Right anterior minithoracotomy with total central cannulation

Our patient was a 71-year-old man who presented with calcified aortic stenosis. His major clinical sign was classic dyspnea. The preoperative work-up showed the following elements: (a) on transthoracic echocardiography, the left ventricular ejection fraction was normal, the valve was calcified with a mean gradient of 42 mmHg and a surface of 0.7 cm²; (b) the results of catheterization of the left heart were normal; (c) the CT scan, performed systematically in all our patients treated with a minimally invasive procedure, showed a favorable aortic angle [1] and an aorta better approached through the 2nd intercostal space. This patient was considered low-risk (E II 1.67%). We decided to replace the aortic valve through a right anterior minithoracotomy, which is our routine approach in this setting. 

The aortic angle (the angle between the right side of the sternum and the left border of the aorta, at the level of the pulmonary bifurcation) was measured on the CT scan with a value of 153°. Based on our experience, when this angle is greater than 140°, we consider the patient to be suitable for a right anterior minithoracotomy. Also, we always do a 3-dimensional reconstruction of the chest to better estimate the level of the right atrial appendage and to choose the appropriate intercostal incision (2nd or 3rd intercostal space). In this case, we chose to make an incision at the 2nd intercostal space. 

The patient is placed supine with a roller pad behind his shoulders and intubated with a single-lumen tube. We no longer use a double-lumen tube for these patients; we strongly believe that the single-lumen tube helps reduce postoperative unilateral reexpansion pulmonary edema [2]. The right axillary artery and groin are also prepared in the sterile surgical field, which can help to establish antegrade peripheral cardiopulmonary bypass (CPB) [3] in difficult cases with limited surgical exposure in which central cannulation can be challenging. 

We make a 6- to 8-cm skin incision. The 2nd intercostal space is opened, and we verify the absence of lung adhesions. The right internal thoracic artery and veins are clipped and sectioned. The cartilaginous part of the inferior rib is also sectioned at the level of the sternum. A soft tissue retractor and a rib spread retractor are placed. A large surgical gauze is placed temporarily within the chest, because it helps with surgical exposure and to protect the lung. 

We open the pericardium. Stay sutures are placed (usually 3 posterior and 3 anterior). The posterior ones are passed through the chest wall laterally and tractionned. This maneuver greatly improves surgical exposure. We start with the venous cannulation at the level of the right atrial appendage. A 3-stage 29 Fr venous cannula (LivaNova, Saluggia, Italy) is implanted. Vacuum-assisted venous drainage is mandatory. The cannula is passed in the space between the soft tissue retractor and the skin incision. As described in the next 2 sections, this step can be done with 1 or the other of 2 techniques, depending on the surgeon’s preference.   

In the first technique, the rib and soft tissue retractors are removed temporarily, and the venous cannula is placed between the skin and the soft tissue retractor. This technique is easy, but it requires the removal and the new placement of the 2 retractors.  

In the second technique, the tip of the venous cannula is first protected (we use a sterile finger from a surgical glove). A Kelly forceps is passed between the soft tissue retractor and the skin incision and is used to grab the tip of the cannula, which is passed smoothly in this space.  

Aortic cannulation is done as high as possible with an elongated 1-piece arterial cannula (Medtronic, Minneapolis, MN, USA), which has the advantage of being very flexible. This cannula can be easily pulled away from the surgical view. Retro priming is done routinely in our practice before we connect the aortic cannula to the CPB device. The cardioplegia and left vent lines are installed as usual. The left vent catheter is passed through the chest.

The aortic cross-clamp is done with a transthoracic Chitwood clamp. At the end of the cardioplegia, the tourniquets and the cardioplegia line are inserted in the chest in order to improve the surgical exposure.

The aortic valve can be removed as usual. One can use a surgical blade or scissors as is done for a sternotomy. Decalcification of the annulus can be completed with a rongeur. All types of surgical valves can be implanted; here we choose to implant an L-sized Perceval valve (LivaNova, Saluggia, Italy). Three guiding sutures are placed at the nadir of each cusp. We ve rify the good position of the guiding sutures with a smaller sizer (position of the 3 guiding sutures at 120°). The valve is parachuted and implanted. We no longer use balloon valvuloplasty for these valves. It is important to emphasize the fact that the Perceval valve must not be oversized. At the end, we carefully inspect and confirm that the valve is correctly placed. 

The CO2 line is inserted through a Y-connection of the cardioplegia line. The aorta is closed with a single or double-layer polypropylene 5-0 running suture. The epicardial wire must be implanted before the heart is filled. Two pericardial and 1 pleural 10 French drains are left in place. Transesophageal echocardiography is mandatory even for sutured valves. After the patient is weaned from the CPB, we close the pericardium. The rib is reattached to the sternum and the intercostal space is closed. The incision is infiltrated with local anesthesia; an anesthetic delivery catheter is left in place for 1 day. The skin is closed with an absorbable running suture, and surgical glue is applied.  

The cross-clamp time was 46 minutes. The patient was extubated after 2 hours. He was able to sit in a chair 6 hours after the surgery. Chest tubes were removed on postoperative day 1. The postoperative period was uneventful. The patient was discharged home on postoperative day 7.