This distal anastomosis is reinforced with pledgeted prolene sutures where necessary to ensure an absolute hemostasis. After completion of the open distal anastomosis, antegrade systemic perfusion is resumed via the side-arm perfusion limb of the Ante-Flo graft.
The patient is rewarmed towards 37 degrees centigrade. Once the root procedure is completed, the proximal valve conduit is trimmed just above the valsalva portion of the graft. The distal Ante-Flo graft is put under a stretch and cut to an appropriate length.
A graft-to-graft anastomosis is performed using a continuous running prolene suture Figure The spacing between the adjacent stitches needs to be narrow and precise when doing a graft-to-graft anastomosis, usually a couple of millimeters apart.
Finally, the aortic root vent is inserted, the aortic cross clamp is slowly released and a gauge needle is used to de-air the graft. In order to ensure an absolute hemostasis, pledgeted prolene sutures are applied to reinforce the proximal anastomosis when necessary.
A bi-polar temporary pacing wire is inserted in the epicardium over the right ventricular outflow tract. One 28 Fr soft drain is inserted and brought out below the xiphoid cartilage. Hemostasis is carefully checked and the patient is weaned from CPB. Protamine is given to reverse the Heparin effect. The surgical site is packed with small gauze sponges for a period of minute hemostatic pause. Once the hemostasis is deemed satisfactory, four stainless steel wires are used to approximate the sternum.
The skin is closed with a Monocryl subcuticular suture. This completes the Mini-Bentall procedure. An important goal in modern cardiovascular and thoracic surgery is reducing surgical trauma to achieve faster recovery for our patients. The benefits of minimally invasive surgery are evident 4 , 6 - 8. More surgeons are comfortable with aortic valve replacement via upper hemi-sternotomy or right mini-thoracotomy, and thus naturally there is a growing interest in performing aortic surgery via a minimal access incision.
The present illustrated article described the technical details of Mini-Bentall procedure and hemi-arch replacement for selected patients with aortic root and ascending aortic aneurysms.
The mini-sternotomy is performed using a hand-held electrical saw from the superior extent of the manubrium. In addition, access to the right superior pulmonary vein for venting is made easier. Under this circumstance, a pulmonary artery vent is used instead of right superior pulmonary vein vent.
It should be cautioned that when inserting a pulmonary artery vent, the heart needs to be kept full or even before going on CPB. This will avoid injury to the posterior wall of the pulmonary trunk with the tip of the pulmonary artery cannula.
It is preferable to have a central arterial cannulation whenever possible to provide adequate antegrade systemic perfusion and avoid potential retrograde embolization and vascular complications that may be associated with peripheral cannulation 9.
Should femoral arterial cannulation be used, a 2. A polypropylene purstring suture is placed in the anterior aspect of the common femoral artery. The artery is cannulated using a Seldinger technique. A guide wire is passed up in the descending thoracic aorta. Its presence within the descending aorta is confirmed with TEE. After progressive manual dilatation of the femoral artery puncture site, a wire re-enforced femoral arterial cannula should be inserted without any resistance.
In order to provide adequate exposure and surgical accessibility, it is important to anteriorize the aortic root, as well as bring the aortic annulus cephalad. This is achieved by placing three pledgeted Ti-Cron horizontal mattress sutures above the commissures and hitching them up to the skin edges. This simple manoeuvre provides an excellent exposure of the aortic valve for the minimal access surgical approach. Even though the mini-sternotomy terminating at the level of sinotubular junction, this manoeuvre could bring the aortic annulus forward in the cephalad direction by 2 to 3 cm.
Composite graft replacement of the ascending aorta and aortic valve was first introduced by Bentall and De Bono in 1. According to this technique, the aortic tissue surrounding the coronary ostia is directly sutured to the openings in the composite graft. These anastomoses were all made within the ascending aorta, and then the aortic wall is tightly wrapped over the conduit. Coronary artery dehiscence and coronary false aneurysms may result from tension created by bleeding into the space between the graft and the wrap A few technical modifications have been implemented, including the use of a reinforcement suture joining the cut edge of the aortic wall and the prosthetic sewing ring This technique described two separate proximal suture lines, an interrupted one between the most proximal part of the valve sewing ring and the aortic valve annulus, and a continuous one between the more distal portion of the sewing ring and the cut edge of the proximal aorta.
In a Mini-Bentall procedure, absolute hemostasis must be achieved. This technique works well for a mechanical valve conduit St. Additional stitches buttressed with teflon-felt pledgets are often required. Unfortunately, sensitivity to bacterial implantation and the proximity to the sternotomy line could make the foreign material of the pledgets responsible for chronic infections and fistulas.
Methods: Two simple square stitches orthogonal to each other could be a very useful suture combining simplicity with effectiveness. To do this, two polypropylene half-threads are put obliquely through the full thickness of the aortic wall, to and fro with inverse obliquities. Volume Article Contents Abstract. Majid Harmouche , Majid Harmouche. Oxford Academic. Google Scholar. Eric Karim Slimani. Adeline Heraudeau. Jean-Philippe Verhoye. Revision received:. Select Format Select format.
Permissions Icon Permissions. Issue Section:. Download all slides. Comments 1. Traumatic ascending aortic transection. All rights reserved In this interesting paper, Harmouche et al. Conflict of interest: none declared. View Metrics. The crossing of the threads covers and closes the hole from inside rather than outside. Bites pass all aortic layers. The technique is also speedy and it requires only two half-threads. Each half-thread can be tied with half of the strain too.
Finally, for years reinforcement of the closure was no longer needed with hundreds of patient and most significantly the use of teflon-felt pledgets was stopped. Accordingly, we have no longer seen any type of remaining chronic infection or fistula.
Cardiac Surgery. Google Scholar. J Cardiovasc Surg Torino. CAS Google Scholar. Eur J Cardiothorac Surg. Casadevall A, Pirofski LA: Host-pathogen interactions: basic concepts of microbial commensalism, colonization, infection, and disease. Infect Immun. Download references. You can also search for this author in PubMed Google Scholar. Correspondence to Ernesto Tappainer. This article is published under license to BioMed Central Ltd.
Reprints and Permissions. Tappainer, E. A stitch in time saves nine: closing the hole after removal of the aortic root cannula. J Cardiothorac Surg 4, 2 Download citation. Received : 09 October Accepted : 05 January Published : 05 January Anyone you share the following link with will be able to read this content:.
Sorry, a shareable link is not currently available for this article. Provided by the Springer Nature SharedIt content-sharing initiative. Skip to main content. Search all BMC articles Search. Download PDF. Research article Open Access Published: 05 January A stitch in time saves nine: closing the hole after removal of the aortic root cannula Ernesto Tappainer 1 Journal of Cardiothoracic Surgery volume 4 , Article number: 2 Cite this article Accesses 2 Citations Metrics details.
Abstract Background On completion of the surgical procedure the hole in the ascending aorta has to be closed after withdrawal of the aortic root cannula. Methods Two simple square stitches orthogonal to each other could be a very useful suture combining simplicity with effectiveness.
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