increased
Antiphospholipid antibody syndrome Increased
PE, Pulmonary embolism; VA, ventriculoatrial.
Figure 34.1
Figure 34.1 Preoperative V/Q scan in a patient with CTEPH and a pulmonary artery systolic pressure of 100. Notice the reduced global
perfusion to the right lung and segmental defects.
◆ A right heart catheterization is finally performed to measure the hemodynamics of the pulmonary
circulation and obtain a two-plane pulmonary angiogram. Typical findings include delayed
filling of vessels, branch occlusions, webs, pouches, and narrowed vessels (Fig. 34.2). A left
heart catheterization is performed in those with suspected or reasonably possible coronary
disease based on age and atherosclerosis risk factors. Ideally, an experienced multidisciplinary
CTEPH team reviews the evaluation and makes an operability decision. In general, the degree
of identified PA obstruction should match the pulmonary artery pressure (PAP) and pulmonary
vascular resistance (PVR). The vast majority of patients are operable in experienced centers
if there are at least several segmental PA obstructions because imaging studies usually under-
estimate the degree of disease found at pulmonary thromboendarterectomy (PTE). True distal
disease should be avoided but is uncommon. Particularly in patients with acute or chronic
PE, it is important to determine if there is still clotting in the deep venous systems of the
legs. If vascular ultrasound suggests this, addition of an inferior vena cava (IVC) filter should
be considered. Although IVC filters are accompanied by some degree of controversy, if used
in this setting, consideration should be given to removing them within 6 postoperative months.
Although routine IVC filters used to be advocated for all patients with CTEPH, this is an area
of unresolved controversy, and we usually do not place them in the typical patient. We have
occasionally proceeded to surgery based solely on the V̇ /Q̇ scan and echocardiographic estimation
of PA pressure in patients with classic histories who present acutely and are very ill.
Step 2. Indications for Surgery
◆ The indications to perform a PTE are straightforward—a symptomatic patient, significant

pulmonary hypertension, segmental or proximal obstructive disease amenable to clearance
with PTE, and the absence of severe comorbid disease. A controversial indication is symptomatic
patients with only exercise-induced pulmonary hypertension. The reasons for performing a
PTE include not only improving exercise capacity, but also stabilizing the longer term prognosis
by preventing progression of distal PA arteriopathy and continued loss of right ventricular
(RV) function. Patients with atrial level shunts can also become desaturated, particularly with
exercise.
Figure 34.2
Figure 34.2 Pulmonary angiogram of a patient with CTEPH demonstrating missing segmental branches and pouches.
◆ Although these patients can be hemodynamically tenuous, generally they can be anesthetized
safely. A potential exception is the patient who may have acute or chronic PE, with severe
right heart failure. To the extent possible, a PA catheter should be placed before the induction
of anesthesia; rising central venous pressure (CVP) during the induction of anesthesia should
trigger concern that right heart function is declining. Patients are positioned supine and
prepped as per cardiac surgery routine. In the unusual situation in which a concomitant
coronary bypass is planned, the preparation should include access for harvesting conduit.
Concomitant cardiac procedures can be included and, in general, the operative strategy should
include planning the concomitant procedure during rewarming after the period of hypothermic
circulatory arrest needed for PTE.
◆ The anesthesia technique should take into consideration minimizing right heart afterload.
Hypercarbia should be assiduously avoided, and mean airway pressure should be kept to a
minimum. The addition of pulmonary vasodilators has not been required. Maintaining generous
systemic pressure is key to maintaining stable right heart function. Transesophageal echocar-
diography is routinely included and, specifically, the following issues are examined:
◆ Is there a clot in transit through the right heart?
◆ Is there any patency of the interatrial septum?
◆ Is there severe tricuspid valve regurgitation with a dilated tricuspid annulus?
◆ Is right heart function impaired and to what degree?
◆ Routine median sternotomy is used, and the incision should not be made too short. These
patients require generous exposure, particularly in the upper half of the thorax. The pericardium
is then opened in the midline and fashioned into a cradle as usual. The superior vena cava
(SVC) is then mobilized from under the pericardial reflection and off the right PA. The
ascending aorta is mobilized free from the PA. Exposure and patient stability permitting, the
right and left pulmonary arteries are mobilized from under their pericardial reflections. If any
surgery is required through the right atrium, the IVC is also circumferentially mobilized.
◆ In a given cardiac surgery center, the cannulation and perfusion protocol described here can
be modified according to institution custom and practice. Aortic cannulation is per routine.
Through purse-string sutures placed on the right atrial free wall, angled cannulae are inserted.
The SVC purse string should be close to the cavoatrial junction so that the SVC cannula
reaches well into the SVC (Fig. 34.3). For the average-sized patient, a 28-mm, short-tipped
cannula is placed in the IVC, and a 24 F, long-tipped cannula is directed into the SVC. The
longer cannula is required for retraction of the SVC to avoid SVC obstruction while on
cardiopulmonary bypass and while the SVC is being retracted. In patients who are over
approximately 100 kg, a 31-mm cannula can be used in the IVC and a 28-mm, long-tipped
cannula can be used in the SVC.
◆ During the initial setup for the case, the perfusionist should be asked to set the temperature
on the heat exchanger jacket at 16°C (60.8°F) and to circulate the prime so cooling will start
immediately. Bypass is then instituted. Following initial cooling, 100 mg of lidocaine can be
given to prolong the period of cooling time before ventricular fibrillation occurs. When bypass
is instituted, a small opening is made in the proximal left PA, and a cardiotomy suction
catheter is inserted as a PA vent. A cardioplegia catheter is inserted in the ascending aorta for
cardioplegia infusion. As much time as possible is allowed to elapse before it is necessary to
cross-clamp the aorta because cooling time is often a limiting factor in the initial phase of
the operation. When ventricular fibrillation occurs, the aorta is cross-clamped, and cardioplegia
is administered. The cardioplegia cannula in the aorta may also be used as a left ventricular
(LV) vent. The SVC and aorta are retracted apart with a Weitlaner retractor (Fig. 34.4). It is
important to monitor the CVP as the retraction is applied to be sure that there is no SVC
obstruction.
Aortic cannula
SVC cannula
PA vent
IVC cannula
Figure 34.3
SVC and aorta spread apart

to expose right pulmonary artery
Figure 34.4
Figure 34.3 This is the basic cardiac surgical setup used for perfusion. The long-tipped cannula in the SVC is used to prevent SVC
obstruction when the SVC and ascending aorta are retracted apart. Note that in some circumstances (depending on individual patient
anatomy), the SVC must be retracted to the left to permit access to the more distal parts of the right pulmonary artery.
Figure 34.4 Retraction for exposure of the right pulmonary artery.

◆ An incision is made in the anterior wall of the right PA and is extended past the pars anterior
origin and into the interlobar artery. A reduced-size cardiotomy suction catheter is placed
distally to collect back-bleeding from the bronchial circulation. The PTE plane is initiated
and, visibility permitting, as much of the initial dissection as possible is done.
◆ Selecting the endarterectomy plane is a critical step and may be initiated two ways. It can be
either initiated on the back wall of the PA with a small scalpel (Fig. 34.5), or it can be initiated
at the cut edge of the pulmonary arteriotomy with a fine scalpel or coronary endarterectomy
instrument (Fig. 34.6). The depth of the endarterectomy plane is a key point in this operation.
The plane is subintimal and just into the media; if it is too deep, the wall of the PA can be
at risk to dehisce, resulting in massive hemoptysis when the PA is repressurized. If it is too
thin, the dissection will fail, with premature breaking off of the specimen.
◆ Although the endarterectomy specimen may sometimes be quite thin at the point of initiation,
it becomes thicker as more pathology is approached distally in the endarterectomy. The correct
plane is white and transverse fibers from the media are visible. The intima may have pale
yellow plaques from a previous embolic clot. The plane is then continued distally, as much
as possible, until back-bleeding limits visibility. Special forceps are used in a hand over hand
manner, placing gentle traction on the specimen until the dissection is advanced as far as
possible and the specimen gives somewhat. Then the specimen is grasped more distally with
another pair of forceps and the first pair of forceps is released, all the time maintaining gentle
traction (Fig. 34.7). The endarterectomy plane is developed and extended using special fine,
SVC
Right pulmonary artery
Aorta
A B
Figure 34.7
Figure 34.5 Initiation of the endarterectomy plane in the posterior pulmonary artery with a #15 blade in a transverse fashion incising the
intima to reach the superficial media.
Figure 34.6 Initiation of the endarerectomy plane in the cut edge of the pulmonary artery wall in a longitudinal fashion between the
intima and the media with a #11 blade.
Figure 34.7 (A) Forceps especially designed for use in PTE. Four different types are used: regular length, with regular and fine jaws; and
extra-long forceps, with regular and fine jaws. Two types of Jamieson dissecting suckers are shown. The straight one is used for most of the
dissection, whereas the curved one is useful for the middle lobe and upper lobe at times due to its gentle curve. (B) Detail of tips of PTE
forceps. The regular one is used for most work and the fine tip one is useful in small segmental branches.
blunt-tipped suction attached to the cardiotomy return—the Jamieson dissecting sucker (Figs.
34.8 and 34.9). The amount of endarterectomy that can be done is limited by collateral blood
return affecting visibility.
◆ A small-caliber cardiotomy suction inserted into the distal interlobar artery and pars anterior
can help extend the dissection. Usually, it is possible to carry an endarterectomy plane into
the pars anterior and interlobar artery. When blood return obscures the view too much,
hypothermic circulatory arrest should be instituted. Usually, cooling time before cross-clamp
application plus cooling time during the initial dissection is adequate. With the perfusion
protocol we use, and with the anticipated circulatory arrest times used, we generally cool for
at least 45 minutes before instituting circulatory arrest.
◆ Cardioplegia is then renewed, magnesium is administered (100 mg/kg), and ice packs are
placed around the patient’s head, including under the occiput, to maintain local hypothermia.
The circulation is then arrested, and several large breaths are given by the anesthesiologist to
help exsanguinate the lungs, which improves exposure of the interior of the PA. A request
to the perfusionist is made to call out the arrest time, starting 10 minutes into the arrest
period and then every 5 minutes thereafter.
◆ The right-sided PTE then continues. It is our practice to endarterectomize the entire circulation
into each segmental artery because often additional small obstructions are found that were
not evident on imaging studies. One important point to keep in mind is that there will be
the rare patient with long-standing disease that has calcified. Extreme caution is suggested
when endarterectomizing such a territory because the calcified specimen may inadvertently
carry the plane deeper than desired, resulting in compromise of the integrity of the PA.
◆ As the endarterectomy plane is developed, it is important to maintain gentle traction on the
endarterectomy specimen; the hand over hand technique is continued to permit eversion of
the artery being cleared. Using the dissecting Jamieson sucker, the remaining artery is gently
pushed off the specimen circumferentially, gradually going deeper and deeper into the distal
segmental artery. The specimen will eventually break off, ideally beyond the thickened intima,
which has a pale yellow color, and into an area of now normal, almost translucent, intima.
Depending on the difficulty and exposure, the right side can often be cleared with 15 to 20
minutes of circulatory arrest. If it is predicted that a longer time is going to be required—more
than about 25 minutes—hypothermic reperfusion is reinstituted, and cardioplegia is renewed.
Once the venous saturation reaches 100%, the circulation can be arrested again.
◆ The right-sided PTE is then completed. The small-caliber cardiotomy suction is then placed
in the distal right PA, and hypothermic reperfusion is reinstituted. The pulmonary arteriotomy
is closed using two layers of continuous 6-0 Prolene sutures (Fig. 34.10). Cardioplegia is
renewed.
◆ The heart is retracted upward and toward the right, using a retractor-mounted flexible retractor
(Fig. 34.11). The opening used for the PA vent is enlarged out on to the left PA. The PA vent
catheter is then turned into the right PA origin. As on the right side, a thromboendarterectomy
plane is initiated and, visibility permitting, the endarterectomy is carried as far distally as
possible.
◆ Cardioplegia is renewed and, again, the circulation is arrested. The left PTE usually can be
completed with one arrest because the disease is often less severe here. However, if additional
time is needed for some reason, the same principle is applied and, rarely, an additional period
of circulatory arrest is required.
◆ On completion of the left side, hypothermic reperfusion is reinstituted until the venous satura-
tion reaches 100%, and full rewarming is begun; ice packs are removed from around the
head. The PA vent is then withdrawn to the main PA. The left PA arteriotomy is closed again
using two layers of continuous 6-0 Prolene sutures, starting distally and extending proximally.
The suture line is then interrupted, leaving a small proximal opening large enough for the
PA vent. The PA closure sutures and their needles are left in place for later closure of the rest
of the pulmonary arteriotomy. Fig. 34.12 demonstrates a typical specimen retrieved after PTE.
◆ In general, we wait until the perfusion temperature reaches 30° to 32°C (86°–89.6°F) before
removing the cross-clamp. Accordingly, additional cardioplegia usually has to be administered

