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Ann Thorac Surg 2007;84:1071-1072
© 2007 The Society of Thoracic Surgeons

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Correspondence

Reply

Department of Cardiovascular and Thoracic Surgery, OLV Clinic, Moorselbaan 164, Aalst, 9300 Belgium

(Email: filip.casselman{at}olvz-aalst.be).

To the Editor:

We thank Nagy and Peterffy [1] for their interesting letter related to our previously published article on minimally invasive aortic valve replacement [2].

We agree that removing the air from the heart and potentially defibrillating the heart are important steps during the operation. Care should be taken to execute these steps very cautiously so as not to compromise the operative result.

The measures we take with regard to removal of the air are the following: The operative field is flooded with CO₂ as soon as the aorta is opened. A small venting device is placed through the aortic valve into the left ventricle. However its aim is only to have a good view of the aortic valve and annulus (for valve excision, suture placement, and valve implantation). By no means do we aim to completely aspirate all blood from the left ventricle.

When the valve is tied down and the surgeon starts to close the aortotomy, blood is allowed to fill the left ventricle and eventually even cover the aortic valve prosthesis. Again, the only view that is needed at this point is the closure line of the aortotomy. Most of the surgeons in our group close the aorta in two layers (one Blalock suture over which another running suture is placed). Therefore, once the first layer is finished, filling of the heart and gentle suction on the aortic needle permits the blood to further fill the ascending aorta and aspirate potential air (or residual CO₂). The CO₂ is only stopped when the second suture line is completed. At this point further suction is applied to the aortic needle, the heart is completely filled, ventilation is resumed, and echocardiographic guidance indicates whether air or CO₂ removal is complete. The aortic clamp is only removed when this is the case.

Using this strategy we have been very satisfied in removing the air from the heart, and we have not needed to use pulmonary artery venting.

It is correct that ventricular fibrillation can be hazardous since defibrillating paddles cannot be inserted through a mini-sternotomy. Therefore, if this occurs after release of the aortic cross-clamp, we have been injecting potassium chloride into the aortic root (20 meq-4 meq per mL solution-added to 5 mL of saline). This initiates a cardiac arrest which usually lasts less than one minute. Invariably, the heart resumes in a spontaneous cardiac rhythm once the effect of the potassium chloride is washed out.

Using these little tricks, we have been very satisfied with our minimally invasive technique and we continue to apply it in the overwhelming majority of patients undergoing isolated aortic valve replacement.

	References

Top References

 

1. Nagy ZL, Peterffy A. Minimally invasive aortic valve replacement: a word of caution(letter) Ann Thorac Surg 2007;84:1071.[Free Full Text]
2. Bakir I, Casselman FP, Wellens F, et al. Minimally invasive versus standard approach aortic valve replacement: a study in 506 patients Ann Thorac Surg 2006;81:1599-1604.[Abstract/Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Filip P. Casselman Ihsan Bakir Francis Wellens Ivan Degrieck Frank Van Praet Hugo Vanermen Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Casselman, F. P. Articles by Vanermen, H. Search for Related Content PubMed Articles by Casselman, F. P. Articles by Vanermen, H. Related Collections Valve disease Related Article