Name: technique and patient selection criteria of right anterior mini-thoracotomy for minimal access aortic valve replacement
Uploaded: 2018-03-26T15:00:00
Description: Watch this Scientific Journal Video about Technique and Patient Selection Criteria of Right Anterior Mini-Thoracotomy for Minimal Access Aortic Valve Replacement at JoVE.com

This work was supported by a grant (N&#176; 32119) of the Swiss Cardiovascular Foundation to RT.

The protocol follows our institutional guidelines of the human research ethics committee.
1. Patient Selection (Table 1)
<ol>
	<li>Identify patients necessitating isolated aortic valve replacement14.</li>
	<li>Select among these patients a subgroup without major chest deformities (Kypho-scoliosis), previous history of irradiation or surgery of the right hemi-thorax, need for emergency operation, and operation for active endocarditis.</li>
	<li>Perform a chest computed...

<ol>
	<li>Supino, P. G., Borer, J. S., Preibisz, J., Bornstein, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+epidemiology+of+valvular+heart+disease:+a+growing+public+health+problem.">The epidemiology of valvular heart disease: a growing public health problem.</a> Heart. Fail. Clin. 2 (4), 379-393 (2006).</li><li>Carabello, B. A., Paulus, W. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Aortic+stenosis.">Aortic stenosis.</a> The Lancet. 373 (9667), 956-966 (2009).</li><li>Bonow, R. O., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Focused+update+incorporated+into+the+ACC/AHA+2006+guidelines+for+the+management+of+patients+with+valvular+heart+disease.">Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease.</a> Circulation. 118 (15), 523-661 (2008).</li><li>Brown, J. M., O'Brien, S. M., Wu, C., Sikora, J. A. H., Griffith, B. P., Gammie, J. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Isolated+aortic+valve+replacement+in+North+America+comprising+108,687+patients+in+10+years:+changes+in+risks,+valve+types,+and+outcomes+in+the+Society+of+Thoracic+Surgeons+National+Database.">Isolated aortic valve replacement in North America comprising 108,687 patients in 10 years: changes in risks, valve types, and outcomes in the Society of Thoracic Surgeons National Database.</a> J. Thorac. Cardiovasc. Surg. 137 (1), 82-90 (2009).</li><li>Cribier, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Percutaneous+transcatheter+implantation+of+an+aortic+valve+prosthesis+for+calcific+aortic+stenosis.+First+human+case+description.">Percutaneous transcatheter implantation of an aortic valve prosthesis for calcific aortic stenosis. First human case description.</a> Circulation. 106 (24), 3006-3008 (2002).</li><li>Leon, M. B., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transcatheter+aortic-valve+implantation+for+aortic+stenosis+in+patients+who+cannot+undergo+surgery.">Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery.</a> N. Engl. J. Med. 363 (17), 1597-1607 (2010).</li><li>Popma, J. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transcatheter+aortic+valve+replacement+using+a+self-expanding+bioprosthesis+in+patients+with+severe+aortic+stenosis+at+extreme+risk+for+surgery.">Transcatheter aortic valve replacement using a self-expanding bioprosthesis in patients with severe aortic stenosis at extreme risk for surgery.</a> J. Am. Coll. Cardiol. 63 (19), 1972-1981 (2014).