at this point.
SVC
Right pulmonary artery
Clot
Aorta
Line of arteriotomy in
left pulmonary artery
Figure 34.12
Figure 34.8 The hand-over-hand method of applying traction on the thromboendarterectomy specimen. Note the suction dissection tool
used to develop the endarterectomy plane.
Figure 34.9 A Jamieson dissection sucker used for PTE. Notice the fine blunt tip with holes in the end and on the sides.
Figure 34.10 Closure of the right pulmonary artery with two running 6-0 prolene sutures.
Figure 34.11 Exposure for left pulmonary artery thromboendarterectomy with the aide of a table-mounted retractor.
Figure 34.12 Typical PTE specimen with abnormal intimal thickening and obstruction of numerous segmental arteries.
◆ Ifconcomitant cardiac surgery is required, such as patent foramen ovale (PFO) closure or
the rare patient who needs tricuspid reconstruction or coronary bypass, it is done during the
rewarming period so as to use this time effectively. On completion, the cardioplegia cannula
in the aorta is placed on low-level suction, and the aortic cross-clamp is removed. Pacing
wires are placed and, when appropriate and if needed, the patient is defibrillated. Once a
stable rhythm is obtained with stable cardiac activity, the vent is withdrawn from the main
PA, the right heart is de-aired by allowing it to fill and eject through the PA vent site, and
the remaining small opening in the PA is closed using two layers of continuous 6-0 Prolene
sutures, using the ends of the sutures that were left from the initial PA closure.
◆ In general, we try to rewarm the patients thoroughly. A warming blanket may be started
underneath the patient, largely for maintenance of temperature after bypass. The room
temperature is turned up after the cross-clamp is released. Cardiopulmonary bypass and
hemodynamic management are routine at this point. Nitrous oxide or epoprostenol sodium
(Flolan) have very rarely been required because good patient selection results in substantial
PA pressure reduction, with resultant unloading of the right ventricle after PTE. When the
right side is initially pressurized is the best time to examine the left and right PA suture lines
in the event that any repair stitches are needed. In general, we have accomplished this using
horizontal mattress sutures of 5-0 Prolene and pericardial pledgets. Also, the anesthesiologist
is asked to check the airway to make sure that there is no blood at this time.
◆ Cardiopulmonary bypass is weaned, and the patient is decannulated in routine fashion.
Heparin is reversed, as per routine. The mediastinum is drained using a traditional straight
anterior chest tube, and a soft Silastic Blake drain (Ethicon, Somerville, NJ) is placed posteriorly
and brought up along the left side of the main PA. Many of these patients will have a prolonged
period of serous drainage from the dissection around the PAs, and this small drain appears
to reduce the incidence of troublesome pericardial effusions. Chest closure is per routine.
◆ Postoperative care and, in particular, the duration of ventilator support, is determined by

whether or not patients have a reperfusion injury and an increased alveolar-arterial (A-a)
oxygen gradient. Although many patients can be extubated per intensive care unit (ICU)
routine for cardiac surgery, attention to the trend in oxygenation and oxygen requirement
will dictate the postoperative plan. If the A-a gradient increases, diuresis and positive-pressure
ventilation will generally resolve any reperfusion injury in 24 to 48 hours.
◆ Anticoagulation is started at a low level the day after surgery. This can be according to
institutional routine, using unfractionated heparin (aiming for an initial partial thromboplastin
time [PTT] of ~50–55 seconds and increasing to 60–70 seconds over the first 2–3 postoperative
days) or enoxaparin given bid in patients with normal renal function. If enoxaparin is used,
the initial dose for the first postoperative day is about 0.6 mg/kg bid increasing to 0.9 mg/
kg bid over approximately 2 to 3 days. Overshoot of anticoagulation must be assiduously
avoided. Depending on whether or not the patient has a concomitant coagulation disorder,
warfarin is started on the first or second postoperative day. The anticoagulation goal for these
patients is an international normalized ratio (INR) of 2.5 to 3.5.
◆ Patients are managed as per cardiac surgery routine, with a few minor edits. Cardiac surgical
practice guidelines strongly suggest that postoperative patients receive beta blockade. We
have generally included this, at least at low dose. The posterior Blake drain is left in until
close to the time of discharge to ensure that there is no serous effusion accumulating. We
generally obtain a V̇ /Q̇ scan to assess the initial result and provide a basis for follow-up. In
addition, postoperative transthoracic echocardiography is performed to estimate RV systolic
pressure, estimate RV and tricuspid valve function, and confirm the absence of pericardial
effusion.
◆ There are a few additional features of postoperative management that should be kept in mind.
If the patient has come to surgery with substantial right heart failure and peripheral edema,
the diuretic plan should be appropriately adjusted to achieve diuresis for him or her to well
below the preoperative weight. The usual complications of cardiac surgery may occur and
are managed as usual, such as atrial fibrillation and pericarditis. Also, if despite opening all
lobar and segmental arteries there is still significant pulmonary hypertension suggested by
the postoperative echocardiogram, consideration may be given to starting or restarting a
pulmonary vasodilator, especially if the patient was on such an agent preoperatively. If required,
we generally start with sildenafil 10 mg tid and advance the dose as tolerated by blood
pressure. If pulmonary hypertension persists in patients who came to surgery on riociguat
(Adempas), this is often restarted. The final PA pressure result is sometimes not known until
several months have passed and pulmonary microcirculation remodeling is complete.
Step 5. Results
◆ The results of PTE for CTEPH are in general very good in experienced centers with an operative
mortality less than 5%. An average result for PTE is a reduction in PVR of about 2/3 and a
reduction in mean PAP of about 1/2.6,7 The incidence of reperfusion edema ranges from
10–40%.8 The incidence of residual pulmonary hypertension after PTE approximates 30%
but does not seem to effect long-term survival.9 Six-minute walk test and New York Heart
Association functional class improve after PTE.7,8 The 5-year survival rate after PTE is about
80%.6
◆ Make sure the diagnosis of CTEPH is correct.

◆ Starting the proper dissection plane is crucial and the most important step in ensuring a good
outcome. Since it is done during cooling or during reperfusion there is no rush to get the
proper plane and the surgeon should be certain the correct plane is achieved before beginning
distal dissection and proceeding with circulatory arrest.
◆ Gentle traction must be maintained on the specimen and the dissecting sucker does all the
work pushing/separating the wall of the PA off the specimen. If traction is too firm the specimen
will break and disease will be left behind. If traction is too gentle, progress will be too slow
risking prolonged circulatory arrest times.
◆ Once all the segmental branches have been cleared the surgeon should check each segment
one last time to make sure all visible scar is removed.

◆ Very occasionally it is helpful to go lateral to the SVC to access the distal right PA if the
patient’s anatomy prohibits adequate visualization medial to the SVC.

◆ Tilting the heart up before dissecting the left PA can provide better access to the distal artery
at times and a trial and error approach should be used to adjust retraction to provide the
best view of the distal left PA.
◆ All patients require extensive diuresis postoperatively to reduce pulmonary edema and reduce
preoperative water retention from preoperative right heart failure.

