Cite this article as: Kocher A, Coti I, Laufer G, Andreas M. Minimally invasive aortic valve replacement through an upper hemisternotomy: the Vienna technique. Eur J Cardiothorac Surg 2018;53:ii29–ii31. Minimally invasive aortic valve replacement through an upper hemisternotomy: the Vienna technique Alfred Kocher, Iuliana Coti, Guenther Laufer and Martin Andreas* Division of Cardiac Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria * Corresponding author. Division of Cardiac Surgery, Department of Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria. Tel: +43-1-4040069660; fax: +43-1-4040069680; e-mail: martin.andreas@meduniwien.ac.at (M. Andreas). Received 7 October 2017; received in revised form 1 December 2017; accepted 25 December 2017 Abstract Minimally invasive approaches for aortic valve replacement are increasingly used in current clinical practice. Herein, we provide insights into our upper-hemisternotomy approach with specific technical considerations and details. Keywords: Aortic valve replacement • Minimally invasive surgery INTRODUCTION Minimally invasive aortic valve replacement became a standard of care in many centres [1]. Patients admitted to our clinic for iso- lated aortic valve replacement are almost exclusively operated through a minimal access, either anterior right thoracotomy [2] or upper hemisternotomy (UHS). Herein, we provide insights into our UHS approach. Patient selection and preoperative planning A computed tomography scan is performed in every patient undergoing heart surgery at our centre. This allows to detect cal- cifications and soft plaques of the ascending aorta, therefore serving as a guide to find the best cannulation and cross- clamping site. Limited combined procedures involving the as- cending aorta are possible as we always extend the UHS through the 3rd or 4th intercostal space. SURGICAL TECHNIQUE External defibrillating pads are placed prior to draping. A 6 to 10-cm midline skin incision starting from the level of the angle Louis to the third intercostal space is performed. We routinely perform a ‘j’-shaped UHS [3], starting from the sternal notch and extended to the 3rd or 4th intercostal space when the annular plane is deep in the thorax. The sternotomy is usually performed with an oscillating saw; a narrower blade may be used for the transverse part. After opening, 4–6 stay sutures are placed through the pericardium and positioned under the sternal retrac- tor to lift the aorta close to skin level. Direct arterial cannulation of the aorta is performed accord- ing to standard techniques. For venous cannulation, a 32-Fr angulated cannula (Medtronic, Minneapolis, MN, USA) is in- serted in the superior vena cava facing towards the right atrium (Fig. 1A). Two 5-0 stay sutures may be placed below the purse- string suture to facilitate cannula insertion by lifting the venous wall upwards during insertion. These sutures are removed directly after cannulation. A vent is placed through the right superior pulmonary vein and advanced into the left ventricle. The aorta is separated from the pulmonary artery and encircled with a band to enable safe cross-clamping. CO 2 inflation with 3 l/min is initiated. Myocardial protection We routinely use 2000 ml of Bretschneider’s solution (Custodiol HTK) in a single shot [4] administered through an aortic root can- nula with vent (Fig. 1B). Whenever significant aortic regurgitation is present, we apply the cardioplegia directly in the coronary ostia. Exposure and valve implantation A hockey stick aortotomy is extended into the non-coronary sinus. Three 3-0 polypropylene sutures are placed at the commis- sures as stay sutures and another three 5-0 sutures through the aortic wall to ensure a good visualization in the valve annulus (Fig. 2A, B). Almost all patients undergoing aortic valve replace- ment are eligible for implantation of a rapid-deployment aortic valve, and therefore, we have accumulated a vast experience of over 500 Intuity prostheses (Edwards Lifesciences, LLC, Irvine, CA, USA). These valves facilitate minimally invasive surgery [5]. Whenever the implantation of this particular valve is not suitable [6], a conventional prosthesis is implanted; in this case, the use of SURGICAL TECHNIQUE V C The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. European Journal of Cardio-Thoracic Surgery 53 (2018) ii29–ii31 SURGICAL TECHNIQUE doi:10.1093/ejcts/ezx514 Downloaded from https://academic.oup.com/ejcts/article/53/suppl_2/ii29/4822216 by guest on 16 November 2021