</li><li>Smith, C. R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transcatheter+versus+surgical+aortic-valve+replacement+in+high-risk+patients.">Transcatheter versus surgical aortic-valve replacement in high-risk patients.</a> N. Engl. J. Med. 364 (23), 2187-2198 (2011).</li><li>Adams, D. H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transcatheter+aortic-valve+replacement+with+a+self-expanding+prosthesis.">Transcatheter aortic-valve replacement with a self-expanding prosthesis.</a> N. Engl. J. Med. 370 (19), 1790-1798 (2014).</li><li>Glauber, M., Ferrarini, M., Miceli, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Minimally+invasive+aortic+valve+surgery:+state+of+the+art+and+future+directions.">Minimally invasive aortic valve surgery: state of the art and future directions.</a> Ann. Cardiothorac. Surg. 4 (1), 26-32 (2015).</li><li>Malaisrie, S. C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Current+era+minimally+invasive+aortic+valve+replacement:+techniques+and+practice.">Current era minimally invasive aortic valve replacement: techniques and practice.</a> J. Thorac. Cardiovasc. Surg. 147 (1), 6-14 (2014).</li><li>Benetti, F. J., Mariani, M. A., Rizzardi, J. L., Benetti, I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Minimally+invasive+aortic+valve+replacement.">Minimally invasive aortic valve replacement.</a> J. Thorac. Cardiovasc. Surg. 113 (4), 806-807 (1997).</li><li>Murtuza, B., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Minimal+access+aortic+valve+replacement:+is+it+worth+it.">Minimal access aortic valve replacement: is it worth it.</a> Ann. Thorac. Surg. 85 (3), 1121-1131 (2008).</li><li>Tavakoli, R., Jamshidi, P., Gassmann, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Full-root+aortic+valve+replacement+by+stentless+aortic+xenografts+in+patients+with+small+aortic.">Full-root aortic valve replacement by stentless aortic xenografts in patients with small aortic.</a> J. Vis. Exp. (123), (2017).</li><li>Roques, F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=LRisk+factors+and+outcome+in+european+cardiac+surgery:+analysis+of+the+EuroSCORE+multinational+database+of+19030+patients.">LRisk factors and outcome in european cardiac surgery: analysis of the EuroSCORE multinational database of 19030 patients.</a> Eur. J. Cardiothorac. Surg. 15 (6), 816-823 (1999).</li><li>Bowdish, M. E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+comparison+of+aortic+valve+replacement+via+an+anterior+right+minithoracotomy+with+standard+sternotomy:+a+propensity+score+analysis+of+492+patients.">A comparison of aortic valve replacement via an anterior right minithoracotomy with standard sternotomy: a propensity score analysis of 492 patients.</a> Eur. J. Cardiothorac. Surg. 49 (2), 456-463 (2016).</li><li>Bethencourt, D. M., Le, J., Rodriguez, G., Kalayjian, R. W., Thomas, G. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Minimally+invasive+aortic+valve+replacement+via+right+anterior+minithoracotomy+and+central+aortic+cannulation:+A+13-Year+experience.">Minimally invasive aortic valve replacement via right anterior minithoracotomy and central aortic cannulation: A 13-Year experience.</a> Innovations (Phila). 12 (2), 87-94 (2017).</li><li>Lamelas, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Minimally+invasive+aortic+valve+replacement:+the+"Miami+Method".">Minimally invasive aortic valve replacement: the "Miami Method".</a> Ann Cardiothorac. Surg. 4 (1), 71-77 (2015).