References
1. Pengo V, Lensing AW, Prins MH, et al. Thromboembolic Pulmonary Hypertension Study Group. Incidence of chronic thromboembolic
pulmonary hypertension after pulmonary embolism. N Engl J Med. 2004;350:2257–2264.
2. Guerin L, Couturaud F, Parent F, et al. Prevalance of chronic thromboembolic pulmonary hypertension after acute pulmonary
hypertension. Thromb Haemost. 2014;112:598–605.
3. Auger WR, Kim NH, Trow TK. Chronic thromboembolic pulmonary hypertension. Clin Chest Med. 2010;31:741–758.
4. Auger WR, Kerr KM, Kim NH, Fedullo PF. Evaluation of patients with thromboembolic pulmonary hypertension for pulmonary
endarterectomy. Pulm Circ. 2012;2:155–162.
5. Lang IM, Madani M. Update of chronic thromboembolic pulmonary hypertension. Circulation. 2014;130:508–518.
6. Madani MM, Auger WR, Pretorius V, et al. Pulmonary endarterectomy: recent changes in a single institution’s experience of more than
2,700 cases. Ann Thorac Surg. 2012;94:97–103.
7. Mayer E, Jenkins D, Lindner J, et al. Surgical management and outcome of patients with chronic thromboembolic pulmonary
hypertension: results from an international prospective registry. J Thorac Cardiovasc Surg. 2011;141:702–710.
8. Jenkins D. Pulmonary endarterectomy: the potentially curative treatment for patients with chronic thromboembolic pulmonary
hypertension. Eur Respir Rev. 2015;24:263–271.
9. Freed DH, Thomson BM, Berman M, et al. Survival after pulmonary thromboendarterectomy: effect of residual pulmonary
hypertension. J Thorac Cardiovasc Surg. 2011;141:383–387.
Index
Page numbers followed by “f” indicate figures, “t” indicate tables, “b” indicate boxes, and “e” indicate online content.
A Aneurysms (Continued)
AccuCinch Ventriculoplasty System, 377, 378f aortic root, 201, 202f, 208f, 209–213
Acurate neo system (Symetis, Dusseldorf, Germany), 245, 246f aortic valve-sparing operations for, 202f, 208f, 209–213
Age, of heart donor, 548 ascending aortic, 157, 202f, 203–209
AI. see Aortic insufficiency left ventricular, 505–519
Alfieri stitch, 296, 297f thoracic aortic, descending, TEVAR for, 455–476
Alfieri technique, 366–368, 367f aneurysm, deployment of endograft in, 464–466, 465f,
Allograft root replacement technique, 230f, 231 467f
Altered ventricular wall stress, remodeling and, 505 aortic dissection, deployment of endograft in, 468, 469f
Amelioration of left ventricular (LV), 505 hybrid arch repair as, 468–472, 471f, 473f
American College of Cardiology/American Heart Association imaging as, 460, 461f
Guidelines for Coronary Artery Bypass Surgery, 85–86 operative steps in, 460–472
AML. see Anterior mitral leaflet aneurysm, deployment of endograft in, 464–466, 465f,
Amplatz super stiff guidewire, 371 467f
Amplatzer Muscular VSD Occluder, 116 aortic dissection, deployment of endograft in, 468,
Anastomosis, 537 469f
in aortic arch replacement, 433, 434f hybrid arch repair as, 468–472, 471f, 473f
aorta-to-graft, 435 imaging as, 460, 461f
graft-to-graft, 435, 436f subclavian revascularization as, 466, 467f
site preparation for, 431, 432f vascular access as, 462, 463f
distal, in minimally invasive coronary artery bypass grafting, pearls and pitfalls in, 472–474, 473f, 475f
77–80, 78f–79f, 81f postoperative care in, 472
in donor implantation, of left atrium, 557 preoperative considerations in
graft, in on-pump coronary artery bypass, 42, 43f, 44, 45f, 46, anatomic requirements and, 457, 458f
47f intraoperative monitoring and, 459
in hybrid coronary revascularization, 96, 97f vascular access and, 459
proximal, in minimally invasive coronary artery bypass grafting, subclavian revascularization as, 466, 467f
75, 76f surgical anatomy in, 455–457, 456f
traditional order of, 557–561 vascular access as, 462, 463f
in type A aortic dissection thoracoabdominal aortic, 438–454. see also Thoracoabdominal
distal, 416, 417f aortic aneurysms
proximal, 420, 421f characterization of, 438
Anesthesia Annular calcification, addressing, 298–300
for hybrid coronary revascularization, 88 Annular circumference, 375, 376f
for minimally invasive cardiac surgical coronary artery bypass Annular plication stitch, 283
grafting, 71 Annular reconstruction, 327, 328f
for off-pump coronary artery bypass, 51 Carpentier method, 301f
for robotic coronary artery bypass grafting, 104–105 Annular stabilization, 181, 187
Aneurysmectomy, 505 Annuloplasty, 359, 360f
Aneurysms band insertion, 398, 399f
aortic arch, 424–437. see also Aortic arch aneurysms percutaneous, 368–369, 375–379, 382
arch replacement in, 433, 434f remodeling ring, 279, 280f, 298
axillary artery cannulation in, 427, 428f via device placement inside coronary sinus, 375
cannulation site and adjunct perfusion strategy in, 427 Annulus
cardiopulmonary bypass and systemic cooling in, 429, 430f aortic, 157, 199–201, 200f
circulatory arrest in, 431 débridement of, 327
closure in, 435, 436f lateral/medial, with pledgeted sutures, 340, 341f
innominate artery in, 429, 430f mitral, 270f, 271
pearls and pitfalls in, 437 calcification of, 298–300
pharmacologic adjuncts in, 426 Anterior descending artery, 261f
postoperative care in, 437 Anterior interventricular sulcus, 348
preoperative considerations in, 426, 426b Anterior intraventricular vein, 365f
preparation for arch replacement in, 431, 432f Anterior leaflet, 307f
surgical anatomy in, 424, 425f preservation of, 325, 326f
579
580 Index
Anterior mitral annulus, 348 Aortic arch aneurysms (Continued)
Anterior mitral leaflet (AML), 270f, 279, 280f, 333f, 349f TEVAR for, 455–476
aortic allograft prepared with, 167–169 operative steps in, 460–472
chordal techniques for, 292–296 aneurysm, deployment of endograft in, 464–466, 465f, 467f
pathology of, repair techniques in, 292–296, 293f aortic dissection, deployment of endograft in, 468, 469f
prolapse, correcting, 292–296 hybrid arch repair as, 468–472, 471f, 473f
Anterolateral leaflet, 307f imaging as, 460, 461f
Anterolateral papillary muscle, 272, 349f subclavian revascularization as, 466, 467f
Anterolateral thoracotomy, 8 vascular access as, 462, 463f
left, 3 pearls and pitfalls in, 472–474, 473f, 475f
submammary, 9, 10f postoperative care in, 472
supramammary, 9, 10f preoperative considerations in
Anteroposterior commissure, 384 anatomic requirements and, 457, 458f
Anteroseptal commissure, 384 intraoperative monitoring and, 459
Antibiotics, in on-pump coronary artery bypass, 35 vascular access and, 459
Anticoagulation, after mitral valve replacement, 344 surgical anatomy in, 455–457, 456f
Antifibrinolytic, use of, 116–117 Aortic arch replacement, 433, 434f
Antiphospholipid antibody syndrome, 566–568 Bentall procedure for, 216
Aorta, 261f, 378f, 386f preparation for, 431, 432f
cross-clamping of Aortic arterial cannulation, ascending, 526, 527f
in aortic valve replacement, 132 Aortic atheroma, Katz classification of, 53t
in mitral valve replacement, 338 Aortic calcification, off-pump coronary artery bypass (OPCAB) and, 50
in Ross procedure, 262 Aortic cannulation, 570
Aortic allograft, prepared from anterior leaflet of mitral valve, Aortic clamp, 550
167–169, 168f Aortic cross-clamp, 509, 510f
Aortic anastomoses, 544 Aortic cusps, 157, 199–201, 200f
Aortic aneurysms geometric height of, 179, 180f
ascending, 157, 202f, 203–209 Aortic dissection repair, type A, 409–423
aortic valve-sparing operations for, 203–213 arterial cannulation, 414, 415f
thoracic, repair of, 455–476. see also Thoracic endovascular aortic distal anastomosis in, 420, 421f
repair initiation of cardiopulmonary bypass in, 413
thoracoabdominal, 438–454 intimal tear in, 409
characterization of, 438 location of, 413–414
repair of operative steps in, 413–420
aortic exposure in, 441–443, 442f pearls and pitfalls in, 422
aortic graft replacement in, 443–447, 444f, 446f, 448f postoperative care in, 420–422
closure in, 449 preoperative considerations in, 411
Crawford classification of, 438, 439f proximal anastomosis, 420, 421f
hypothermic circulatory arrest technique in, 451, 452f surgical anatomy in, 409–411, 410f, 412f
incisions in, 441–443, 442f venous cannulation in, 414
indications for, 440 Aortic graft replacement, in thoracoabdominal aneurysm repair,
intraoperative management strategy in, 441 443–447, 444f, 446f, 448f
pearls and pitfalls in, 453 Aortic insufficiency (AI), 179, 180f
postoperative care in with aortic root aneurysm, 189–191
early management in, 451–453 ascending aortic aneurysms with, 203–209
long-term surveillance in, 453 isolated, 181
preoperative considerations in, 440 Aortic manipulation, off-pump coronary artery bypass (OPCAB)
reversed elephant trunk technique in, 449, 450f and, 50
surgical anatomy in, 438 Aortic regurgitation, indications for transcatheter aortic valve
Aortic annulus, 157, 199–201, 200f replacement in, 244
Aortic arch aneurysms, 424–437 Aortic root
repair of aneurysms of, 157, 199–201, 200f
arch replacement in, 433, 434f aortic insufficiency with, 189–191
preparation for, 431, 432f aortic valve-sparing operations for, 208f, 209–213
axillary artery cannulation in, 427, 428f disease, Bentall procedure for, 215
cannulation site and adjunct perfusion strategy in, 427 dissection repair, type A
cardiopulmonary bypass and systemic cooling in, 429, 430f aortic root management in, 409, 410f
circulatory arrest in, 431 circulatory arrest, 414–416
closure in, 435, 436f enlargement techniques, 156–176
innominate artery in, 429, 430f aortic allograft in, 167–169, 168f
pearls and pitfalls in, 437 Konno and Rastan aortoventriculoplasty in, 156, 159, 160f,
pharmacologic adjuncts in, 426 165–167, 166f, 168f
postoperative care in, 437 left ventricular outflow tract exposure in, 159
preoperative considerations in, 426, 426b Nicks-Nunez technique in, 156, 159, 161–163, 162f, 164f
repair of, hybrid arch, 468–472, 471f, 473f operative steps in, 159–171
surgical anatomy in, 424, 425f pearls and pitfalls in, 175–176
Index 581
Aortic root (Continued) Artificial neochords, 292
postoperative care in, 175 Ascending aorta
preoperative considerations in, 156–157 anatomic segments of, 409–411, 410f
Rittenhouse-Manouguian technique in, 159, 160f, 164f, 166f aneurysms of, 157, 201, 202f
management of, in type A aortic dissection repair, 409, 410f with aortic insufficiency, 203–209, 204f
Ross-Konno reconstruction of, 169–171, 172f aortic valve-sparing operations for, 201, 202f
surgical anatomy of, 157, 158f, 409, 410f cannulation of, 18, 19f
two-directional enlargement, 173, 174f surgical anatomy of, 14, 15f
Aortic valve, 129–130, 261f, 307f, 348, 386f Ascending aortic arterial cannulation, 526, 527f
interleaflet triangle of, 157, 158f Atrial closure, 361
regurgitation, valve replacement for, 132 Atrial fibrillation
stenosis, valve replacement for, 130 in mitral valve repair, 302
surgery, in atrial fibrillation, 485 procedure, 359
visualization of, 141 surgery for, 479–488
Aortic valve repair, 177–198 anatomy in, 480
bicuspid, 193–195, 196f aortic valve surgery in, 485
operative steps in, 181–195 coronary artery bypass graft in, 485
postrepair evaluation, 191–195 Cox-Maze IV procedure in, 480
surgery, 181–191 left atrial appendage in, 483
pearls in, 197 left atrial lesions in, 481–483, 482f, 484f
postoperative considerations in, 197 mitral valve surgery in, 485
medical management, 197 pearls and pitfalls in, 486
outcomes, 197 postoperative care in, 486
preoperative considerations in, 179–181 preoperative considerations in, 480
quadricuspid, 195 pulmonary veins isolation in, 481
surgical anatomy, 177–179, 178f right atrial lesions in, 483, 484f
unicuspid, 195, 196f stand-alone atrial fibrillation in, 486, 487f
Aortic valve replacement, 156 Atrial retractors, 275
for aortic stenosis, indications for, 243 Atrium
Bentall procedure in, 215 left, 378f
considerations in, 173–175 anastomosis of, in donor heart implantation, 557
indications for in donor heart retrieval, 546
aortic regurgitation and, 132 right, cannulation of, 24, 38–40, 39f, 41f, 414
aortic stenosis and, 130 Autograft, pulmonary, used in Ross procedure, 260, 261f
operative steps in, 132–136, 133f, 135f, 137f, 159–171 Axial flow pump, internal, 539
pearls and pitfalls in, 138 Axial traction, 181
postoperative care in, 138 Axillary artery
preoperative considerations in, 130–132, 156–157 cannulation of, 20, 21f, 524, 525f
Ross procedure in, 260–268 in aortic arch aneurysm repair, 427, 428f
surgical anatomy in, 129–130, 131f, 157 in type A aortic dissection repair, 414, 415f
Aortic valve-sparing operations, 199–214 surgical anatomy of, 16, 17f, 522, 523f
for aortic root aneurysms, 201, 202f Axillary artery cut-down technique, 537
for ascending aortic aneurysms, 201, 202f
pearls and pitfalls in, 213–214
postoperative care in, 213
preoperative considerations in, 201 B
steps in, 203–213 Balloon-expandable Edwards SAPIEN valve, 245
surgical anatomy in, 199–201, 200f Balloon mitral valvuloplasty (BMV) for MS, 366
Aortic-to-graft anastomosis, in aortic arch replacement, 435 Barlow syndrome, 272, 273f
Aortopathy, bicuspid aortic valve and, 193–195 Bentall failures, 223
Aortotomy, 150 Bentall operation, 223
aortic valve access through, 132, 133f Bentall procedure, 215–224
transverse-oblique (hockey stick), 494, 495f operative step(s) in, 216–221
vertical, 159 aortic arch replacement as, 216
Aortoventriculoplasty, Konno and Rastan, 159, 160f, 165–167, 166f proximal portion of, 217–221, 218f
Apical hypertrophic cardiomyopathy, 502 pearls and pitfalls in, 223
Apical septal defect, 114 postoperative care in, 221–223
Apical septal myectomy, 500, 501f preoperative considerations in, 216
