Dr. Barnhart provides educational material for young surgeons and surgical trainees so that they may adopt successful techniques related to the surgical technique for Aortic Root Enlargement.
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My name is Dr glenn Barnhart. And I've been asked by Cryolife to uh talk about the onyx valve and specifically to provide educational material for young surgeons just starting out and surgical trainees. Uh so that they may adopt techniques that are successful with the use of the onyx valve. My background is having done training at the Medical College in Richmond Virginia as well as at the National Institutes of Health in Boston Children's Hospital. I practiced at the Medical College of Virginia at as well as Sentara Heart Hospital in Norfolk Virginia for nearly 20 years and then was asked to be executive director of the Swedish Heart and Vascular Institute and Swedish Medical Center as well as chief of cardiac surgery there in Seattle where I was for approximately 11 years and recently have retired. So I'm gonna make a hockey stick incision in the aorta. Obviously in the this is a human heart but it's a bit difficult to be as oriented as in the living heart. We'll open this here, we're gonna take this down into the non coronary sinus. This is basically gonna be a next procedure to enlarge the aortic root. Now this is a quite large heart. And so this would be unnecessary but actually it'll be should be good for demonstration. So if you think that you're gonna need to do an aortic root enlargement, hockey stick incision is preferred because as you can see here is the aortic valve here is the left main here is the right coronary artery. So this is the right leaflet, left leaflet and non coronary leaflet right here. So once you make the judgment that you have to do a um that you have to do a root enlargement procedure, then you can just continue this on down some alcohol. That right there on that side, we're gonna go right into the middle of the non coronary sinus here and then we're gonna stop. So the next thing I'm gonna do is cut out the aortic valve and this valve you can actually see in life had a little bit of calcium right there in it but certainly looked otherwise quite normal. This is going to be the taking out the non coronary leaflet. There is some calcium in this valve but I don't think it was in any human dynamic significance. Yes sir. Probably should post more than three Thomas right there and we'll take you out beads of calcium. We've seen right there. As we look down into the anatomy here, you can see that this is the anti leaflet of the mitral valve right here. And what I'm gonna do is actually take this the autonomy across the Angeles. I'm gonna free up austerely and occasionally one gets into the dome of the left atrium. I'm gonna show you how to fix that. Try to prevent that from happening. Like I say if it does, it's very fixable. And so now we're gonna just extend across and again here is the anti leak in the mitral valve. I'm going to go down to the analyst and across the analysts actually into the answer leaf of the micro valve and you can see already how the circumference of the, of the orifice of the aortic um annual ist is already lengthened by a significant amount, at least a centimeter right there. So we're gonna leave that open. So this is the Sizer, aortic sizer, that one can see here and this is actually holding it together. And once I pull this apart, you can see that the sizer actually fits a lot better. I'm gonna actually clean that up a bit. So one can see then that with this push together as it was originally, it's a little tight. But then once this gets opened up and I think you'll see the um 25 size that fits quite nicely and we'll take the replica sizer and with the clothes, the replica sizer is tight with it open. The replica sizer fits nicely. So the question is always how far to take this down and I'm comfortable taking this down a little further for the purposes of this uh teaching video. When you just snip through this a little bit more. Obviously, the further we take it down into the anti relief of the mitral valve, the wider this space is gonna become, we've actually increased this at least a centimeter and maybe a centimeter and a half the annular circumference, so that that'll be quite significant. So the next thing we're gonna do then, once I've opened this up, what I want to do is place the aortic sutures and I do that because I think it's important to maintain uh focus and um uh orientation for the service. So we're gonna place sutures for the aortic valve as we normally would and lay them out here is the site of the aortic root enlargement again, just to regroup. This was the original uh analyst here, which has been divided down through the hockey stick incision. Um This is the anti relief of the micro valve that I've gone into a little bit in this area here. This is where you can get into the dome of the left atrium. I'm gonna show you some uh schematics on that just a few minutes and how to how to fix that. We won't go into that here today. But all these sutures have been placed. And I think it's important to do that at that step because then you remain oriented as to where the analyst is. Uh and where the remaining part of the operative field is. So what we're gonna do now is take some