</li><li>Murzi, M., Glauber, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Central+versus+femoral+cannulation+during+minimally+invasive+aortic+valve+replacement.">Central versus femoral cannulation during minimally invasive aortic valve replacement.</a> Ann. Cardiothorac. Surg. 4 (1), 59-61 (2015).</li><li>Grossi, E. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Evolution+of+operative+techniques+and+perfusion+strategies+for+minimally+invasive+mitral+valve+repair.">Evolution of operative techniques and perfusion strategies for minimally invasive mitral valve repair.</a> J. Thorac. Cardiovasc. Surg. 143 (4), 68-70 (2012).</li><li>LaPietra, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Incidence+of+cerebrovascular+accidents+in+patients+undergoing+minimally+invasive+valve+surgery.">Incidence of cerebrovascular accidents in patients undergoing minimally invasive valve surgery.</a> J. Thorac. Cardiovasc. Surg. 148 (1), 156-160 (2014).</li><li>Gammie, J. S., Zhao, Y., Peterson, E. D., O'Brien, S. M., Rankin, J. S., Griffith, B. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Less-invasive+mitral+valve+operations:+trends+and+outcomes+from+the+Society+of+Thoracic+Surgeons+Adult+Cardiac+Surgery+database.">Less-invasive mitral valve operations: trends and outcomes from the Society of Thoracic Surgeons Adult Cardiac Surgery database.</a> Ann Thorac Surg. 90 (5), 1408-1410 (2010).</li><li>Grossi, E. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Minimally+invasive+valve+surgery+with+antegrade+perfusion+strategy+is+not+associated+with+increased+neurological+complications.">Minimally invasive valve surgery with antegrade perfusion strategy is not associated with increased neurological complications.</a> Ann. Thorac. Surg. 92 (4), 1346-1350 (2011).</li><li>Murzi, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Antegrade+and+retrograde+arterial+perfusion+strategy+in+minimally+invasive+mitral-valve+surgery:+a+propensity+score+analysis+on+1280+patients.">Antegrade and retrograde arterial perfusion strategy in minimally invasive mitral-valve surgery: a propensity score analysis on 1280 patients.</a> Eur. J. Cardiothorac. Surg. 43 (6), 167-172 (2013).</li><li>Glauber, M., Farneti, A., Solinas, M., Karimov, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Aortic+valve+replacement+through+a+right+minithoracotomy.">Aortic valve replacement through a right minithoracotomy.</a> Multimed. Man. Cardiothorac. Surg. 2006 (1110), (2006).</li><li>D'Agostino, R. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+Society+of+Thoracic+Surgeons+Adult+Cardiac+Surgery+Database:+2016+Update+on+Outcomes+and+Quality.">The Society of Thoracic Surgeons Adult Cardiac Surgery Database: 2016 Update on Outcomes and Quality.</a> Ann. Thorac. Surg. 101 (1), 24-32 (2016).</li><li>Glauber, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Right+anterior+minithoracotomy+versus+conventional+aortic+valve+replacement:+A+propensity+score+matched+study.">Right anterior minithoracotomy versus conventional aortic valve replacement: A propensity score matched study.</a> J. Thorac. Cardiovasc. Surg. 145 (5), 1222-1226 (2013).</li><li>Jones, D. A., Tch&#233;tch&#233;, D., Forrest, J., Hellig, F., Lansky, A., Moat, N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+SURTAVI+study:+TAVI+for+patients+with+intermediate+risk.">The SURTAVI study: TAVI for patients with intermediate risk.</a> EuroIntervention. 13 (5), 617-620 (2017).</li></ol>