Apical ventriculotomy, 500, 501f surgical anatomy in, 215
Arantius, nodule of, 209, 210f Bentall technique, 223
Arrhythmia, ventricular, 507 Bentall-type aortic upsizing procedure, 175
Arterial cannulation, 18–22, 19f, 21f, 23f, 143–144 Beta blockers, preoperative, in atrial fibrillation, 486
Arteriotomy, direct, 144 Biatrial technique, 557
Artery of Adamkiewicz Bicaval cannulation, 272–275, 404
in thoracic endovascular aortic repair, 457 in Ross procedure, 262–266
in thoracoabdominal aortic aneurysm repair, 438 Bicaval midesophageal, 142–143
582 Index
Bicaval technique, 557 Carcinoid syndrome, 385
Bicuspid aortic valves, 242 Cardiac dissection, 555
repair of, 193–195, 194f, 196f Cardiac magnetic resonance imaging, 507
Bicuspidization technique, 195 Cardiac transplantation, explantation procedures for, 541
of tricuspid valve, 396–400, 397f Cardiectomy, 541
Bilateral internal thoracic artery (BITA), 50 Cardioband System, 379, 380f
Billowing anterior leaflet, 294 Cardiomyopathy, hypertrophic, surgery for, 489–504
Bioprosthesis, 318–320, 319f operative steps in
Bioprosthetic valve, used in Bentall procedure, 217, 218f transaortic approach in, 492–498, 493f, 495f, 497f, 499f
BITA. see Bilateral internal thoracic artery transapical approach in, 498–502, 501f, 503f
Bivalirudin, use of, 543 pearls and pitfalls in, 502–504
Blake chest drain, 152 postoperative management in, 502
Bleeding, in aortic arch aneurysm repair, 437 preoperative considerations in
Blower/Mister device, use of, for anastomosis, 51 diagnosis and imaging as, 491
Body habitus, 539 preoperative planning as, 492
Bovine pericardium, use of, 298 septal myectomy in, 491
Brachial artery, access via, in thoracic endovascular aortic repair, 462 surgical anatomy in, 489, 490f
Braile Inovare prosthesis (Braile Biomédica, São José do Rio Preto, Cardioplegia, 191
Brazil), 245, 246f bag, 550, 557
Bundle, 261f cannula, 570, 574
Bundle of His, 333f, 349f cannulation, and venting, 24–26, 25f, 27f
Bypass circuit, 520 retrograde, 146
Bypass surgery, role of, 116 used in Bentall procedure, 219, 220f
Cardiopulmonary bypass, 116–117, 203, 576
access of, in robotic coronary artery bypass grafting, 109–110
in aortic arch aneurysm, 429, 430f
C cannulation techniques for, 14–30
CABG. see Coronary artery bypass grafting operative steps in, 18–28
Cabrol technique, in Bentall procedure, 221, 222f pearls and pitfalls in, 28
Calcification postoperative care in, 28
annular, addressing, 298–300 preoperative considerations in, 16
mitral annulus, 334, 335f surgical anatomy and, 14–16, 15f, 17f
Calcineurin inhibitor, use of, 563–564 central cannulation for, 509–517
Canadian Association of Interventional Cardiology, 86 in heart transplant surgery, initiation of, 554–555, 556f
Canadian Cardiovascular Society, 86 initiating, 274
Canadian Society of Cardiac Surgery Position Statement on for minimally invasive cardiac surgical coronary artery bypass
Revascularization-Multi-vessel Coronary Artery Disease, 86 grafting, 73
Cannulation site, selection of, in aortic arch aneurysm repair, 427 separating from, 561–563
Cannulation techniques in type A aortic dissection repair, initiation of, 413
for ascending aorta, 18, 19f Cardiopulmonary circuit preparation, 413
in on-pump coronary artery bypass grafting, 33, 39f Cardiopulmonary initiation, 413–414
for axillary artery, 20, 21f Cardiovascular magnetic resonance (CMR), 389
in aortic arch aneurysm repair, 427, 428f Carillon mitral contour system, 368, 375
in type A aortic dissection repair, 414, 415f Carpentier repair techniques, 400
for cardiopulmonary bypass, 14–30 Caval valve implantation, 404
operative steps in, 18–28 Central cannulation, for cardiopulmonary bypass, 509–517
pearls and pitfalls in, 28 Centrifugal pump, 521f
postoperative care in, 28 CentriMag devices, 533–535, 537–539, 540f, 544
preoperative considerations in, 16 Cephalosporin, 143
surgical anatomy and, 14–16, 15f, 17f Chest computed tomography angiography, pulmonary embolism
central, for cardiopulmonary bypass, 509–517 protocol (PE-CTA), 566
for femoral artery, 18–20, 19f, 21f, 413, 524, 525f Chest radiography, in hybrid coronary revascularization, 93
for femoral vein, 22, 526 Chordae tendineae, 271, 307f, 349f
for innominate artery, 414 Chordal preservation, 322–325
for retrograde coronary sinus, 24, 25f Chordal techniques, for anterior leaflet, 292–296
for right atrium, 24 Chordal transposition, 294, 295f
in on-pump coronary artery bypass grafting, 38–40, 39f, 41f Chronic thromboembolic pulmonary hypertension (CTEPH),
for right superior pulmonary vein, 26, 27f 566–578
for subclavian artery, 414 anesthesia technique in, 570
transapical, 22, 23f anticoagulation in, 576
in type A aortic dissection repair incidence of, 566–568
arterial, 414, 415f indications for surgery of, 568
venous, 414 operative steps in, 570–576, 571f
of venous-arterial extracorporeal membrane oxygenation, 28, 29f postoperative care in, 576–577
of venous-venous extracorporeal membrane oxygenation, 26, 27f preoperative considerations in, 566–568, 567f
Carbon dioxide, use of, 517 risk factors for, 567t
Index 583
Circulatory arrest Coronary artery bypass grafting (CABG) (Continued)
in aortic arch aneurysm, 431 surgical anatomy and, 33–34
hypothermic, in thoracoabdominal aneurysm repair, 451, 452f vessel harvesting in, 36, 37f, 38–40, 39f, 41f
in type A aortic dissection repair, 414–416 robotic, 103–113
Circumferential pericardial patch, 298 access cardiopulmonary bypass in, 109–110
Circumflex artery, 261f, 307f, 333f, 348, 349f, 365f, 386f anesthesia in, 105, 105b
Clamp time, 549 application of endoballoon in, 109–110
Clamshell approach, 11, 12f exposure of target vessels in, 110
CMR. see Cardiovascular magnetic resonance final maneuvers in, 113
Commissural prolapse, correcting, 298, 299f hardware and procedure versions in, 105–107, 106f
Commissures, 333f, 349f internal mammary artery takedown in, 107, 108f
Computed tomography, of heart, in hybrid coronary introductory considerations in, 103–107
revascularization, 93, 94f patient positioning, prepping, and draping in, 107
Conduit harvesting, in OPCAB, 51–53, 52f patient selection, indications, and contraindications in, 103
Console, 521f pericardial fat pad removal in, 109
Continuous suture, 314–316, 315f pericardiotomy in, 109
Continuous-flow pumps, 544 port placement in, 106f, 107, 108f, 109
CoreValve Evolut R System (Medtronic), 253 postoperative care in, 113
Coronary anastomosis, robotic endoscopic graft to, 111, 112f preoperative workup in, 104, 104b
Coronary angiogram, 156–157 robot docking in, 106f, 107, 108f
Coronary angiography, preoperative, in postinfarction ventricular robotic endoscopic graft to coronary anastomosis in, 111,
septal defect repair, 116 112f
Coronary artery bypass grafting (CABG), 84 Coronary distance, 242
in atrial fibrillation, 485 Coronary reimplantation, 266, 267f
minimally invasive, 70–82 Coronary revascularization, hybrid, 83–102
anesthetic induction for, 71 anastomosis in, 96, 97f
cardiopulmonary bypass for, 73 anesthesia considerations for, 88
closure in, 80 chest radiography in, 93
contraindications to, 71 computed tomography of heart in, 93, 94f
distal anastomoses for, 77–80, 78f–79f, 81f definition and rationale of, 83–84
grafting in, 73–80 direct examination of patient thorax in, 95
incision for, 73, 74f direct internal thoracic artery harvest for, 92
indications for, 70 endoscopic port insertion in, 95
operative technique for, 71–80 history of, 84
patient positioning for, 71, 72f indications for, 85–86
pearls in, 80 intrathoracic visualization in, 93
postoperative considerations in, 80 LITA-LAD anastomosis in, 95
preoperative considerations in, 70–71 methods and techniques for, 88–96
proximal anastomoses for, 75, 76f patient preparation, positioning and draping for, 90, 91f
surgical anatomy in, 70 patient selection in, 85–86, 87f
off-pump, 49–69 perfusion considerations for, 90
aortic calcification and, 50 pericardiotomy in, 95
aortic manipulation and, 50 port placement in, 93
computed tomography in, 50 results, institutional experience, and current evidence in,
conduit assessment in, 50 98–101
coronary stabilization, 60–64 single-lung ventilation in, 90
frequency of, 49 single-stage procedure of, 88, 89f
incision for, 51–53 strategy for, 83
ischemia during, 64–66, 67f two-stage procedure of, 88
operative steps in, 51–66 Coronary sinus, 307f, 365f, 386f
general strategies, tools, and tactics, 51 retrograde, cannulation of, 24, 25f
heart positioning, 54–60 Coronary sinus-based annuloplasty, 364, 365f
inflow preparation, 53–54, 55f Coronary stabilization, 60–64, 63f
pearls and pitfalls in, 68 Coronary valve, 386f
postoperative care in, 68 Cox-Maze IV procedure, in atrial fibrillation, 480, 487f
preoperative assessment and planning in, 50 Crawford classification, of thoracoabdominal aortic aneurysm repair,
sequence of revascularization in, 64 438, 439f
shunting during, 64–66 Cross-clamp, and cardioplegia catheter, removal of, 361
on-pump, 33–48 CTEPH. see Chronic thromboembolic pulmonary hypertension
aortic and right atrial cannulation in, 38–40, 39f, 41f Cusp, 209, 210f, 211, 212f
graft anastomosis in, 42, 43f, 44, 45f, 46, 47f Cusp mobility, 179, 193–195, 194f
intraoperative preparation in, 35 Cusp perforations, 185
operative steps in, 36–46 Cusp prolapse, 181, 182f
pearls and pitfalls in, 48 repair, 183–185, 184f, 186f
postoperative care in, 46 Cygnet cross-clamp, 148
preoperative preparation for, 34–35 Cylindric blade, 539
584 Index
D Donor heart (Continued)
da Vinci surgical system, 347 pearls and pitfalls associated with, 552–553
Dacron conduit, noncoronary sinus in, 266, 267f postretrieval care of, 552
Dacron graft screening for, 548
used in Bentall procedure, 221, 222f selection of, 546, 548
used in type A aortic dissection, 416, 417f Donor operation, preparation, timing, and coordination with, 554
Dacron patch, used in left ventricular aneurysm repair, 515, 516f Double orifice edge-to-edge repair, 296
DDO. see Direct detection optical Double-lumen catheter, 528, 529f
De Vega annuloplasty, 390–391, 396, 397f Double-lung ventilation, 142
Debridement, of postinfarction necrotic tissue Double-valve endocarditis, 236, 237f
anterior/apical septal defects and, 117, 118f Dual-energy computed tomography angiography, 566
posteroinferior septal defects and, 119–121, 120f, 122f Duke criteria, 226
Decalcification, 185 Dysplastic cusp, 195
Deep hypothermic circulatory arrest, 141
Deep stitch-sling technique, for heart positioning, 54
Degenerative mitral regurgitation, 364
Degenerative tricuspid regurgitation, 387 E
Del Nido solution, modified, 148 Echocardiography
Dense connective tissue, 261f preoperative, in aortic valve repair, 179
Descending thoracic aortic aneurysms, TEVAR for, 455–476 for repair of myxomatous degenerated mitral valve, 272
operative steps in, 460–472 transesophageal, 142–143, 191, 201, 302, 511, 522, 537–539,
aneurysm, deployment of endograft in, 464–466, 465f, 467f 561–563, 570
aortic dissection, deployment of endograft in, 468, 469f in robotic coronary artery bypass grafting, 105
hybrid arch repair as, 468–472, 471f, 473f transthoracic, 226
imaging as, 460, 461f for minimally invasive cardiac surgical coronary artery bypass
subclavian revascularization as, 466, 467f grafting, 71
vascular access as, 462, 463f ECMO. see Extracorporeal membrane oxygenation
pearls and pitfalls in, 472–474, 473f, 475f Edge-to-edge and clover leaf repair, 398, 399f
postoperative care in, 472 Edwards SAPIEN valve, 255, 256f
preoperative considerations in Effective orifice area (EOA), 156
anatomic requirements and, 457, 458f ELSO. see Extracorporeal Life Support Organization
intraoperative monitoring and, 459 Embolism, from a ventricular thrombus, 517
vascular access and, 459 Endarterectomy plane, 572–574, 573f
surgical anatomy in, 455–457, 456f Endoballoon, application of, in robotic coronary artery bypass
Diffuse coronary artery disease, 549 grafting, 109–110
Direct aortic-transcatheter aortic valve replacement access, 251 Endocardial scar, 509
Direct arteriotomy, 144 Endocarditis
Direct detection optical (DDO), 554 left heart valve infective
Direct Flow valve (Direct Flow Medical, Santa Rosa, CA), 245, clinical outcomes, 238, 239f
246f considerations related to, 226–227
Direct internal thoracic artery harvest, for hybrid coronary diagnosis of, 226
revascularization, 92 embolism, prevention of, 227
Direct vena cava cannulation, 555 heart failure, 227
Distal anastomoses, in minimally invasive coronary artery bypass indications for, 227
grafting, 77–80, 78f–79f, 81f key pearls for, 240
Distal aortic repair, 416–418, 419f microbiology of, 225
Distal graft anastomosis, 191 pathogenesis of, 225
Distal right coronary artery (RCA), 60 pathology of, 225
stabilization of, 64, 65f postoperative complications and management, 238
Donor aorta, 559 principles of, 228
Donor heart surgery of, 225–241
contraindication of, 548 surgical procedures in, 228–229
female, 548 uncontrolled infection, 227
ideal, 548 mitral valve, 231
implantation native aortic valve, 228–229, 230f
closure, 563 native mitral valve, 232, 233f
left atrium anastomosis in, 557 prosthetic aortic valve, 229–236, 230f
pearls and pitfalls in, 564–565 prosthetic mitral valve, 234, 235f
postoperative care of, 563–564 tricuspid valve, 393
pulmonary artery anastomosis in, 557, 558f Endograft, deployment of, in thoracic endovascular aortic repair,
reperfusion, 561 464–466, 465f, 467f, 468–472, 469f, 471f, 473f
