The patient is positioned supine. Defibrillator paddles are placed on the sides of the chest.

Prepping and draping to the knees. 

CXR checked for height of mediastinum and sternum palpated to mark the intercostal spaces.

Sternotomy

Incision begins an inch lower than the jugular notch and goes up to the 3rd or 4th rib. If long sternum, then 4th space, if short sternum, then 3rd (e.g. women). The intercostal space is measured partly by the spaces themselves, the distance from the angle of Louis and partly by the distance to the xiphisternum. Conserve skin incision to the correct rib, and up to the space itself. Use a backhand to retract back the inferior edge of the incision to get into the intercostal space.

Diathermy is used to cut up to the periosteum, and ‘J’ off to the right 3rd or 4th intercostal space. 

An oscillating saw divides the bone starting at the inferior portion and moving up. The saw is pressed down against the posterior cortex and the hemisternum gives away if cut is complete. Do not drag the saw up and down. The J is cut using the smaller side of the saw. The skin edge is retracted away when using the smaller side as the skin may be damaged by the larger edge. 

A thick metal piece/key for the saw is used to separate the sternal edges. Mayo scissors may be used to cut any soft tissue or ligaments, especially at the superior portion, and in the J. A small swab is placed inside. Bilateral stretching of the sternum may be done before placing the retractor, which could be difficult to achieve. Diathermy and bonewax is used. A retractor is placed in the inferior portion of the wound and the sternum opened. Heparin may be given.

The thymus/anterior mediastinal fat is divided in the midline but not all the way up to the innominate vein, enough to visualise the aorta. The pericardium is opened immediately, and the reflection over the aorta is divided to create space for the cannulation site. Heparin is now given.

At least three pericardial stay sutures (silk) is taken on each side to the skin, with retraction provided initially with a Roberts clamp. The stitches are taken as deep as possible in the pericardium, perhaps using a swab to press the heart away from the pericardium. Deeper stitches give better exposure. The Sellors retractor may be then removed and placed inside the pericardium.

Cannulation

Purse-strings (2-0 Ethibond) are placed on the aorta and right atrial appendage. The aortic cannulation site is placed sufficiently high to provide enough room for the aortotomy. The pericardial reflection may be dissected off the aorta in order to place the purse-strings. The aorta may be retracted inferiorly using the left index finger on a swab. The atrial purse string is left snugged before cannulation to prevent leakage. If the atrium is not accessible from the operator side, it may be visualised from the assistant’s side.

The lines are divided.

During cannulation, the middle finger of the left hand is used to cover the aortotomy while the index finger is used to retract the aorta inferiorly over a swab. Alternatively, the aorta is gently stroked to weaken it until it starts to leak, at which point the cannula is pushed in. The aorta is cannulated, connected to the arterial line and secured at the superior part of the incision with the CO2 tubing pointing into the surgical field, using a pericardial stay suture. The arterial line is secured to the drapes with a towel clip on the assistant’s side.

The atrium is cannulated with the assistant holding one side of the purse-string with forceps and the operator the other side. A 3-stage cannula is used. The stay suture for the snugger is left long for retraction, and placed in the groove of the retractor inferiorly with a clip.

The cardioplegia cannula is placed, and connected to the vents and cardioplegia line.

Cross-clamp is applied. A pair of Debakey forceps is used to compress the aorta to allow the X-clamp to be applied, as space is limited to place fingers around the aorta. Antegrade cold-blood cardioplegia is given – 1-1.5L. Side towels are placed under the retractor and secured with pericardial stays. Ice slush is placed over the heart. The heart is examined for distension, and compressed if necessary. If there is AR, then the RVOT may be compressed against the aortic root to provide AV competence. The root vent is switched on when the cardioplegia dose is completed. CO2 is switched on.

The aortotomy is created with scissors in lazy-S fashion. The scissors point up for the initial incision of the fold of the aorta. A cut is made towards the assistants side towards the PA. The scissors are then pointed inferiorly and the cut is made towards the  middle of the non-coronary sinus, staying above the STJ.

The assistant is ready with a large Ross (no. 6) retractor if needed. The pump sucker is placed inside the ventricle to vent. 3 commissural stay sutures are taken with Ethibond with their ends needle-less and clipped on to artery forceps which have line-clamps on them for weight.

Coronary ostia are examined. A rough sucker (metallic) clears the surgical field of debris while excising the valve. The leaflets are excised in order – right, left, non. The leaflets and the annulus may be grabbed with the forceps. After excision, the LVOT and annulus is washed out with saline. The edges of the annulus are examined for bare, or weak areas. They may be reinforced with separate interrupted 4-0 prolene, or be included in the valve sutures.  A further cardioplegia dose may be given at this point with a DLP ostial cannula. 3 huck towels are placed on above the lines.

