Through a small two-inch incision and without cutting the breastbone, Dr. Neelan Doolabh performs a minimally invasive aortic valve replacement surgery at Clements University Hospital.
Alright go on bypass please. So now that we're on full heart lung machine support, we're able to enter the chest without needing the lungs to be ventilated. So they will be out of our way. We refer to this operation as the mini thoracotomy approach which means the sternum or the breastbone is not opened. And that's the big difference with this type of surgery. Without the breastbone being opened. There is no bone that needs to heal after surgery which typically takes six or eight weeks. We're very fortunate here at UT Southwestern in which we offer this operation to every patient. There's no limitations based on your weight or your age. Things of that nature. In fact the sicker you are, the more de conditioned you are, the better it is for you because again you're allowed to use your hands after surgery. You can stabilize your body and move around and get out of bed. Things of that nature. So it really helps the patients with bad knees, bad hips, the elderly, the frail or the obese. What we're doing is we're pulling the edges of the pericardium towards us and that brings the valve and the heart along with it. Patients typically have prepared cardio fat so we need to get that all mobilized and out of the way. So now we have all the exposure that we need and the order is the main blood vessel that we open to get access to the aortic valve, the heart's still beating, it's on the heart lung machine so it's decompressed. There's no need for the lungs because the heart lung machine is providing the oxygen and such to the patient. With this approach, we're actually able to get a better view of the valve. We mobilize the pericardium and cardiac structures to bring it right into our view and we get a direct view of the valve. Often better than we get with traditional surgery. Mm hmm. So right now we are getting access to the right upper superior pulmonary vein. This drain will go under the left atrium. This will drain all the fluid underneath the aortic valves. You will be able to see inside the heart perfectly with a good view. So now we've positioned the area to cross clamp, which is what we will use to clamp the heart and arrested. Yeah. So at this point, Don is cooling the patient so we can protect the heart muscle even more naturally. You want your heart arrested for the least possible amount of time. So we use a cardiac procedure or medication that's designed to protect and arrest the heart. The nice thing about this operation is it's very efficient. We often do these operations quicker than we can do the traditional operation. So if we keep an eye on the monitor there, you'll see that the heart rate is slowly slowing down and it will eventually flatten out and it has already. How much did that take done? Most people have their hearts stopped for in the range of an hour or so and the entire operation takes somewhere in the range of 2, 2.5 hours. With this approach, we have no limitations as to what type of valve we can place, we can place a mechanical valve which can offer a patient life long durability. Or we can place a bio prosthetic valve which as well has its advantages for the patient. So we're not limited by the approaches to what we can implant. We can virtually do anything. We want to the aortic valve. The nice thing about surgery is we excise the old valve. This is a portion of the valve. I will show you the whole thing as we get it out. And as you can see in this video here is his valve and you can see what an absolute rock pile is. I wish you could feel it. Sometimes these valves are quite calcified and rigid when this differentiates us from the trans catheter valve technique, in which you're placing a valve inside of the patient's valve. We're gonna place suture organizer and we're gonna put a few sutures at the time, gain exposure, then go clean it up some more and put some more sutures, clean it up and just work our way all the way around. Mhm. Which so these valves in using somewhere in the range of 15-18 sutures. I'm gonna make sure we have a smooth possible surface to so to and it's looking really good in here. Once the sutures are in place, we will put these sutures through the valve itself and then we will lower the valve in place. And then we will tie all these sutures down. So the valve is really, really secured in place. It's not gonna go anywhere. And so this allows us to get a more secure and firm placement without any leakage around the valve. So now we're gonna go rinse out the heart in case there's any microscopic debris in place and we will suction it out. So we'll clean this area up very nicely in preparation for the new valve. Mhm mm hmm. Now, what we do is replace those sutures that replaced earlier through the valve which will allow us to lower this valve in place. Mm hmm. Now the valve is completely secured in place and all we have to do now is close the aorta which we will work on now. Mhm. So the patient is warming now, which is good. And so the timing will work out perfectly as soon as we get this the order closed and the patients warm, we will take this clamp off and the heart will restart. Mhm mm hmm. We're gonna need two up and hold val salvias please. Whenever you're ready to fire away please. So what we're doing is we're essentially forcing the air out of the heart. Now. Post surgery patients are often intimidated by what they can and cannot do. And this is why we provide them with a 24/7 number that they can call us. And ask any questions that they may have. Mhm. Open atmosphere please. Okay. Flow down volume back please. Okay so now we're going to remove the air across cramp. We're waiting for the heart to wake up and it looks like it's well on its way. Nice work. We'll let the heart relax for a few minutes. It looks really good. The valve is very well seated. There's no leaking around it well that's functioning well. So if that's the case take your volume back please. Thanks. So through our little site here that we had placed our other drains we will not put the drainage tube for after surgery. After surgery patients are allowed to do anything that they desire were just asked that they don't utilize their right arm for any forceful activity. They are seen in the office at a month and the month. We check the range of motion, the healing of their incision and at that point patients are cleared for activity. We divided the cartilage to get access into the chest. So we're going to use a little titanium plate that will put the cartilage back together. And what this does is it really stabilizes the chest wall immediately. We use a little local anesthetic around the incision sites with this approach. You don't have a bone that is broken that is trying to heal. So the pain requirements in the long run after the operation are less than they would be with a traditional operation. 10 Dr Abraham appreciate very much. Thank you.