management of, 548–549 Endoscopic port insertion, in hybrid coronary revascularization, 95
older, 549 Endoscopic robotic harvesting, of left internal thoracic artery and/or
operative step on, 549–552 right internal thoracic artery, 93–95
organ recovery as, 550–552, 551f Endovascular approach, to thoracoabdominal aortic aneurysms,
visualization as, 549–550 440
Index 585
Endoventricular circular suture, techniques for, 511 Heart, 348
EOA. see Effective orifice area catheterization, preoperative left, 507, 508f
Epiaortic scanning, 53, 53t donor
Epoprostenol sodium, 576 contraindication of, 548
Explantation procedures, for cardiac transplantation, 541, 544 female, 548
External rings, use of, in cusp repair, 187 ideal, 548
Extracorporeal Life Support Organization (ELSO), 520 implantation
Extracorporeal membrane oxygenation (ECMO), 116 closure, 563
approaches and techniques for, 520–530, 521f left atrium anastomosis in, 557
contraindications to, 522 pearls and pitfalls in, 564–565
indications for, 522 postoperative care of, 563–564
operative steps in, 524–528 pulmonary artery anastomosis in, 557, 558f
pearls and pitfalls in, 530 reperfusion, 561
percutaneous peripheral, 522 management of, 548–549
postoperative care in, 530 older, 549
preoperative considerations in, 522 operative step on, 549–552
surgical anatomy in, 522 organ recovery as, 550–552, 551f
axillary artery, 522 visualization as, 549–550
femoral vessels, 522 pearls and pitfalls associated with, 552–553
systemic anticoagulation during, 530 postretrieval care of, 552
venous-arterial, 28, 29f screening for, 548
venous-venous, 26, 27f selection of, 546, 548
Extracorporeal ventricular assist devices, 543 excision, native, in heart transplantation, 554–555
Extrathoracic cannulation, 520 failure, 227
positioning of, 54–60
anterior wall, 56, 62, 63f
inferior wall, 60, 61f, 62, 63f
F lateral wall, 58, 62
Femoral arterial access, 535–537 Heart surgery, incision in
in thoracic endovascular aortic repair, 462, 463f anterolateral thoracotomy, 8
Femoral artery left, 3
cannulation, 18–20, 19f, 21f, 413, 524, 525f submammary, 9, 10f
surgical anatomy of, 14, 15f supramammary, 9, 10f
Femoral cut-down technique, 537 closure of, 11
Femoral venous cannulation, 22, 526 combination of minimally invasive, 11
Femoral vessels, surgical anatomy of, 522, 523f other, 4, 5f, 11, 12f
Fibrillatory arrest strategies, 274 posterolateral thoracotomy, 3, 9, 10f
Figure-of-eight atrioventricular mattress sutures, 300, 301f Heart transplantation, 546–565
Flail, 281–292 adult recipient in, 553–565
Fontan stitch, 513, 514f operative steps for, 554–563
placement of, in left ventricular aneurysm repair, 511, 512f, 515, preoperative considerations for, 553–554
516f preparation, timing, and coordination for, 554
Fossa ovalis, 370f selection of, 553–554
Freehand technique, 294 surgical anatomy in, 553
Freestyle valve sizer, 189–191, 190f cardiopulmonary bypass in, initiation of, 554–555
Functional valve disease, repair technique in, 350 donor for
left atrium anastomosis in, 557
management of, 548
operative step on, 549–552
G pearls and pitfalls associated with, 552–553
GARY. see German aortic valve registry postretrieval care of, 552
Gelweave graft, used in Bentall procedure, 219, 220f pulmonary artery anastomosis in, 557
German aortic valve registry (GARY), 243 native heart excision in, 554–555
Gore-Tex membrane, 541 organ recovery in, 550–552, 551f
Gore-Tex neochordae, 357 preoperative considerations in, 548–549
Graduated dilators, 528, 529f preparation, timing, and coordination with donor operation in,
Graft anastomoses, 544 554
Graft sizing, 189–191 recipient of, 554
Graft-to-graft anastomosis, in aortic arch replacement, 435, 436f surgical anatomy of, 546, 547f
Great cardiac vein, 365f HeartMate II, 535, 536f, 539, 540f, 541, 543
Heartstring Proximal Seal System, 53
HeartWare HVAD, 535, 536f, 541, 542f, 543
Hegar dilator, 189–191, 190f, 296
H Hemashield graft, used in Bentall procedure, 219, 220f
Haircut technique, 288, 289f Hemiarch reconstruction, in type A aortic dissection, 416, 417f
HCR. see Hybrid coronary revascularization Hemisternotomy, 274
586 Index
Hemodynamic monitoring, in on-pump coronary artery bypass, 35 In situ grafts, 53
Heparin, 142 Incision
intravenous, in axillary cannulation, 414 for aortic aneurysm repair, thoracoabdominal, 441–443, 442f
use of, 549, 555 further considerations in, 11, 12f
Hepatitis C, as contraindication to heart donation, 548 for heart surgery
High-grade stenosis, 50 anterolateral thoracotomy, 8
Horizontal mattress sutures, 539 left, 3
in left ventricular aneurysm repair, 517, 518f submammary, 9, 10f
Horseshoe sign, in calcification of mitral annulus, 334, 335f supramammary, 9, 10f
Hybrid coronary revascularization (HCR), 83–102 closure of, 6, 7f
anastomosis in, 96, 97f combination of minimally invasive, 11
anesthesia considerations for, 88 median sternotomy, 3–4
chest radiography in, 93 other, 11, 12f
computed tomography of heart in, 93, 94f posterolateral thoracotomy, 3, 9, 10f
definition and rationale of, 83–84 in hybrid coronary revascularization, 92
direct examination of patient thorax in, 95 for minimally invasive cardiac surgical coronary artery bypass
direct internal thoracic artery harvest for, 92 grafting, 73, 74f
endoscopic port insertion in, 95 for minimally invasive mitral valve replacement, 334, 335f
history of, 84 transseptal, 338, 339f
indications for, 85–86 for myxomatous degenerated mitral valve repair, 273f, 274
intrathoracic visualization in, 93 for off-pump coronary artery bypass, 51–53, 52f
LITA-LAD anastomosis in, 95 operative steps in, 4
methods and techniques for, 88–96 Infarct exclusion, in postinfarction ventricular septal repair
patient preparation, positioning and draping for, 90, 91f anterior/apical defects and, 123, 124f
patient selection in, 85–86, 87f posteroinferior defects and, 123, 124f
perfusion considerations for, 90 Infective endocarditis, left heart valve
pericardiotomy in, 95 clinical outcomes, 238, 239f
port placement in, 93 considerations related to, 226–227
results, institutional experience, and current evidence in, 98–101 diagnosis of, 226
single-lung ventilation in, 90 embolism, prevention of, 227
single-stage procedure of, 88, 89f heart failure, 227
strategy for, 83 indications for, 227
two-stage procedure of, 88 key pearls for, 240
Hybrid repairs microbiology of, 225
arch, for aortic arch aneurysm, 468–472, 471f, 473f pathogenesis of, 225
of thoracoabdominal aortic aneurysm, 440 pathology of, 225
Hypercarbia, 570 postoperative complications and management, 238
Hypertrophic cardiomyopathy, surgery for, 489–504 principles of, 228
operative steps in surgery of, 225–241
transaortic approach in, 492–498, 493f, 495f, 497f, 499f surgical procedures in, 228–229
transapical approach in, 498–502, 501f, 503f uncontrolled infection, 227
pearls and pitfalls in, 502–504 Inferior aneurysms, 517
postoperative management in, 502 Inferior septal infarction, 114
preoperative considerations in Inferior vena cava, division of, in heart transplantation, 546, 550
diagnosis and imaging as, 491 Inflow cannula, 541
preoperative planning as, 492 Ink test, for mitral valve repair, 302, 303f
septal myectomy in, 491 Innominate artery
surgical anatomy in, 489, 490f in aortic arch aneurysm repair, 429, 430f
Hypertrophy, remodeling and, 505 cannulation of, 414
Hypothermia, circulatory arrest initiated after, in thoracoabdominal Inotropic agent infusions, 554
aneurysm repair, 451, 452f Inotropic support, 561
Interatrial septum, 310, 311f
retraction of, 339f
Intercommissural distance, ring sizing and, 279
I Interleaflet triangle, of aortic valve, 157, 158f
Iatrogenic functional mitral stenosis, 279 Internal axial flow pump, 539
Iliac artery Internal centrifugal flow pump, 541
access via, in thoracic endovascular aortic repair, 462 Internal mammary artery (IMA)
surgical anatomy of, 14, 15f harvesting of, in on-pump coronary artery bypass, 36, 37f
IMA. see Internal mammary artery surgical anatomy of, 33
Imaging takedown of, in robotic coronary artery bypass grafting, 107,
in hypertrophic cardiomyopathy, 491 108f
modalities, in thoracic endovascular aortic repair, 460, 461f Internal thoracic artery (ITA), 53
Immunotherapy, 557 surgical anatomy of, 33
Impella devices, 533–537, 534f, 544 International Society for Heart and Lung Transplantation (ISHLT),
insertion of, 537, 538f 553–554
Index 587
Interrupted sutures Left fibrous trigone, 333f, 349f
with pledgets, 316, 317f Left heart catheterization, 568
without pledgets, 316, 317f Left heart valve infective endocarditis
Intimal tear clinical outcomes, 238, 239f
in type A aortic dissection, 409 considerations related to, 226–227
location of, 413 diagnosis of, 226
Intraaortic balloon counterpulsation, 517 embolism, prevention of, 227
Intraaortic balloon pump, placement of, 114 heart failure, 227
Intracoronary shunt, use of, 68 indications for, 227
Intrathoracic cannulation, 520 key pearls for, 240
Intrathoracic visualization, in hybrid coronary revascularization, microbiology of, 225
93 pathogenesis of, 225
Intraventricular cavity, 511 pathology of, 225
Inverted-T pericardial incision, 51, 52f postoperative complications and management, 238
IRIS complete annuloplasty ring, 379 principles of, 228
Ischemia surgery of, 225–241
during OPCAB, prevention of, 64–66, 67f surgical procedures in, 228–229
strategies for, 66, 67f uncontrolled infection, 227
spinal cord, associated with thoracic endovascular aortic repair, Left internal thoracic artery (LITA), 50
459 harvest of, in minimally invasive coronary artery bypass grafting,
ISHLT. see International Society for Heart and Lung Transplantation 73, 74f
Isolated aortic insufficiency, 181 Left main coronary artery, 157, 158f, 261f, 307f, 386f
ITA. see Internal thoracic artery Left radial arterial line, 142
Left trigone, 349f
Left ventricle, 349f, 378f
remodeling of, 505–519
J Left ventricular aneurysm
Jamieson dissecting sucker, 572–574, 575f diagnostic imaging of, 507, 508f
Jenavalve TA system (Jenavalve Technology, Munich), 245, 246f surgery for, 505–519
J-tipped guidewire, 525f, 528 operative steps in, 509–517, 510f, 512f
pearls and pitfalls in, 517
postoperative care in, 517
preoperative considerations in, 505–507
K surgical anatomy in, 505, 506f
Katz classification, of aortic atheroma, 53t Left ventricular assist device (LVAD), 531
Khonsari biatriotomy, 312, 313f indications for, 533–535
Khonsari I technique, 325 operative steps in, 535–543
Kissing lesions, 232 external temporary devices, 535–539
Konno and Rastan aortoventriculoplasty, 159, 160f, 165–167, 166f, pearls and pitfalls in, 544
168f postoperative care in, 543
preoperative considerations in, 533–535
surgical anatomy in, 531, 532f
Left ventricular outflow tract, exposure of, in aortic root
L enlargement, 159
Labetalol, preoperative administration of, in type A aortic dissection Lima stitch, 54, 57f
repair, 411 LITA. see Left internal thoracic artery
Landing zones, evaluation of, in thoracic endovascular aortic repair, LITA-LAD anastomosis, in hybrid coronary revascularization, 95
457, 458f Logistic EuroScore (ES), 243
Lateral papillary muscle, 307f Long-term surveillance, of thoracoabdominal aneurysm repair,
Leaflet cusp, 318–320, 319f 453
Leaflets, 348, 384 Loop technique, 294, 295f
Left anterior descending (LAD) artery, 307f, 365f, 386f Lotus valve (Boston Scientific, Marlborough, MA), 245, 246f
in on-pump coronary artery bypass, 44, 45f Lower hemisternotomy, 140
revascularizing, 64 Low-porosity Dacron, used in postinfarction ventricular septal
surgical anatomy of, 33 repair, 117, 118f, 122f
territory, in off-pump coronary artery bypass, 50 LV outflow tract (LVOT) obstruction, in hypertrophic
Left atrial appendage, in atrial fibrillation, 483 cardiomyopathy, 489
Left atrial dome approach, 275, 276f–278f LV volume reduction, 505
Left atrial lesions, in atrial fibrillation, 481–483, 482f, 484f LVAD. see Left ventricular assist device
Left atriotomy via Sondergaard’s groove, 308, 309f
Left atrium, 378f
anastomosis of, in donor heart implantation, 557
in donor heart retrieval, 546 M
Left circumflex artery, 157 Magnetic resonance angiography (MRA), for chronic
surgical anatomy of, 33 thromboembolic pulmonary hypertension, 566
Left coronary cusp, 349f Maladaptive ventricular dilation, remodeling and, 505
588 Index
Mannitol, before circulatory arrest, 413 Minimally invasive mitral valve replacement, partial sternotomy
Manubrium, 335f approach to, 332–346, 333f
MAP. see Mean arterial pressure advantages of, 344
Mattress sutures closure in, 344
in left ventricular aneurysm repair, 517, 518f disadvantages of, 346
in postinfarction ventricular septal repair, 121, 122f dissection in, 336–344, 337f
McGoon plication repair, 290, 291f incision in, 334, 335f
Mean arterial pressure (MAP), 537 indications for, 332
Mechanical circulatory support, 116 operation, conduct of, 334–344
Mechanical prosthesis, 320, 321f operative risk, 334
Medial papillary muscle, 307f pearls and pitfalls in, 346
Median sternotomy, 116–117, 549 postoperative care in, 344–346
for cardiopulmonary bypass, 509–517 preoperative considerations in, 332–334
for on-pump coronary artery bypass, 36 Minithoracotomy
Mediastinal drainage tubes, 543 aortic valve replacement, 140–155
Medtronic CoreValve, 253, 254f benefits of, 141
Methylprednisolone, postoperative, for heart transplant recipient, right, 140–141, 144, 145f
557 MitraClip procedure, 366–368
Metzenbaum scissors, 150 MitraClip system, 371–373, 372f, 374f
