Physical Address
304 North Cardinal St.
Dorchester Center, MA 02124
Mitral Operation: Sternotomy Approach
LEARNING OBJECTIVES
-
Understand the indications for sternotomy approach to mitral valve surgery.
-
Understand the standard setup and cannulation strategy for mitral valve surgery through sternotomy.
-
Understand tips and tricks for optimizing exposure through sternotomy.
INTRODUCTION
Mitral repair or replacement via median sternotomy is the gold standard for surgical interventions upon the mitral valve and remains the most common approach. Median sternotomy is universally available, safe, and provides. Cvalvular apparatus. In certain patients, for example, those with severe peripheral vascular disease or unsuitable anatomy for limited access approaches, it is the only option. In other patients, a limited approach to the mitral valve is converted to a sternotomy approach for a number of reasons. The sternotomy approach also provides considerable versatility in managing complex cases, extending exposure in challenging scenarios, and should be the foundational technique in a surgical mitral valve program, even one which includes or is starting a minimal access program. Here we describe our practice of median sternotomy mitral valve surgery.
MEDIAN STERNOTOMY AND CANNULATION
We perform a limited skin incision and a full sternotomy to provide complete access to the heart and great vessels. Pericardial stay sutures are placed on the right side to allow the left atrium to be rotated and pulled into view. Following systemic heparinization, central cannulation is achieved with a dispersion tip aortic cannula in the lesser curve of the distal ascending aorta, allowing space for placement of an aortic root vent and any other concomitant procedures such as aortic valve replacement or coronary bypass grafts. The superior vena cava (SVC) is directly cannulated with a 20 to 22 Fr metal tip right angle drainage cannula, and the inferior vena cava (IVC) is cannulated with a single-stage 32 to 36 Fr venous drainage cannula. A coronary sinus cannula is placed through the body of the right atrium for retrograde cardioplegia. The oblique sinus is opened, and the SVC is dissected free from its pericardial connections to promote mobility of the heart which may be rotated around the great vessels. Cardiopulmonary bypass is commenced, the root vent is placed and the aorta is cross-clamped, and cold blood high-K + cardioplegia is administered for diastolic cardiac arrest. During this time, the sidebar of a standard Carpentier mitral retractor is attached. Once cardioplegia is complete, surgical access to the mitral valve begins. Fig. 15.1 demonstrates this standard setup.
You're Reading a Preview
Become a Clinical Tree membership for Full access and enjoy Unlimited articles
If you are a member. Log in here