In this protocol, we describe in detail the technique of right anterior mini-thoracotomy for isolated aortic valve replacement, and highlight the patient selection criteria for this procedure. As for any other therapeutic intervention, proper patient selection is the key to successful accomplishment of the procedure. The optimal CT measurements for consideration of patients for this technique are precisely described in this protocol, and are based on experience and consider the extensive work of Dr. Glauber and coworkers...

Among heart valve lesions diagnosed as hemodynamically relevant and clinically receiving particular attention, aortic valve stenosis is the most common valvular pathology in the United States and developed countries1,2. In the Cardiovascular Health Study, 2% of patients had frank aortic stenosis, with a clear increase in prevalence with growing age: 1.3% in patients aged 65-75 years, 2.4% in those aged 75-85 years, and 4% in patients older than 85 years1. For symptomatic patients presenting with severe aortic valve stenosis, aortic valve replacement is a Class I recommendation in the guidelines of the American Heart Association for the management of patients with valvular heart disease3.
Conventional surgical aortic valve replacement through median full sternotomy (FS) has been established as the gold standard for treating aortic valve stenosis with excellent results in terms of morbidity and mortality4. These results have encouraged the extension of therapeutic indications to older patients and patients with a higher risk profile. A number of treatment strategies have been implemented in these patient subsets to maintain the same good results achieved by conventional surgical aortic valve replacement in the general population. Among these alternative treatment modalities, transcatheter aortic valve implantation (TAVI) was introduced in 2002 by Cribier and colleagues5. Performed initially in moribund patients, TAVI has rapidly emerged as the treatment of choice for patients with severe aortic stenosis who are not suitable for conventional surgical aortic valve replacement6,7, or as a less invasive approach for surgery for patients at high risk8,9.
Despite the improved outcomes of TAVI in selected patient subsets, many patients with symptomatic aortic valve stenosis are still candidates for surgical aortic valve replacement. In these patients, FS aortic valve replacement is the most frequently used approach by cardiac surgeons. Nevertheless, various &#39;minimally invasive&#39; techniques have been developed with the rationale of reducing surgical trauma10. All these minimal-access techniques have aimed at improving patient comfort by reducing post-operative pain and accelerating patient recovery by shortening the hospital stay and potentially saving global costs10. Among minimally invasive incisional approaches upper hemi-sternotomy (UHS) and right anterior mini-thoracotomy (RAMT) have become the predominant techniques reported in the literature11. Right anterior mini-thoracotomy for aortic valve replacement was initially reported by Benetti et al.12, and upper hemi-sternotomy was first described by several authors11. In addition to incisional alternatives, two arterial perfusion strategies are currently used: i) peripheral femoral arterial cannulation, which is more frequently employed than ii) central aortic cannulation.
In spite of reported improvement in patient outcomes following minimally invasive aortic valve replacement, concerns about the disadvantages of restricted operative field and peripheral arterial perfusion strategies13 lead many cardiac surgeons to not let their patients benefit from potential advantages of minimal access approaches for aortic valve replacement. The goal of this protocol is to describe in detail this technique of minimally invasive aortic valve replacement through a right anterior mini-thoracotomy without rib resection/fracture, and with central aortic cannulation for arterial perfusion. By following this protocol, a larger number of cardiac surgeons can perform right anterior mini-thoracotomy for aortic valve replacement in certain patient groups. Patient selection and limitations of the technique are discussed. Early results are compared to those of a cohort of patients undergoing isolated aortic valve replacement by full sternotomy.

