2024 FSA Podium and Poster Abstracts
P028: REPLACEMENT OF AORTIC VALVE, AORTIC ROOT, AND ASCENDING AORTA USING MINIMALLY INVASIVE RIGHT ANTEROLATERAL THORACOTOMY APPROACH WITHOUT CIRCULATORY ARREST
Christopher P Emerson, MD1; Michael Fabbro II, DO1; Joseph Lamelas, MD2; 1Division of Cardiothoracic Anesthesiology, UHealth, University of Miami Hospital, Miami, FL, 33136; 2Division of Cardiothoracic Surgery, UHealth, University of Miami Hospital, Miami, FL, 33136
Introduction: Conventional sternotomies have historically been the mainstay operative approach for valve replacement surgery, coronary artery bypass grafting, and replacement of ascending aorta due to aneurysm. Since the late 1990s, minimally invasive thoracotomy approaches have been utilized for management of aortic valve pathologies. Proponents have argued that a smaller incision leads to less surgical trauma (resulting in less pain and allowing for faster patient recovery), and less postoperative bleeding resulting in fewer blood transfusions.
Methods: 45-year-old male, ASA IV, 183cm, 123kg, presented for minimally invasive aortic valve replacement, aortic root replacement, and ascending aorta replacement. His history was noted for essential hypertension, obstructive sleep apnea on CPAP, obesity, ascending aorta aneurysm and aortic valve insufficiency. Preoperative studies revealed normal sinus rhythm on ECG; 5.4cm dilation of aortic root; and 6.0cm dilation of ascending aorta on CTA; trileaflet AV with moderate AI with EF of 65% on echocardiogram; and normal perfusion of the coronary arteries on cath lab. Preprocedural radial artery line and pulmonary catheter were placed. The patient underwent general endotracheal anesthesia with continuous intraoperative TEE monitoring and mechanical ventilation in the immediate postoperative period.
Results: A 5 to 6 cm skin incision was performed over the right anterolateral chest wall and then the third intercostal space was entered. After heparinization, cardiopulmonary bypass was performed via femoral cannulas and the pericardium was opened over the aorta. A left ventricular clamp was inserted through the right superior pulmonary vein. A Chitwood clamp was placed over a distal portion of a nonaneurysmal section of the aorta. Transverse aortotomy was performed and cardioplegia was administered directly into the left and right coronary ostia to maintain electromechanical arrest of the heart. The aortic valve leaflets were thin and short before resecting down to the annulus. Coronary buttons were established for the left and right coronary ostia and later anastomosed into the sinus of Valsalve graft. A 27 mm Edwards Inspiris sinus of Valsalva valved conduit was sutured in a supra-annular position. The ascending aorta was transected 1 cm from the clamp and end-to-end anastomosed to the distal end of the Hemashield graft with appropriate length. Cross-clamp of the aorta was removed, followed by de-airing maneuvers before protamine reversal to come off bypass.
Discussion/Conclusion: Improvements in surgical technique and instrumentation design have allowed minimally invasive approaches to valvular replacement surgery. Literature data is demonstrating lower stoke rates, shorter lengths of stay, shorter ventilator time, lower incidence of renal failure and less mortality with a minimally invasive anterolateral thoracotomy approach to aortic valve replacement surgery. In this case, the patient qualified for “fast-track” cardiac recovery resulting in extubation on POD 0 and transferring out of the CVICU the following day and being discharged on POD 3. His recovery was uneventful, allowing for a rapid return to function within two weeks with an improved quality of life. This case highlights that more complex cardiac procedures (aortic root dilation and ascending aorta replacement) can be safely performed through a minimally invasive anterolateral thoracotomy technique.