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International Society For Minimally Invasive Cardiothoracic Surgery

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The Modified Atrial Well: A Trans-atrial Access For Off-pump Beating-heart Procedures Reconsidered For The Modern Age Of Cardiac Surgery
Paul Werner1, Marco Russo1, Christoph Gross1, Iuliana Coti1, Markus Mach1, Alfred Kocher1, Guenther Laufer1, Jude Sauer2, Martin Andreas1.
1Medical University of Vienna, Vienna, Austria, 2Medical University of Rochester, Rochester, NY, USA.

Objective This proof of concept trial features the key concept of open-port access to the right atrium originally developed for atrial-septum defect closure. We assessed the feasibility of this access in a modern, imaging-guided hybrid-setting for off-pump beating-heart tricuspid valve (TV) repair in an in-vivo animal model. Methods A specific RA cannulation strategy based on the concept of the "atrial well” was investigated in 4 pigs for TV interventions. Surgical access was gained via lateral thoracotomy with stand-by cardiopulmonary bypass for reperfusion of lost blood. Visualization of the procedures was performed in a hybrid-setting with multimodal echocardiographic and fluoroscopic imaging. The 1st version of the cannula was investigated in 2 pigs undergoing off-pump TV annuloplasty. The cannula (length 16.8cm, 3.2cm outer-diameter, 1.6cm inner-diameter) was designed with a larger orifice, allowing the passing of a tricuspid valve annuloplasty ring (Figure 1A). To minimize the risk of cannula-dislocation and maintain intracardiac manoeuvrability, a mechanical holding-arm was used for fixation. Vertical orientation of the cannula was necessary to prevent blood leakage. Annular suturing, ring implantation, and knot fixation were performed through the cannula under imaging guidance. The 2nd version of the cannula was tested in two pigs undergoing off-pump TV plication. This version of the cannula (length 26.0cm, 1.75cm outer-diameter, 1.6cm inner-diameter) was designed with a smaller orifice and an integrated hemostatic valve, minimizing blood-leakage and allowing horizontal orientation of the cannula (Figure 1B). To improve manoeuvrability of the holding arm, a ball joint was integrated subsequent to the mounting bracket. Annular plication was then performed through the cannula under imaging guidance.ResultsThe cannulation concept with both versions of the RA-cannulas was effective in all four cases, allowing successful performance of off-pump TV procedures in 4 animals. No adverse events (coronary obstruction, atrial rupture, complete AV block, massive bleeding, sudden death) were recorded.Conclusion
The present proof-of-concept study demonstrates the feasibility of a novel approach to the known concept of trans-atrial cannulation for minimally-invasive TV repair in a hybrid-setting. We believe that this is a promising approach which could facilitate the performance of right-sided off-pump procedures under advanced imaging guidance.
LEGEND:
RA cannulation with specific cannulae for A) off-pump TV valve annuloplasty B) off-pump TV annular plication


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