<table border="0" cellpadding="0" cellspacing="0" style="width:761px;" width="761">
	<colgroup>
		<col />
		<col />
		<col />
		<col />
	</colgroup>
	<tbody>
		<tr height="20">
			<td height="20" style="height:20px;width:368px;">Heart surgery infrastructure:</td>
			<td style="width:163px;"></td>
			<td style="width:151px;"></td>
			<td style="width:80px;"></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Heart Lung Machine</td>
			<td>Stockert</td>
			<td>SIII</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">EOPA 24Fr. arterial cannula</td>
			<td>Medtronic</td>
			<td>77624</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">FemFlex arterial cannula</td>
			<td>Edwards</td>
			<td>FEMII20A</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Quickdraw 25Fr. femoral venous cannula</td>
			<td>Edwards</td>
			<td>QD25</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Biomedicus 25Fr. Nextgen venous cannula</td>
			<td>Medtronic</td>
			<td>96670-125</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">LV vent catheter 17Fr.</td>
			<td>Edwards</td>
			<td>E061</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Antegrade 9Fr. cardioplegia cannula</td>
			<td>Edwards</td>
			<td>AR012V</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Coronary artery ostial cannula 90&#176;</td>
			<td>Medtronic</td>
			<td>30155</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Coronary artery ostial cannula 45&#176;</td>
			<td>Medtronic</td>
			<td>30255</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Soft tissue retractor</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">STAR soft tissue atraumatic retractor</td>
			<td>Estech</td>
			<td>EC400220</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Soft tissue retractor</td>
			<td>Edwards</td>
			<td>TRM</td>
			<td></td>
		</tr>
		<tr height="23">
			<td height="23" style="height:23px;">Electrocautery</td>
			<td>Covidien</td>
			<td>Force FXTM</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Sutures:</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Polypropylene 4/0</td>
			<td>Ethicon</td>
			<td>8871H</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Polypropylene 5/0</td>
			<td>Ethicon</td>
			<td>8870H</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Braided polyesther 2/0 ligature with polybutylate coating&#160;</td>
			<td>Ethicon</td>
			<td>X305H</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Braided polyesther2/0 with pledgets V5</td>
			<td>Ethicon</td>
			<td>MEH7715N</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Braided polyglactin 2/0 suture</td>
			<td>Ethicon</td>
			<td>V114H</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Braided polyglactin 0 suture</td>
			<td>Ethicon</td>
			<td>W9996</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Drugs:</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Midazolam</td>
			<td>Roche Pharma</td>
			<td>N05CD08</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Rocuronium</td>
			<td>MSD Merck Sharp &#38; Dohme&#160;</td>
			<td>M03AC09</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Propofol</td>
			<td>Fresenius Kabi</td>
			<td>N01AX10</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Fentanil</td>
			<td>Actavis</td>
			<td>N01AH01</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Heparin</td>
			<td>Braun</td>
			<td>B01AB01</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Protamin</td>
			<td>MEDA Pharmaceutical</td>
			<td>V03AB14</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Custodiol cardioplegia solution</td>
			<td>Dr. F. K&#246;hler Chemie GmbH</td>
			<td>B05CX10</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Instruments:</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Window access retractor SI</td>
			<td>Estech</td>
			<td>400-400</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">SI retractor blade 40W50L</td>
			<td>Estech</td>
			<td>400-172</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Ceramo atraumatic forceps 2.8x15/350</td>
			<td>Fehling</td>
			<td>FE-MRA-3</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Ceramo HCR valve forceps 3.0x15/350</td>
			<td>Fehling</td>
			<td>FE-MRA-0</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Ceramo HCR needle holder 2x10/340</td>
			<td>Fehling</td>
			<td>FE-MRB-2</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Ceramo TC HCR needle holder curved 3x10/340</td>
			<td>Fehling</td>
			<td>FE-MRG-9</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Ceramo HCR valve scissors 350</td>
			<td>Fehling</td>
			<td>FE-MRA-7</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Ceramo HCR curved scissors 350</td>
			<td>Fehling</td>
			<td>FE-MRA-6</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Cygnet flexible arched aortic clamp</td>
			<td>Vitalitec</td>
			<td>V10143</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Intrack insert set double traction</td>
			<td>Vitalitec</td>
			<td>N10122</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Dissection forceps Carpentier</td>
			<td>Delacroix-Chevalier</td>
			<td>DC13110-28&#160;</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Scissors Metzenbaum</td>
			<td>Delacroix-Chevalier</td>
			<td>B351751</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Needle holder Ryder</td>
			<td>Delacroix-Chevalier</td>
			<td>DC51130-20&#160;</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Dissection forceps DeBakey</td>
			<td>Delacroix-Chevalier</td>
			<td>DC12000-21&#160;</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Lung retractor</td>
			<td>Delacroix-Chevalier</td>
			<td>B803990</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Allis clamp</td>
			<td>Delacroix-Chevalier</td>
			<td>DC45907-25&#160;</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">O&#8217;Shaugnessy Dissector</td>
			<td>Delacroix-Chevalier</td>
			<td>B60650</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">18 blade knife</td>
			<td>Delacroix-Chevalier</td>
			<td>B130180</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">11 blade knife</td>
			<td>Premiere</td>
			<td>9311-2PK</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Leriche haemostatic clamp</td>
			<td>Delacroix-Chevalier</td>
			<td>B86555</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Data analysis</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Mann-Whitney and Chi-square tests</td>
			<td>GraphPad</td>
			<td>Prism 7</td>
			<td></td>
		</tr>
	</tbody>
</table>

technique and patient selection criteria of right anterior mini-thoracotomy for minimal access aortic valve replacement