MICS CABG. see Minimally invasive cardiac surgery-coronary artery Mitral annulus, 270f, 271, 306, 307f
bypass grafting calcification of, 298–300, 327–329, 328f, 330f, 334, 335f
Midline sternotomy incision, in heart transplantation, 3, 5f calcium, 231
Midventricular obstruction, in hypertrophic cardiomyopathy, 489, sizing of, 279
500, 501f Mitral regurgitation, 272
Minimally invasive aortic valve surgery degree of, 507
anatomy in, 141 functional cause of, 368
anesthesia for, 142 percutaneous treatment, 366–369, 370f, 371–379, 381–382
antibiotics for, 143 posterior leaflet prolapse and, 281–292
benefits of, 140 Mitral stenosis, percutaneous treatment of, 366
indications and contraindications to, 140–141 Mitral valve, 306, 307f, 339f, 386f
monitoring lines of, 142 annuloplasty, 507, 508f
operative steps in, 143–152 anterior leaflet of, aortic allograft prepared with, 167–169, 168f,
aortic replacement, 150, 151f 170f
arterial cannulation, 143–144, 145f apparatus, 348, 349f
closure, 152, 153f components of, 269–272, 270f
drains, 152, 153f dysfunction, 332
exposure, 148, 149f endocarditis, 231
incision, 144 exposing and examining, 275
left ventricular venting, 146, 147f myxomatous degenerated, repair of, 269–305
pacing wires, 150–152, 151f cardiopulmonary bypass for, initiating, 274
preparation and positioning, 143 echocardiography for, 272
retraction, 146, 147f evaluating, 302, 303f
retrograde cardioplegia, 146 incision in, 273f, 274
temperature, 148 left atrial enlargement in, 302
venous cannulation, 144 operative conduct in, 272–302, 273f
postoperative management in, 154 pearls and pitfalls in, 304
preoperative preparation in, 141 postoperative care in, 302
transesophageal echocardiography of, 142–143 preoperative considerations in, 272
ventilation for, 142 remodeling ring annuloplasty for, 279, 280f
Minimally invasive cardiac surgery-coronary artery bypass grafting surgical anatomy in, 269–272, 270f
(MICS CABG), 70–82 surgical approach in, 272–274
anesthetic induction for, 71 repair of, 332, 344, 345f, 355–359
cardiopulmonary bypass for, 73 surgery, in atrial fibrillation, 485
closure in, 80 Mitral valve replacement, 306–331, 359
contraindications to, 71 access in, 308–312, 309f
distal anastomoses for, 77–80, 78f–79f, 81f anatomy of, 306, 307f
grafting in, 73–80 annular reconstruction, 327, 328f
incision for, 73, 74f chordal preservation, 322–325
indications for, 70 mitral annular calcification, 327–329, 328f, 330f
operative technique for, 71–80 partial sternotomy approach to, 332–346, 333f
patient positioning for, 71, 72f advantages of, 344
pearls in, 80 closure in, 344
postoperative considerations in, 80 disadvantages of, 346
preoperative considerations in, 70–71 dissection in, 336–344, 337f
proximal anastomoses for, 75, 76f incision in, 334, 335f
surgical anatomy in, 70 indications for, 332
Index 589
Mitral valve replacement (Continued) On-pump coronary artery bypass grafting (Continued)
operation, conduct of, 334–344 pearls and pitfalls in, 48
operative risk, 334 postoperative care in, 46
pearls and pitfalls in, 346 preoperative preparation for, 34–35
postoperative care in, 344–346 surgical anatomy and, 33–34
preoperative considerations in, 332–334 vessel harvesting in, 36, 37f, 38–40, 39f, 41f
prosthesis orientation, 318–320 ON-Q Pain Relief System, 152
suture replacement for, 314–316, 315f OPCAB. see Off-pump coronary artery bypass
Mitralign device, 377, 378f Organ recovery, donor, for heart transplantation, 550–552, 551f
Modified cardiopulmonary bypass techniques, 347 Outflow graft, 539
Monofilament sutures, 298 Oxygen blender, 521f
Mycophenolate mofetil, use of, 563–564 Oxygenator, 521f
Myectomy, 173, 174f
Myocardial thinning, 509
Myotomy, 173, 174f
P
Pacing wires, 150–152, 576
Pain management, in minimally invasive coronary artery bypass
N grafting, 80
Native aortic valve endocarditis, 228–229, 230f PAP. see Pulmonary artery pressure
Native mitral valve endocarditis, 232, 233f Papillary muscle
NCC. see Noncoronary cusp of mitral valve, 269–272, 270f, 298
Necrotic postinfarction septal tissue, debridement of sliding plasty, 298
anterior/apical defects and, 117, 118f Paravertebral block, for minimally invasive cardiac surgical coronary
posteroinferior defects and, 119–121, 120f, 122f artery bypass grafting, 71
Neoaortic sinus, 205, 206f Partial aortic clamp, 537, 539
Neochord placement, techniques for, 292, 294, 295f Partial sternotomy, 6, 7f
Neochordae implantation, 357, 358f Patch reconstruction
Neochordae placement, 325, 326f in Nicks-Nunez method of aortic root enlargement, 160f,
Neocommissure, 195 161–163, 162f, 164f
Neuromonitoring, intraoperative, in thoracic endovascular aortic in Rittenhouse-Manouguian method of aortic root enlargement,
repair, 459 163–165, 164f, 166f
Nicks-Nunez technique, patch reconstruction, of aortic root Patent foramen ovale (PFO), 576
enlargement, 159, 160f, 161–163, 162f, 164f Patient positioning, for minimally invasive cardiac surgical coronary
Nitrous oxide, 576 artery bypass grafting, 71, 72f
Noncoronary cusp (NCC), 179, 349f PCI. see Percutaneous coronary intervention
Nonresectional butterfly technique, 286 PDA. see Posterior descending artery
Nontransmural infarcts, 505 PE. see Pulmonary embolism
Percutaneous access technique, 535–537
Percutaneous annuloplasty, 368–369, 375–379, 382
Percutaneous cannula placement, 26–28, 27f, 29f
O Percutaneous coronary intervention (PCI), 84
Octopus nonsternotomy tissue stabilizer (Medtronic), 75, 76f, 77 Percutaneous dual-stage venous cannula, 539
Off-pump coronary artery bypass (OPCAB), 49–69 Percutaneous edge-to-edge repair, 366–368, 367f, 379, 381–382
aortic calcification and, 50 Percutaneous mitral valve repair techniques, 364–383
aortic manipulation and, 50 operative steps in, 369–379
computed tomography in, 50 pearls and pitfalls, 381–382
conduit assessment in, 50 postoperative care, 379
coronary stabilization, 60–64 postoperative considerations, 366–369
frequency of, 49 surgical anatomy in, 364
incision for, 51–53 Percutaneous peripheral ECMO cannulation, 522
ischemia during, 64–66, 67f Percutaneous treatment
operative steps in, 51–66 of mitral regurgitation, 366–369, 371–379, 372f, 381–382
general strategies, tools, and tactics, 51 of mitral stenosis, 366, 369, 370f, 379, 381
heart positioning, 54–60 Percutaneous tricuspid valve intervention, 404
inflow preparation, 53–54, 55f Perfusion strategy, adjunct, in aortic arch aneurysm, 427
pearls and pitfalls in, 68 Pericardial fat pad removal, in robotic coronary artery bypass
postoperative care in, 68 grafting, 109
preoperative assessment and planning in, 50 Pericardial patch, 185, 186f
sequence of revascularization in, 64 Pericardial stitches, for heart positioning, 54, 57f
shunting during, 64–66 Pericardiotomy
On-pump coronary artery bypass grafting, 33–48 in hybrid coronary revascularization, 95
aortic and right atrial cannulation in, 38–40, 39f, 41f in robotic coronary artery bypass grafting, 109
graft anastomosis in, 42, 43f, 44, 45f, 46, 47f Pericardium, 337f, 339f
intraoperative preparation in, 35 autologous, nontreated, 185
operative steps in, 36–46 preparation, in OPCAB, 51–53, 52f
590 Index
PFO. see Patent foramen ovale Pulmonary vein
Pituitary rongeurs, 298–300 isolation of, in atrial fibrillation, 481
Pledgeted sutures right superior, cannulation for venting of, 26, 27f
in aortic root enlargement, 162f Pump insertion, anatomy of, 531
in aortic valve replacement, 134, 135f, 136, 137f Purse-string sutures, 144, 526, 527f, 537–539, 570
Bentall procedure, 217, 218f PVC. see Premature ventricular contraction
in mitral valve replacement, 340, 341f PVR. see Pulmonary vascular resistance
in postinfarction ventricular septal defect repair, 117, 118f
sub-commissural annuloplasty, 188f
Ti-Cron, 539
Plicating sutures, 195 Q
Polypropylene monofilament suture, 513, 517, 518f Quadrangular resection, 283, 284f–285f, 298, 299f
Polypropylene sutures, 181, 182f, 184f, 281, 286, 294, 298, 539, with sliding repair, 355
540f Quadricuspid aortic valve, 195
Polytetrafluoroethylene (PTFE) suture, 185, 292, 294, 325, 326f
Port placement
in hybrid coronary revascularization, 93
in robotic coronary artery bypass grafting, 106f, 107, 108f, 109 R
Portico device (St. Jude Medical, St. Paul, MN), 245, 246f Radial artery
Postablation atrial fibrillation, 486 harvesting of, in on-pump coronary artery bypass, 38, 39f
Posterior descending artery (PDA), 60, 61f surgical anatomy of, 34
revascularizing, 64 Radial traction, 181
Posterior mitral valve leaflet, 269–272, 270f, 307f, 333f, 349f, Ramus intermedius (RI) artery, surgical anatomy of, 33
365f Raphe, 193–195, 194f
calcification of, 342, 343f RCC. see Right coronary cusp
haircut technique for, 288, 289f Redo sternotomy, 541
preservation of, 322, 323f–324f Redo tricuspid valve intervention, 402
prolapse, correcting, 281–292, 282f Reduced-size cardiotomy suction catheter, 572
Posterior ventricular anchoring neochordoplasty, 292, 293f Redundant anterior leaflet, 294
Posterolateral thoracotomy, 3, 9, 10f Regurgitation, aortic, aortic valve replacement for, 132
Posteromedial commissure, 307f Remifentanil, 142
Posteromedial papillary muscle, 272, 349f Remodeling, of left ventricular aneurysm, 505–519
Posteroseptal commissure, 384 Remodeling ring annuloplasty, 279
Postoperative transthoracic echocardiography, 576 Renal insufficiency, preoperative, thoracoabdominal aneurysm repair
Premature ventricular contraction (PVC), in hypertrophic mortality and, 440
cardiomyopathy, 492–498, 493f Reperfusion, in donor implantation, 561
Primary chordae tendineae, 271, 348 Retractor-mounted flexible retractor, 574, 575f
Prolene purse-string suture, 143–144, 150 Retrieval team, for heart transplantation
Prolene sutures, 574, 575f donor heart management by, 549
Prolene technique, 541 organ recovery by, 550–552
Prosthesis-based annuloplasty, 187 visualization by, 549–550
Prosthetic aortic valve endocarditis, 229–236, 230f Retrograde cardioplegia, 146, 149f
Prosthetic mitral valve endocarditis, 234, 235f cannula for, 338, 339f
Proximal anastomoses, in minimally invasive coronary artery bypass Retrograde cerebral perfusion, 141
grafting, 75, 76f Retrograde coronary sinus, cannulation of, 24, 25f
Proximal aortic repair, 420 Revascularization
Proximal aortic root anastomosis, 191 complete, in left ventricular aneurysm repair, 507
Proximal suture line, 231 hybrid coronary, 83–102
PTE. see Pulmonary thromboendarterectomy anastomosis in, 96, 97f
Pulmonary arterial anastomosis, 559 anesthesia considerations for, 88
Pulmonary arteriotomy, 574, 575f chest radiography in, 93
Pulmonary artery, 386f computed tomography of heart in, 93, 94f
anastomosis of, in donor heart implantation, 557, 560f, 562f definition and rationale of, 83–84
division of, in donor heart retrieval, 550, 552 direct examination of patient thorax in, 95
donor, 559 direct internal thoracic artery harvest for, 92
Pulmonary artery pressure (PAP), obstruction in, 568 endoscopic port insertion in, 95
Pulmonary autograft, used in Ross procedure, 260, 261f history of, 84
Pulmonary embolism (PE), 566–568 indications for, 85–86
Pulmonary thromboendarterectomy (PTE), 568 intrathoracic visualization in, 93
indications for, 568 LITA-LAD anastomosis in, 95
pearls and pitfalls of, 577 methods and techniques for, 88–96
postoperative care for, 576–577 patient preparation, positioning and draping for, 90, 91f
results of, 577 patient selection in, 85–86, 87f
right-sided, 574 perfusion considerations for, 90
Pulmonary valve, 261f, 307f, 348, 386f pericardiotomy in, 95
Pulmonary vascular resistance (PVR), 568 port placement in, 93
Index 591
Revascularization (Continued) Rolling the groove, 275, 276f–278f
results, institutional experience, and current evidence in, Rongeur, 150
98–101 Ross procedure, 260–268
single-lung ventilation in, 90 operative steps in, 262–266, 263f, 265f
single-stage procedure of, 88, 89f pearls and pitfalls in, 268
strategy for, 83 postoperative care in, 268
two-stage procedure of, 88 preoperative considerations for, 260, 261f
sequence of, in OPCAB, 64 surgical anatomy in, 260, 261f
Reverse “ T ” incision, for off-pump coronary artery bypass, 52f Ross-Konno reconstruction, of aortic root, 156, 169–171, 172f
Reversed elephant trunk technique, of thoracoabdominal aneurysm Routine median sternotomy, 570
repair, 449, 450f Rummel tourniquet, 56
Rheumatic tricuspid stenosis, features of, 385 RVAD. see Right ventricular assist device
Right atrial appendages, 312, 386f
Right atrial lesions, in atrial fibrillation, 483, 484f
Right atrial transseptal approach, 275, 276f–278f
Right atrium, 386f S
cannulation of, 24, 38–40, 39f, 41f, 414 SACP. see Selective antegrade cerebral perfusion
Right coronary artery, 157, 261f, 307f, 386f Saline test, for mitral valve repair, 302, 303f
Right coronary cusp (RCC), 179, 349f SAM. see Systolic anterior motion
Right femoral vein, 521f Saphenous vein
Right fibrous trigone, 333f, 349f harvesting of, in on-pump coronary artery bypass, 36, 37f
Right heart catheterization, 568, 569f, 575f surgical anatomy of, 33
Right internal jugular vein, 521f SAVR. see Surgical aortic valve replacement
Right internal thoracic artery (RITA), 53 SCA. see Subcommissural annuloplasty
Right minithoracotomy, 140–141 Secondary chordae, 271
Right superior pulmonary vein, cannulation for venting of, 26, 27f Secondary tricuspid regurgitation, 387–389, 388f
Right trigone, 349f Seldinger technique, 143–144, 535–537