of this photo fix, You can either use bovine pericardium or photo effects the originators of this technique, Manoukian Nunes and nick's used Dacron was back in the seventies and eighties. So obviously that's not preferable today with these other nice um materials that we have. But I'm gonna create a ton of tissue that will extend down into the that defect that we have created. I'm gonna leave it quite long. And I want to point out that this needs to remain um tongue shaped and oval and not pointed. We'll leave this long. I'll show you why there's obvious little bit later. We're going to round this up a little bit. So that's sort of the effect that you want not triangular, not sharp, you want to keep it like that. Alright so then we're gonna take for a protein. We're gonna start right at the base of our incision down here and take a good bite of that into take the other end that right beside the other stitch mattress style lose down. And they simply just run this up the side running fashion. We're not gonna transition to the wall of the aorta, leave this outside on a snap and we'll come up the other side. You wanna make sure that right at the base of this you get a good deep bite obviously that be a bleeding site. We'll come out here, put a snap on this and we'll put it to the side. Now let me stop there and just say that this is you can see now how we have increased the diameter of the annuals which will come right across here. Once we put in the remaining stitches and how much bigger the annuals is. So if you have a patient who's measuring out at 21 or 19, you're gonna at least get a 21 and probably a 23 in that patient with this technique. So next we're gonna take more valve sutures. I'll show you how we create the continuity of the sutures across here. So we're completing the native annual futures. I don't do this original initially because I think they get in the way of putting the patch in and so we're gonna set these and next I'm going to take the photo fix patch and rotate it over this way and sort of look on the backside here because this is we're gonna put our sutures now from outside in. So when we go outside in we're gonna make sure that that future comes out fairly close to the other suture. Budgets of course, will end up on the outside. Usually it's only about three or 4 that run across here. Come out close to where that other stitch. You can see other stitches right here. I'm gonna come out. Right so that but nothing gets it provides nice continuity across there. So you can see this is a 25 sizer and in this um postmortem heart it's a little difficult for sizing because there's not quite as much substance in the in the tissue. But I'm pretty comfortable with that. That looks quite good. And the replica Actually fits quite nicely too. So we'll go with the 25 um valve. So now we're gonna lower this into place. Looks very good. It's fitting in nicely and we're gonna use the remote technique to put the valve down. So what we've done here is we've put these rommel sutures down, which helps to uh fix the valve down as uh as low as possible in the nature. We have one here in the left coronary sinus, one here in the right coronary sinus and one in the non coronary sinus, which you can see is pretty close to the middle where we've done the uh the root enlargement. So next we're gonna tie the, tie the valve in 1st. I'm gonna be removing um hold on, we're going to get the plastic. I'm gonna look inside to make sure that we don't have any significant issues with pledges dangling. We don't, there's one pledged back there, but I'm pretty confident that will pull up. Of course, yeah. So I'm gonna start tying back here because that one pledge it is out that I want to make sure it comes up before we get too far committed and there it sits back. Yeah, I think it's very important that we, the surgeon visualizes the sub annular plane uh in its entirety. While you're sewing this in a common mistake is to be sewing with the leaflets closed and you have no idea what's happening below the valves. And once you're done, you are done and there's no way you can change any of that as you go along, you can make adjustments to make sure that you don't have any pledges out. Again, just to reinforce the importance of that. You don't want to have any material, either valvular sub valvular or uh pledging material underneath the valve. Now certainly one can use a non pledge it'd technique and I think that's perfectly acceptable. Although there are times that I think pledge its are helpful. So there's another, yeah, there's another pledge it over here. I want to make sure it comes up so so everybody can see this. I'm gonna turn this so there's a pledge it right there and again, if the leaflets were closed, I would not be seeing that while I was tying it down. You see how the pledge it went away. You see the pledge, it is now gone, snuck up underneath the valve housing which is the desired outcome. And now we can with confidence just keep moving around and sewing in. Well, I should reiterate that one. Should never take anything metal and stick it through the leaflets. Um The reason for that of course is that the paralytic carbon carbon is quite sensitive to any sort of scratches in any sort of scratched surface. Even if you don't see it could be a source of nitrous for three majestic formation of