Aortic valve stenosis has become the most prevalent valvular heart disease in developed countries, and is due to the aging of these populations. The incidence of the pathology increases with growing age after 65 years. Conventional surgical aortic valve replacement through median sternotomy has been the gold standard of patient care for symptomatic aortic valve stenosis. However, as the risk profile of patients worsens, other therapeutic strategies have been introduced in an attempt to maintain the excellent results obtained by the established surgical treatment. One of these approaches is represented by transcatheter aortic valve implantation. Although the outcomes of high-risk patients undergoing treatment for symptomatic aortic valve stenosis have improved with transcatheter aortic valve replacement, many patients with this condition remain candidates for surgical aortic valve replacement. In order to reduce the surgical trauma in patients who are candidates for surgical aortic valve replacement, minimally invasive approaches have garnered interest during the past decade. Since the introduction of right anterior thoracotomy for aortic valve replacement in 1993, right anterior mini-thoracotomy and upper hemi-sternotomy have become the predominant incisional approaches among cardiac surgeons performing minimal access aortic valve replacement. Beside the location of the incision, the arterial cannulation site represents the second major landmark of minimal access techniques for aortic valve replacement. The two most frequently used arterial cannulation sites include central aortic and peripheral femoral approaches. With the purpose of reducing surgical trauma in these patients, we have opted for a right anterior mini-thoracotomy approach with a central aortic cannulation site. This protocol describes in detail a technique for minimally invasive aortic valve replacement and provides recommendations for patient selection criteria, including cardiac computer tomography measurements. The indications and limitations of this technique, as well as its alternatives, are discussed.

Statistical analysis is done for continuous variables (presented as means &#177; SD) in Table 2, Table 3, and Table 4 using the non-parametric Mann Whitney test. Categorical variables are presented as percentages in Table 2, Table 3, and Table 4, and are compared by the Chi-square test. The statistical analyses are performed using commercially available software, with a statistical signif...

Watch this Scientific Journal Video about Technique and Patient Selection Criteria of Right Anterior Mini-Thoracotomy for Minimal Access Aortic Valve Replacement at JoVE.com

Technique and Patient Selection Criteria of Right Anterior Mini-Thoracotomy for Minimal Access Aortic Valve Replacement

The goal of this protocol is to describe in detail the technique of minimally invasive aortic valve replacement through a right anterior mini-thoracotomy and central aortic cannulation. This technique can potentially enhance patients&#39; comfort and, by reducing post-operative morbidity, promote lowering the length of stay and global costs.

Aortic valve stenosis has become the most prevalent valvular heart disease in developed countries, and is due to the aging of these populations. The ...