A clean large swab is placed on the edge of the surgical wound. The assistant holds the valve in the LEFT hand, and the suture followed in the right hand for the first part of the sutures.

A single-ended 2-0 prolene stitch with a Dunhill artery clip on its end – the clip is placed at the head-end. The needle is passed from above the cuff to below, and subsequently below the annulus to above. The bite on the cuff is as deep as possible to ensure a good fit of the prosthesis.

Care is taken to take wider bites across any weak parts of the debrided annulus. The stitching starts at the left-right commissure, and runs anti-clockwise across the left annulus towards the left-non commissure. The stitching on the valve goes from left-hand side to right-hand side.

The left sinus is stitched back-hand (below annulus to above) upto the nadir, followed by fore-hand.  The non is taken with backhands. Two sutures are usually taken for each sinus (roughly 5-6 stitches per suture).

When starting suturing in the left-right commisure, the interleaflet triangle is not stretched apart, so use the forceps to get a good bite in this area between the leaflet attachments. The last sutures are then taken in the non-coronary sinus by switching to back-hand and going across the left-non commisure at the same height. If the valve is large, then go up further.

Keep the valve low on the swab, to get more stitches in. Ensure the assistant keeps the valve pulled back keeping the suture taut, preventing any loops from getting in the field. Keep the angle of the prosthesis suitable for easy stitching of the cuff.

The assistant switches to holding the valve in their right hand once the left sinus is completed. Another suture is clipped together starting at the left-right commissure, running towards the right-non commissure across the right sinus. The LV sucker is placed between the sutures to keep it away from the field. This time the suture is passed first on the annulus, from above to below, and on the sewing ring from below to above. The right sinus begins with a backhand (above annulus to below), with the elbow high up. The back of the needle may be used to push away the sinus to get an adequate bite. The forceps are used to retract the sutures away to get a good view. Backhands upto the nadir followed by forehand. Backhand shots are used. The needle is held further away from the tip to get a large bite.

Copious saline is poured to lower the valve suture by suture going around in an anti-clockwise manner, retracting the valve away from the annulus to see the loops straighten. Use a nerve hook to tease out any overlapping sutures on the valve. The valve is tilted through the STJ if needed. Once placed inside, check each suture to ensure both ends are running. The holder is then removed.

The annulus is inspected for any loops inside the valve. The stitch next to the non-coronary commissure is held tight while cinching down and tying the first knot. The stitches in front and behind are then held tight when laying down the rest of the sutures. Roberts or forceps may be used to expose the valve edge and push the prosthesis down. The infra-annular area is inspected to make sure no loops are present.

5-0 double-ended prolene on a Castroviejo needle-holder is used to close the aortotomy starting on the operator side, starting with back-hands. The knot is placed beyond the corner of the aortotomy with a single bite. One end is placed on a rubber-shod forceps. Backhand continuous bites are placed until the mid-portion of the aortotomy and the end placed on a rubbershod. The same is undertaken on the opposite side, and the sutures tied down.The root vent is switched off. The second layer is completed similarly, with the green vent off, to allow the heart to fill. CO2 is switched off.

The root vent is switched back on and the heart filled, blows on the lungs, agitate the heart with the handle of an instrument. After deairing the heart is emptied, with the root vent still on. Bioglue is applied after drying with a small swab. Place right ventricular pacing wires. Bring it up above the sternum. Tuck the extra length under the sternum. Place single (or 2) drain below the incision, using a long Roberts. The other option is to come parasternally.

Fill the heart, suck on the green, head down, empty out, flow down, crossclamp off, flow back up, sucking on the root. Pace the heart. Check TOE for valve function and air bubbles.

Place extra purse-string around atrial cannula, and put it on a rubbershod, after removing the needles.

Fill the heart. Wean off bypass. Keep the root vent on. Agitate for deairing.

Remove cardioplegia cannula.

Clamp the venous line. Holding the atrial snugger with the left hand, remove the venous cannula and hand it to the scrub nurse. Snug the atrial purse-string. Once the protamine is given and there is no need for the atrial cannula, tie off the atrial sutures.

Remove the aortic cannula, place extra sutures over the cannulation site.

Haemostasis. Ensure J is dry, especially that mammary is not injured. Place drains.

Pericardial closure with 3-0 or 4-0 prolene interrupted.

Sternal closure with the wire on the operator side more superior than the assistant side to push the J down.

Ensure drain is tied.

 

Post-op

Leave drains for 2 days.

Routine CXR to check for pneumothorax.

Hb > 90. MAP > 1mmhg*age

Keep well-filled, especially with LVH.

Warm wean and wake.

Usually very little bleeding. <400/24h if pericardium closed.

Sit out in chair before taking drains out.