Mini-Bentall Procedure and Hemiarch Replacement:Graft Anastomosis and Mini-Sternotomy Closure
In this video, the final episode in a seven-part series, Tristan Yan demonstrates how to anastomose the Ante-Flo graft to the Valsalva graft, wean the patient off bypass, and close the mini-sternotomy incision.
- Once the root procedure is completed, the proximal valve conduit is trimmed just above the Valsalva portion of the graft.
- The distal Ante-Flo graft is put under a stretch and cut to an appropriate length.
- A graft-to-graft anastomosis is performed using a continuous 3-0 running prolene suture. The spacing between the adjacent stitches needs to be narrow and precise when doing a graft-to-graft anastomosis, usually only a couple of millimeters apart.
- The aortic root vent is inserted, the aortic cross clamp is slowly released, and a 21-gauge needle is used to de-air the graft. In order to ensure an absolute hemostasis, pledgeted 4-0 prolene sutures are applied to reinforce the proximal anastomosis.
- A bi-polar temporary pacing wire is inserted in the epicardium over the right ventricle.
- Two 28 Fr soft drains are inserted and brought out below the xiphoid cartilage.
- Hemostasis is carefully checked and the patient is weaned from cardiopulmonary bypass.
- Protamine is given to reverse the Heparin effect. Topical Floseal Hemostatatic Matrix (Baxter Healthcare, Zurich, Switzerland) is applied around the anastomotic sites.
- Once the hemostasis is deemed satisfactory, two stainless steel double wires are used to approximate the sternum.
This completes the Mini-Bentall procedure and hemiarch replacement. As shown in this video series, the fundamental principles of a traditional aortic root replacement must be respected. It also cannot be emphasized enough that a meticulous surgical technique to ensure absolute hemostasis is of utmost importantance in minimally invasive surgery. This results in a complete aortic repair via a minimal access incision, and successful treatment in selected patients with aortic root and/or ascending aortic aneurysm.