The overall goal of this protocol is to perform a minimally invasive aortic valve replacement through a right anterior mini-thoracotomy with central aortic cannulation. This method can help answer key questions regarding minimally invasive approaches for other heart valves, including the mitral and the tricuspid valves. The main advantage of this technique is that it combines a central aortic cannulation with the preservation of rib integrity.After marking the incision site, use an 18 blade knife to make an eight centimeter transverse incision one centimeter to the right of the sternal edge over the intercostal space of interest, followed by electrocauterization of the pectoralis and the superficial layers of the intercostal muscles. Enlarge the intercostal muscle opening with electrocautery. Then, enter the right pleura with Metzenbaum scissors to avoid injury to the right lung and free the right internal thoracic pedicle from the fascia and soft tissue.Insert a soft tissue retractor into the right pleura and secure the retractor in place. Place a minimal access retractor over the soft tissue retractor, and gently open the minimal access retractor. Gently push down the right lung with a gauze to expose the pericardium and cut the fat with electrocautery.Open the pericardium cranially over the ascending aorta and caudally over the right atria. After locating the right superior pulmonary vein, to expose the distal end of the ascending aorta, use a peanut gauze to gently push down the ascending aorta. Use a 4-0 polypropylene suture to place the first purse-string for aortic cannulation just below the distal pericardial reflection line over the ascending aorta.Use another 4-0 polypropylene suture to add a second purse-string around the first suture to complete the aortic cannulation preparation. After delivering 300 IU of heparin per kilogram through the IV line, puncture the right femoral vein and place the guide wire through the needle into the vein. Enlarge the skin opening with an 11 blade knife and dilate the puncture site with successive dilators.Introduce the femoral venous cannula percutaneously over the guide wire. Then, puncture the ascending aorta in the middle of the purse-strings and cannulate the aorta over the guide wire. Next, gently push the superior vena cava toward the left side, and use a 4-0 polypropylene monofilament suture to place a purse-string on the right upper pulmonary vein.Insert the left ventricular vent through the purse-string to unload the left heart. Extend the aortotomy through the non-coronary sinus to one centimeter above the aortic annulus and check the left and right coronary ostia. Using endo forceps, grasp the left coronary cusp and use endo scissors to excise the left coronary cusp.Check the mitral valve through the aortotomy and use commercially available valve sizers to identify a valve that comfortably passes through the aortoventricular junction. Use an endo needle holder to place the first braided polyester 2-0 with a pledget U-suture onto the commissure between the left and right coronary sinuses, and pass the suture from the ventricle upward so that the pledget is on the ventricle side, continuing the placement of the braided polyester 2-0 with pledget U-sutures clockwise to complete the right coronary sinus. Place clockwise braided polyester 2-0 with pledget U-sutures on the non-coronary sinus and place a counterclockwise braided polyester 2-0 with pledget U-sutures on the left coronary sinus to complete the annulus sutures, using a Ryder needle holder to pass the braided polyester 2-0 sutures onto the sewing ring of the valve prosthesis.Slide down the valve prosthesis and remove the valve holder. Tie the sutures and check for any gaps between the sutures and the aortic annulus, verifying that the left and right coronary ostia are unobstructed. Use Metzenbaum scissors to cut the tied sutures ends and remove the 5-0 exposure sutures on the inferior and superior ridge of the aortotomy.Place one 5-0 polypropylene running hemi-suture starting on the nadir of the aortotomy in the non-coronary sinus to the middle of the aortotomy. Place a second 5-0 polypropylene running hemi-suture starting on the left end of the aortotomy, and continue toward the right end of the incision to meet the end of the first hemi-suture. After tying both suture ends together, gently aspirate the left ventricular vent.Place the ventricular pacing wires on the right ventricle before unclamping the aorta. Remove the aortic cross clamp and tie down the first purse-string and double-secure the aortic cannulation site with a figure of eight 4-0 polypropylene suture, and close the wound in layers according to the standard protocols. In this representative study, compared to the full sternotomy approach, a right anterior mini-thoracotomy necessitated significantly longer ischemic, cardiopulmonary, and operative times, while the proportion of biological versus mechanical valve substitutes did not differ between groups.In spite of the longer operation times, the right anterior mini-thoracotomy did not increase the rate of major adverse cardiovascular and cerebrovascular events in comparison to the full sternotomy incision. Patients undergoing right anterior mini-thoracotomy also tended to be extubated earlier, and stayed for a shorter period in the intensive care unit than those operated through full sternotomy, although these differences were not statistically significant. Compared to full sternotomy, right anterior mini-thoracotomy patients also had a significantly reduced need for pain medication and transfusion requirements, a reduced incidence of new onset atrial fibrillation and deep wound infection, and a reduced global length of hospital stay.In addition, right anterior mini-thoracotomy patients reported greater satisfaction with the cosmetic results. Once mastered, this technique can be completed in four hours if it is performed properly. Following this protocol, other heart valves, including the mitral and the tricuspid, can be operated by this approach.After its introduction, this technique paved the way for other minimal access approaches in both adult and pediatric open heart surgeries. After watching this video you should have a good understanding of how to perform a aortic valve replacement through a right anterior mini-thoracotomy. Don't forget that performing aortic valve replacement through a right anterior mini-thoracotomy can be very challenging, and that each step should be meticulously completed before beginning the next one.

