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Partial everting mattress method for easy and secure placing of annular sutures during minimally invasive aortic valve replacement
Toshinori Totsugawa, Taichi Sakaguchi, Arudo Hiraoka, Kentaro Tamura, Hidenori Yoshitaka.
The Sakakibara Heart Institute of Okayama, Okayama, Japan.

OBJECTIVE: In minimally invasive aortic valve replacement (MIAVR), it is usually hard to obtain good exposure of the annulus of right coronary cusp (RCC) because of the leaning aortic sinus wall. Here we present the efficacy of partial everting mattress (PEM) technique for easier approach to the RCC annulus.
METHODS: From October 2012 to September 2014, single surgeon performed MIAVR through right anerolateral mini-thoracotomy for 48 patients having aortic stenosis. Among these patients, 20 patients underwent MIAVR with PEM method because of poor exposure of the RCC annulus (group P). Patients’ characteristics, surgical data and postoperative echocardiographic data were compared with those of remaining 28 patients in which prosthetic valve was placed in a supra-annular position (group S). In PEM method, non-everting mattress sutures with pledgets in left ventricular side are placed at the annuls of the left coronary cusp (LCC) and the non coronary cusp (NCC); everting mattress sutures with pledgets in aortic side are for the RCC annulus. Needles can be grasped in forehand at the all three coronary cusps. Exposure of the RCC annulus is secured by pushing the leaning right coronary sinus away by a minimally-invasive needle holder when placing the needle down into the annulus. Finally, a prosthetic valve is implanted in a supra-annular position for the LCC and NCC and in an intra-annular position only for the RCC.
RESULTS: In patients’demographic characteristics, mean age of group S was significantly higher than that of group P (77.1±8.8 versus 71.1±10.1, p=0.03). In surgical data, there were no significant difference between two groups in operative time (270±42 min versus 265±29 min, p=0.60), aortic cross-clamping time (104±19 min versus 106±13 min, p=0.61) and prosthetic valve size (20.3±1.8 mm versus 21.1±1.7 mm, p=0.15). Postoperative echocardiographic data including mean aortic valve pressure gradient and effective orifice area index were almost the same between the two groups (12.5±3.5 mmHg versus 12.1±2.7 mmHg, p=0.69; 0.94±0.13 cm2/m2 versus 0.93±0.14 cm2/m2, p=0.70, respectively).
CONCLUSIONS: Our PEM technique can lead easy and secure placing of annular sutures under a poor exposure of the RCC annulus, without adverse influences on prosthetic hemodynamic performances.

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