course stroke and T. I. A potential. So that's to be avoided at all times. So just to reiterate, we have been able to put in a 25 valve very nicely in this situation with actually the the Angelus was not insignificantly calcified. So it would have been a little problematic. I think putting in this big of a valve even though initially it looks like its size to a 25. I don't think we would have gotten 25 in. Of course 25 is really not an issue. But the issue is when you're dealing with a small patient or a large um obese patient in which the patient prosthesis mismatches very predictable by the pebereau charts and needs to be avoided at all costs because the mortality Of patient prosthesis mismatches extraordinarily high especially if you have reduction in your left ventricular function. Pirro's show that it's 70 times higher in the first year if the um Left ventricular ejection fraction is less than 40%. So that obviously is very dramatic. And so every effort needs to be made to minimize um any facing prosthesis mismatch. So this leaves us With our three sutures. We're gonna tie these last three now. Um and again stick with her rule, we're gonna open this up, make sure that we don't see the pledge. It's I want to show that better in just a minute. All the pledges are have receded and are not visible which is what we want. I think this is a very important technique for the surgeon to have in his tool box because you will encounter a patient that is gonna need to have an aortic root enlargement. There are things that will keep you from doing this needless to say if you have a calcified uh Angeles heavily calcified analyst or you have a micro valve anti leaflet that's calcified. Then you're not gonna be able to do these things. But you can anticipate that by number one. Anticipating possibly needing an A. R. E. Uh pre operatively from from the T. E. Or the T. From the T. T. Or T. T. E. And if you are suspicious enough then once you get a C. T. Scan to evaluate where exactly the calcium is in today's world with to var and all the work that's been done by our radiology imaging colleagues. You can see it quite nicely this entire area. So now we have we have completed the valve replacement. This is obviously the valve is now planning tied in. Here's our photo photo fix back here for our repair. Now we're gonna look down inside. You can see everywhere that there are no pledges anywhere. They've all receded nicely and the valve is well seated. That's exactly what you want it to look like. What one does is take the tongue of the photo fix and run it up on both sides incorporating it in the closure of the autonomy. Now this autonomy that I made. So this film is quite generous. Usually autonomy is not this large but you can see that this can augment the autonomy quite nicely um in the real situation I like the way this photo fix handled it, very flexible. Malleable and yet it's has good strength. You can see we're closing the autonomy now just in a routine fashion, I'm not for the purposes of time, I'm not going to do a double layer closure here. Normally I probably would do a double layer closure um but I'm just gonna close this simple over and over so I can demonstrate how to handle the final end down here. Been sort of glancing down here to make sure that getting too much aorta on one side or the other and compensating for that as you go if need be. So as you can see we have completed um the aortic closure along here and here and the photo fix, which was brought up as a tongue of tissue now has been incorporated in that closure actually takes tension off this area. You can see these pledges here on the outside. These are the pledges that are used to um right along here are used to complete the suture suturing of the valve and it's usually three or four that are along here, that's all that's needed. But this entire distance here is what one has gained by using this technique. Now, occasionally, as I said initially one can get into the left atrium dome in the left atrium back here, That's not a huge deal. If that happens you end up with a little triangular defect. And what you do is you take a piece of photo fix and a and a little bit larger triangle, so there's no tension and you simply so photo fixed a photo fix back Here and photo fixed to left Atrium along here. Remember this is gonna be a low pressure system coming off. That maybe happens 3-5% of the time. You can avoid that by freeing up back here as I did freed up before we got started and dissected down in this area to dissect the dome of the left atrium off this area. So again, this is a I think a nice technique is a safe technique. Some times some concerns expressed about the mitral valve. I've never had a case of um mitral valve regurgitation following this procedure, I think it works very nicely. Let me show you the proper application and technique of bio. Below this is the delivery system here. You can see that this fits in very nicely in this location. You see there's air in this location right here, continue to hear it, make sure we've got a nice steady stream of both substances and then we can go apply and I think it's important to apply this pretty generously in this area here and one of the keys about bio blue I think is to make sure it's coming out relatively slowly. A lot of times you see people just push it out like