Aortic Valve Reimplantation Through Right Anterior Minithoracotomy With Totally Central Cannulation
Enrico Ramoni, Vincenzo Smorto, Diego Magnano, Roberto Ceresa, Mauro Del Giglio.
Department of Cardiovascular and Thoracic Surgery, Villa Torri Hospital, GVM Care & Research, Bologna, Italy.
BACKGROUND: To examine the initial experience with aortic valve reimplantation (“Tirone-David” procedure) through right anterior mini-thoracotomy (RAT). At our institution, isolated valve operations have been routinely performed by RAT for at least 10 years. Based on it, and on our experience with aortic valve reimplantation using mini-sternotomy and totally central cannulation, from October 2020 we started to perform Tirone-David procedures through RAT, to combine advantages of the mini-thoracotomy access with the effectiveness of the aortic valve reimplantation procedure.
METHODS: From 01-10-2020 we prospectively collected preoperative, intraoperative and in-hospital postoperative data of patients undergoing Tirone-David procedure via RAT with totally central cannulation.
RESULTS: From 01-10 to 10-12-2020, 8 consecutive patients underwent aortic valve reimplantation for aortic root and ascending aorta replacement, both without aortic valve insufficiency and with different degrees of aortic regurgitation. Mean age was 55 years ± 5.8; 6 was male. Mean left-ventricle ejection fraction was 70%±6.4%. In all cases RAT with a 5-6 cm skin incision was performed in a single-Surgeon setting with complete central cannulation (inflow to the proximal aortic arch and outflow from the right atrium) (figure), normothermic systemic perfusion and crystalloid-plus-blood cardioplegia. Based on our experience gained with mini-sternotomy, we simplified the Tirone-David technique, using a systematic approach to assess the potential valve disfunction and to measure the optimal vascular graft size (figure). All the procedures went successfully. The mean CPB duration and cross-clamping time were respectively 146±55.9 and 129.5±51.9 minutes; the mean ventilation time was 5.4±21 hours; the mean ICU stay was 2.1±1.2 days. The mean total in-hospital stay duration was 8 days. No patients died during the hospital course. None had aortic regurgitation more than mild at discharge. The only noteworthy complication was postoperative transitional atrial fibrillation in 2 patients.
CONCLUSIONS: Our preliminary experience would suggest that the proven efficacy and safety of aortic valve reimplantation, can also be guaranteed with a particularly minimally invasive approach such as RAT with totally central cannulation. These encouraging data need to be confirmed by a broader case series and data of the follow-up.
Figure legend: Left section: Implantation of the Valsalva dacron graft. Middle section: Correct reimplantation of the aortic valve in the dacron graft. See the patient-inflow arterial cannula (on the left) and the patient-outflow venous cannula on the right, just under the green drape and near the left ventricular vent cannula. Right section: the 5.5 cm skin-incision for the right anterior mini-thoracotomy. 