Right ventricular assist device (RVAD), 543 ultrasound-guided, 524, 525f
Right ventricular outflow tract (RVOT) obstruction, 564 Selective antegrade cerebral perfusion (SACP), during circulatory
Ring annuloplasty, 279, 280f arrest, 416–418
RITA. see Right internal thoracic artery Self-expanding Medtronic CoreValve (Medtronic, Minneapolis),
Rittenhouse-Manouguian technique, of aortic root enlargement, 159, 245
160f, 163–165, 164f, 166f Septal artery, 261f
Robot docking, in robotic coronary artery bypass grafting, 106f, Septal defect, ventricular, postinfarction, 114–126
107, 108f operative steps in, 116–125
Robotic coronary artery bypass grafting, 103–113 general principles of, 116–117
access cardiopulmonary bypass in, 109–110 modified technique: infarct exclusion, 123, 124f
anesthesia in, 105, 105b right ventricular approach, 125
application of endoballoon in, 109–110 standard technique: debridement of necrotic tissue, 117–121,
exposure of target vessels in, 110 118f, 120f, 122f
final maneuvers in, 113 pearls and pitfalls in, 125
hardware and procedure versions in, 105–107, 106f postoperative care in, 125
internal mammary artery takedown in, 107, 108f preoperative considerations in, 114–116
introductory considerations in, 103–107 surgical anatomy in, 114
patient positioning, prepping, and draping in, 107 Septal myectomy, in hypertrophic cardiomyopathy, 491
patient selection, indications, and contraindications in, 103 Shunting, during OPCAB, prevention of, 64–66
pericardial fat pad removal in, 109 Side-biting clamping, 53
pericardiotomy in, 109 Silastic Blake drain, 576
port placement in, 106f, 107, 108f, 109 Silk stay sutures, 275
postoperative care in, 113 Simplified nonresectional leaflet remodeling technique, 290, 291f
preoperative workup in, 104, 104b limitations of, 292
robot docking in, 106f, 107, 108f Single deep suture-sling technique, 56, 57f
robotic endoscopic graft to coronary anastomosis in, 111, 112f Single-lumen endotracheal tube, ventilation, 142
Robotic mitral valve surgery, 347–363, 347.e1 Single-lung ventilation
aortic occlusion, cardioplegia, and exposure, 353, 354f in hybrid coronary revascularization, 90
benefits of, 347 for minimally invasive cardiac surgical coronary artery bypass
cannulation and docking, 351–353, 352f, 354f grafting, 71
contraindications for, 350t Sinotubular junction, surgical anatomy of, 409, 410f
final steps in, 361 Siphon, 561
mitral valve repair, 355–359 Skeletonization, 51
operative steps in, 350–361 Sliding leaflet plasty, 286, 287f, 298
pearls and pitfalls, 362 Sling-aided method, 58, 59f
postoperative care in, 362 Small-caliber cardiotomy suction, 574
preoperative considerations, 348–350 Snare snuggers, 526, 527f
setup and port placement, 351, 352f Sodium bicarbonate, in thoracoabdominal aneurysm repair, 441
surgical anatomy in, 348 Soft tissue retractor, 146
592 Index
Sondergaard groove, 275, 276f–278f Sutures
left atriotomy via, 308, 309f annuloplasty, 279, 280f
Special forceps, 572–574, 573f in aortic valve replacement, 134, 135f, 136, 137f
Spinal cord ischemia, associated with thoracic endovascular aortic in mitral valve replacement, 342, 343f
repair, 459 monofilament, 298
St. Jude valve, used in Bentall procedure, 219, 220f polytetrafluoroethylene, 292
Stand-alone atrial fibrillation, 486, 487f SVC. see Superior vena cava
Standard central aortic cannulation, 272–274 SVR. see Surgical ventricular reconstruction
Starfish nonsternotomy heart positioner (Medtronic), 77, 78f–79f Swan-Ganz catheters, 517
Stay sutures, placement of, in left ventricular aneurysm repair, 511, Systolic anterior motion (SAM), risk factor for, in mitral valve repair,
512f 279, 286, 287f, 302
Stenosis, aortic, aortic valve replacement for, 130
Sternal body, 335f
Sternal wound infection, 3
Sternotomy, 274, 539 T
closure of, 6, 7f TAAAs. see Thoracoabdominal aortic aneurysms
median Table tilt maneuvers, 51
for cardiopulmonary bypass, 509–517 Target vessels, exposure of, in robotic coronary artery bypass
for heart surgery, 3–4, 5f grafting, 110
for off-pump coronary artery bypass, 51–53 TAVI. see Transcatheter aortic valve implantation
for on-pump coronary artery bypass, 36 TECAB. see Totally endoscopic coronary bypass grafting
for minimally invasive mitral valve replacement, 332–346, 333f TEE. see Transesophageal echocardiography
partial, 6, 7f Teffects ipw package, 98
Sternum, 261f Teflon felt strip, used in Bentall procedure, 219, 220f
Steroids, use of, 563–564 Teflon polypropylene, 537–539
Stroke, associated with thoracic endovascular aortic repair, 459 Teflon strips, 517, 518f
Subclavian artery Temporary ventricular assist devices, 533–535
cannulation of, 414 Tertiary chordae, 271
thoracoabdominal aneurysm encroachment on, 443 TEVAR. see Thoracic endovascular aortic repair
Subclavian revascularization, in thoracic endovascular aortic repair, Thoracic aortic aneurysms, descending, TEVAR for, 455–476
466, 467f aneurysm, deployment of endograft in, 464–466, 465f, 467f
Subcommissural annuloplasty (SCA), 181, 187, 188f aortic dissection, deployment of endograft in, 468, 469f
Subcommissural triangle, 199 hybrid arch repair as, 468–472, 471f, 473f
Subvalvular apparatus, 271–272, 348 imaging as, 460, 461f
Suction-driven positioning devices, for heart positioning, 54, 56 operative steps in, 460–472
Superior vena cava (SVC), 570 aneurysm, deployment of endograft in, 464–466, 465f, 467f
Supradiaphragmatic pocket, body of pump in, 539 aortic dissection, deployment of endograft in, 468, 469f
Surgery hybrid arch repair as, 468–472, 471f, 473f
for atrial fibrillation, 479–488 imaging as, 460, 461f
anatomy in, 480 subclavian revascularization as, 466, 467f
aortic valve surgery in, 485 vascular access as, 462, 463f
coronary artery bypass graft in, 485 pearls and pitfalls in, 472–474, 473f, 475f
Cox-Maze IV procedure in, 480 postoperative care in, 472
left atrial appendage in, 483 preoperative considerations in
left atrial lesions in, 481–483, 482f, 484f anatomic requirements and, 457, 458f
mitral valve surgery in, 485 intraoperative monitoring and, 459
pearls and pitfalls in, 486 vascular access and, 459
postoperative care in, 486 subclavian revascularization as, 466, 467f
preoperative considerations in, 480 surgical anatomy in, 455–457, 456f
pulmonary veins isolation in, 481 vascular access as, 462, 463f
right atrial lesions in, 483, 484f Thoracic artery, internal, surgical anatomy of, 33
stand-alone atrial fibrillation in, 486, 487f Thoracic endovascular aortic repair (TEVAR), 455–476
for hypertrophic cardiomyopathy, 489–504 operative steps in, 460–472
operative steps in aneurysm, deployment of endograft in, 464–466, 465f, 467f
transaortic approach in, 492–498, 493f, 495f, 497f, 499f aortic dissection, deployment of endograft in, 468, 469f
transapical approach in, 498–502, 501f, 503f hybrid arch repair as, 468–472, 471f, 473f
pearls and pitfalls in, 502–504 imaging as, 460, 461f
postoperative management in, 502 subclavian revascularization as, 466, 467f
preoperative considerations in vascular access as, 462, 463f
diagnosis and imaging as, 491 pearls and pitfalls in, 472–474, 473f, 475f
preoperative planning as, 492 postoperative care in, 472
septal myectomy in, 491 preoperative considerations in
surgical anatomy in, 489, 490f anatomic requirements and, 457, 458f
Surgical aortic valve replacement (SAVR), 242 intraoperative monitoring and, 459
Surgical sealants, use of, 116–117 vascular access and, 459
Surgical ventricular reconstruction (SVR), 505 surgical anatomy in, 455–457, 456f
Index 593
Thoracoabdominal aortic aneurysms (TAAAs), 438–454 Transthoracic Chitwood clamp, 274
characterization of, 438 Transthoracic echocardiography (TTE), 226
repair of for minimally invasive cardiac surgical coronary artery bypass
aortic exposure in, 441–443, 442f grafting, 71
aortic graft replacement in, 443–447, 444f, 446f, 448f Transverse aortotomy, 181
closure in, 449 Transverse arteriotomy, 524
Crawford classification of, 438, 439f Transverse-oblique (hockey stick) aortotomy, 494, 495f
hypothermic circulatory arrest technique in, 451, 452f Trendelenburg position, 51, 58
incisions in, 441–443, 442f Triangular resection, 281, 282f
indications for, 440 with ventricularization, 355, 356f
intraoperative management strategy in, 441 Tricuspid stenosis, 385
pearls and pitfalls in, 453 Tricuspid valve, 307f, 348, 384, 386f
postoperative care in assessment of, 389
early management in, 451–453 to other structures, relation of, 385, 386f
long-term surveillance in, 453 Tricuspid valve annulus, 385
preoperative considerations in, 440 Tricuspid valve diseases
reversed elephant trunk technique in, 449, 450f causes of, 385–389
surgical anatomy in, 438 degenerative tricuspid regurgitation, 387
Thoracoabdominal incisions, in aortic aneurysm repair, 441–443, 442f prosthesis and ring size, 393
Thoracotomy, 8–11 prosthetic valve type, choice of, 391
anterolateral, 8 repair technique, choice of, 390–391, 392f
left, 3 secondary tricuspid regurgitation, 387–389, 388f
submammary, 9, 10f tricuspid stenosis, 385
supramammary, 9, 10f tricuspid valve, assessment of, 389
approaches in, 8 tricuspid valve intervention, indications for, 389–390, 390t
closure of, 11 tricuspid valve regurgitation, 387
in hybrid coronary revascularization, 92 Tricuspid valve endocarditis, 393
posterolateral, 3, 9, 10f repair, 400
Thorax, direct examination of, in hybrid coronary revascularization, 95 resection, 402
Thrombosis, prevention of, 520 Tricuspid valve intervention, indications for, 389–390, 390t
Totally endoscopic coronary bypass grafting (TECAB), 103 Tricuspid valve operations, 384–406
contraindications to, 104b bicuspidization, 396–400, 397f
Transaortic approach, 275, 276f–278f annuloplasty band insertion, 398, 399f
in hypertrophic cardiomyopathy, 492–498, 493f, 495f, 497f, 499f edge-to-edge and clover leaf repair, 398, 399f
Transaortic-transcatheter aortic valve replacement access, 249–251, tricuspid valve repair, assessment of, 400
250f, 252f De Vega technique for, 396, 397f
Transapical approach, in hypertrophic cardiomyopathy, 498–502, operative steps in, 394
501f, 503f surgical access and exposure, 394, 395f
Transapical cannulation, for cardiopulmonary bypass, 22, 23f pearls and pitfalls, 404–405
Transcatheter aortic valve implantation (TAVI), 243 postoperative care in, 402–403
Transcatheter aortic valve replacement, 242–259 preoperative considerations in, 385–393
access closure, 255 procedures in, 396
access-related issues, 258, 259t surgical anatomy of, 384–385
hybrid operating suite, 247, 248f, 250f tricuspid valve endocarditis, 393
implantation, 253–255 tricuspid valve intervention, results of, 403–404
operative steps, 247–255 tricuspid valve replacement, 400, 401f
access, 249–251 Tricuspid valve regurgitation, 387
patient preparation, 247 Tricuspid valve repair, 361
safety net, 247, 248f, 250f Tricuspid valve replacement, 400, 401f
pearls and pitfalls, 257–258 True distal disease, 568
postoperative care, 257 TTE. see Transthoracic echocardiography
preoperative considerations, 243–247 Tubularized autograft
preoperative planning, 244, 244t distal suture of, 266, 267f
procedure-related issues, 257 used in Ross procedure, 266, 267f
surgical anatomy, 242
valve choice, 245, 246f
valve-related issues, 257–258
Transesophageal echocardiography (TEE), 142–143, 191, 201, 302, U
511, 522, 537–539, 561–563, 570 UAV. see Unicuspid aortic valve
in robotic coronary artery bypass grafting, 105 Unicuspid aortic valve (UAV), 195, 196f
Transfemoral-transcatheter aortic valve replacement access, 249, 250f
Transmural infarcts, 505
Transplantation, heart, 546–565. see also Heart transplantation
Transpulmonary gradient, 553–554 V
Trans-septal incision, in minimally invasive mitral valve replacement, Vacuum-assisted venous drainage, 336
338, 339f VAD. see Ventricular assist device
594 Index
Valsalva graft, 189–191, 192f Ventricular septal defect, postinfarction (Continued)
Valve replacement, 342, 343f pearls and pitfalls in, 125
Valve sutures, 150 postoperative care in, 125
Valvuloplasty, 251, 252f preoperative considerations in, 114–116
Vancomycin, 143 surgical anatomy in, 114, 115f
Vascular access, in thoracic endovascular aortic repair, 462, 463f Ventricular thrombus, embolism from, 517
preoperative considerations for, 459 Ventricular venting, left, 146
Vasoplegia, 561 Ventricularization, triangular resection with, 355, 356f
Venous cannulation, 22–24, 144, 528 Ventriculogram, 507
Venous-arterial extracorporeal membrane oxygenation, 28, 29f Ventriculotomy, 509, 517, 518f
central cannulation, 526–528 closure with Teflon strips, 517
peripheral cannulation, 524–526 Venus A-Valve (Venus MedTech, Hangzhou, China), 245, 246f
Venous-venous extracorporeal membrane oxygenation, 26, 27f, Vertical transseptal biatriotomy, extended, 310, 311f
522 Vessels
peripheral percutaneous cannulation, 528, 529f circumferential dissection of, 144
recirculation during, 530 femoral, surgical anatomy of, 522, 523f
Ventilation-perfusion (V̇ /Q̇ ) scan, 566, 567f Vicryl suture, 152
Ventricular arrhythmia, 507 Visualization, of heart donor, 549–550
Ventricular assist device (VAD), 539 Vitamin K, use of, 554
bleeding in, 543
removal, 543
use of, 116
Ventricular septal defect, postinfarction, 114–126 W
operative steps in, 116–125 Weitlaner retractor, 570, 571f
general principles of, 116–117
modified technique: infarct exclusion, 123, 124f
right ventricular approach, 125
standard technique: debridement of necrotic tissue, 117–121, Z
118f, 120f, 122f Zone of coaptation, 271