that. that doesn't work. What you want to do is apply it so that it's setting up just as it's emerging from the delivery system. So I make a very generous application back here in this area. You can put it all over the autonomy if you want to. But you can see how it's setting up as it comes out. If you run again, if you push it out too quickly, it's just going to run down the hill. You don't want that. You want it to be setting up as you are applying the bible. But I think this is this is obviously an essential piece to this procedure because the concern and the crux of this procedure is bleeding in this area. Obviously once you come off pump it's gonna get pressurized. And the likelihood of bleeding down here will be great unless you have this viable of application. So when one is using bio glue in procedures such as aortic or mitral procedures, there are several instances in which I would routinely use it in my opinion, that would be on the coronary buttons. Um certainly on the aortic graft anastomosis, If one is doing an aortic dissection, then I would use it on the aortic anastomosis in those cases and certainly any tissue anywhere that looks fragile or friable. A place that bio glue is essential is when one is doing aortic root enlargement and on the outside of the heart never use bio glue on the inside of the heart. But on the outside of the heart where the tongue of tissue goes down uh That has on augmented the aortic root, one needs to place bio glue in that area because bleeding in that site is difficult if not impossible to control after an aortic root enlargement with bio glue, that will not be a problem. And so bio glue is essential to be used in that area to remove bleeding risk after an aortic root enlargement, Let's speak for a couple of minutes about um the aortic root enlargement procedure, which video is accompanying this. Uh The sequence of the operation is very important and I hope that came out in the video in that you want to set this up in a in a manner such that you understand and remain oriented as to the the analysts and also the placement of the patch. That placement of the patches very important. But I think to add to once the incision is made, once the determination is made that you're gonna need to do an aortic root enlargement and the incision is made into the non coronary sinus and extending into through the annuals and into the anti relief of the mitral valve for a couple of three millimeters. Then placing those sutures in the analyst, I think helps to continue to keep you oriented toward the operation. It also helps to stabilize the the operative field then sutures are placed as in the in the video accompanying video and uh and then the sutures, the remaining sutures. Uh And where the defect has been created in the 1 to 1.5 centimeters have been um gained in the annular circumference are placed from outside in making sure that where the sutures are in the conventional location in the analysts and the sutures are on the outside coming in are appropriately placed so that there's no gap for leak. Once that is done then the conventional aortic valve replacement is completed. Suture placement in the analyst after it's been of course sized again and the valve and serve sutures are tied and cut the patch then comes up and is incorporated into the closure of the autonomy as I have demonstrated. Um And then bio glue is placed. It's very important to place the bio glue. It's essential to do this because the achilles heel of this operation is bleeding down near where you have placed the patch and that is very difficult to control. So that can be completely prevented and avoided by proper suit your placement of the pralines and the patch coming up. Uh Making sure that the bites are full thickness on the aortic wall and the analysts and the and the mitral tissue and also bio glue placement on the outside so that that area is well sealed. Now let me just mention that occasionally one can get into the dome of the left atrium, one can avoid that in most cases if beforehand. 12 sex free. Once the cross clamp is place 12 sex free, the tissues separating the dome of the left atrium from the aortic wall. But occasionally one can still get in that area down there. That's not a huge problem and can be handled in the following manner. Once you have placed the patch then you can cut a piece of triangular uh photo fix or bovine pericardium, whatever the material that you're using um And so the bovine pericardium or uh or photo fix to the photo fix that you have used as the tongue of patch material. And then that triangle of tissue can be sewn to the two edges of the dome of the left atrium. You can see that in the accompanying diagram that and the accompanying slides that you see here now and that shows very nicely how that can be done. Additionally, bio group bio glue needs to be placed on that entire triangular area to make sure remember this is a low pressure system so bleeding from this Area is not going to be as extensive as you might think if it's properly managed in that fashion with all that you have increased and upside the patient probably at least one maybe two sizes of valves. So it's really worth the time to do that. It adds about 20-25 minutes to cross clamp time. And is um well serving your patients to be able to do that for their long term survivability.