Suspending Commissural Sutures for Exposure of the Aortic Valve in Mini-thoracotomy Aortic Valve Replacement
Eunji Kim, Joon Bum Kim
Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea, Seoul, Korea, Republic of
BACKGROUND: Though attractive, mini-thoracotomy aortic valve (AV) replacement (AVR) has a limitation of the limited exposure of the AV. Here we present a simple exposure technique for a more efficient mini-AVR.
METHODS: The technique involves making 3 half-depth stitches with 1-0 silk at each of commissures, which are anchored to each corresponding pericardial surface. These stitches are tightened up so that the aortic root is axially expanded and is pulled upward. Standard approaches of isolated (i-AVR) and combined AVR (c-AVR) were right anterior and anterolateral mini-thoracotomy (5-7cm), respectively. The data present from inaugural experiences of this approach.
RESULTS: From Nov 2017 through Sept 2020, 93 patients (age, 67.6±11.2 yrs) underwent AVR (72 isolated and 21 combined) with this approach. C-AVR involved mitral repair/replacement in 8(8.6%), tricuspid repair in 5(5.4%), ablation of atrial fibrillation in 12 (12.9%), and closure of the atrial septal defect in 5 (5.4%). Sutureless/rapid-deployment devices were used in 31 cases (33.3%). There were 3 cases of conversion to sternotomy (3.2%). Mean aortic clamping and cardiopulmonary bypass times were 54.6 ± 23.3 min and 82.1 ± 36.6 min, respectively in i-AVR, and were 106.6 ± 39.4 min and 159.0 ± 56.5 min, respectively for c-AVR. There was one case of early mortality (1.1%). Major complications occurred were temporary neurologic deficits in 3 (3.2%), reoperation for bleeding in 1 (1.1%), new-dialysis in 3 (3.2%), permanent pacer implantation in 1 (1.1%), and re-AVR due to paravalvular leakage in 1 (1.1%).
CONCLUSIONS: The technique of suspending commissural sutures seems to offer reasonable exposure of the AV in mini-AVR showing excellent early surgical outcomes. 
LEGEND: Suspending commissural sutures to exposure the aortic valve