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Atlas of

Marc Ruel, MD, MPH

ATLAS OF CARDIAC SURGICAL TECHNIQUES, SECOND EDITION ISBN: 978-0-323-46294-5

Copyright © 2019 by Elsevier, Inc. All rights reserved.

Previous editions copyright © 2010.

Publisher: Russell Gabbedy

Last digit is the print number: 9 8 7 6 5 4 3 2 1

Arvind K. Agnihotri, MD Munir Boodhwani, MD, MMSc

Joseph E. Bavaria, MD Garrett Coyan, MD, MS

Jolian Dahl, MD Jacqueline H. Fortier, MSc

Tirone E. David, MD Ravi K. Ghanta, MD

John R. Doty, MD David Glineur, MD

Faisal Hasan, MD S. Ram Kumar, MD, PhD

John S. Ikonomidis, MD, PhD Scott A. LeMaire, MD

Tomislav Mihaljevic, MD Vivek Rao, MD, PhD

Ourania Preventza, MD, FACS, MBA Marc Ruel, MD, MPH

Christopher Sciortino, MD, PhD Vaughn A. Starnes, MD

Dai Une, MD Y. Joseph Woo, MD

Section I Bc.lsic Techniques

Section 11 Operations for Corondry Artery Dis 'dSC

CHAPTER 4 OFF-PUMP CORONARY ARTl:RY BYPASS GRAl·-r!NG -w

CHAPTER ·1 1\1li':l1\'1ALLY INVASIVE CORO 'ARY ARTERY BYPASS GRAFT! 'G 70

CHAPTER 6 I IYBRID COR01 ,.\RY REVASCULARIZATION Bs

CHAPTER; ROBOTTC CORONARY ARTERY BYPASS GR1\FTTNG 105

CHAPTER H POSTTNFARCTION VE TTRICLTLAR SEPTAL OF.FF.CT REPAIR 1q

Section 111 Opcrntions for Va lvul a r Hec1rt Disc;1sc

CHAPTER 10 1\\li'\llv�ALLY INVASIVE, 1'v\1Nl-Tl lORACOT01\\Y AORTIC VALVE

CHAPTER 11 AORTIC ROOT ENLARGE,\ \.E1 T TECI INJQUES 1'>6

CHAPTER u AORTIC VALVE REPAIR IT/

CHAPTER 1-s AORTIC VALVE-SPARlNG OPERATIO S 199

CHAPTER q HE TALL PROCEDURE .215

CHAPTER 16 TRA 'SCATHETER AORTIC VALVE RIPLACEi\\E T :i.µ

CHAPTER 17 ROSS PROCEDURE 260

CHAPTER 18 REPA JR J JG DEGE fRA TlVE .t'vUTRAL VALVE DISEASE

CHAPTER 19 MTTRAL VALVE REPLACE1\l\ENT 306

CHAPTER 20 MJNIMJ\Ll Y INVASIVE MITRAl VALVE SURGERY:

CHAPTER 2·1 ROBOTIC MTTRAL VALVE SURGERY 34/

CHAPTER :u PERCUTANEOUS MITRAl VALVE REPAIR TECHNIQUES 364

CHAPTER 1·5 TRTCUSPID VALVE OPERATIONS 384

section lV Operations for Aortic Disease_

CHAPTER 25 AORT I C ARCI J At'-IEURYSMS 424

CHAPTER 27 THORACIC ENDOVASCULAR AORTIC REPAIR FOR DESCENDING TIIORACIC

Section V 1\!\iscella.neous Operations

CHAPTER 28 SURGERY FOR ATRIAL FIBRILLATION 479

CHAPTER 29 SURGERY FOR TTYPERTROPTTTC CARDJ01\l\YOPATITY 489

CHAPTER 31 APP ROACHES AND TECHNIQUES FOR EXTRACORPOREAL 1\1\EMBRANE

CHAPTER 32 VEN TRJC ULAR ASSISTANCE AND SU PPORT 531

CHAPTER 33 HEART TRA1 SPLN TATl01 546

CHAPTER 34 CHRONIC THROJ\11BOEMJ30LIC PULMONARY HYPERTENSION "66

CHAPTER 4 Off-Pump Coronary Artery Bypass Grafting

CHAPTER 5 Minimally Invasive Coronary Artery Bypass Grafting

CHAPTER 12 Aortic Valve Repair

CHAPTER 22 Percutaneous Mitral Valve Repair Techniques

CHAPTER 26 Thoracoabdominal Aneurysms

Step 1. Operative Steps

Jugular venous arch

Step 2. Partial Sternotomy

Step 3. Sternotomy Closure

by putting two together in a figure-of-eight fashion. Reinforcement of the sternum edge is

View from the side

Step 1. Approaches in Thoracotomy

Step 2. Operative Steps

Supramammary Anterolateral Thoracotomy

Submammary Anterolateral Thoracotomy