technique-patient-selection-criteria-right-anterior-mini-thoracotomy

Research

JoVE Journal

Medicine

Minimal Erythema Dose (MED) Testing

Ultraviolet radiation (UV) therapy is sometimes used as a treatment for various common skin conditions, including psoriasis, acne, and eczema. The dosage of UV light is prescribed according to an individual's skin sensitivity. Thus, to establish the proper dosage of UV light to administer to a patient, the patient is sometimes screened to determine a minimal erythema dose (MED), which is the amount of UV radiation that will produce minimal erythema (sunburn or redness caused by engorgement of capillaries) of an individual's skin within a few hours following exposure. This article describes how to conduct minimal erythema dose (MED) testing. There is currently no easy way to determine an appropriate UV dose for clinical or research purposes without conducting formal MED testing, requiring observation hours after testing, or informal trial and error testing with the risks of under- or over-dosing. However, some alternative methods are discussed.

Minimal Erythema Dose MED Testing

This article describes how to conduct minimal erythema dose (MED) testing in order to determine the lowest dose of ultraviolet radiation that will cause erythema (burning) when administered to an individual.

Ultraviolet radiation (UV) therapy is  sometimes used as a treatment for various common skin conditions, including  psoriasis, acne, and eczema. The ...

Full-root Aortic Valve Replacement by Stentless Aortic Xenografts in Patients with Small Aortic Roots

In patients with small aortic roots who need an aortic valve replacement with biological valve substitutes, the implantation of the stented pericardial valve might not meet the functional needs. The implantation of a too-small stented pericardial valve, leading to an effective orifice area indexed to a body surface area less than 0.85 cm2/m2, is regarded as prosthesis-patient mismatch (PPM). A PPM negatively affects the regression of left ventricular hypertrophy and thus the normalization of left ventricular function and the alleviation of symptoms. Persistent left ventricular hypertrophy is associated with an increased risk of arrhythmias and sudden cardiac death. In the case of predictable PPM, there are three options: 1) accept the PPM resulting from the implantation of a stented pericardial valve when comorbidities of the patient forbid the more technically demanding operative technique of implanting a larger prosthesis, 2) enlarge the aortic root to accommodate a larger stented valve substitute, or 3) implant a stentless biological valve or a homograft. Compared to classical aortic valve replacement with stented pericardial valves, the full-root implantation of stentless aortic xenografts offers the possibility of implanting a 3-4 mm larger valve in a given patient, thus allowing significant reduction in transvalvular gradients. However, a number of cardiac surgeons are reluctant to transform a classical aortic valve replacement with stented pericardial valves into the more technically challenging full-root implantation of stentless aortic xenografts. Given the potential hemodynamic advantages of stentless aortic xenografts, we have adopted full-root implantation to avoid PPM in patients with small aortic roots necessitating an aortic valve replacement. Here, we describe in detail a technique for the full-root implantation of stentless aortic xenografts, with emphasis on the management of the proximal suture line and coronary anastomoses. Limitations of this technique and alternative options are discussed.

Full-root aortic valve replacement by stentless aortic xenograft is a viable option in patients with small aortic roots. We describe, a technique for the full-root implantation of stentless aortic xenografts, with emphasis on the management of the proximal suture line and coronary anastomoses, and discuss its limitations and alternative options.

In patients with small aortic roots who need an aortic valve replacement with biological valve substitutes, the implantation of the stented pericardial ...

Technique of Minimally Invasive Transverse Aortic Constriction in Mice for Induction of Left Ventricular Hypertrophy

Transverse aortic constriction (TAC) in mice is one of the most commonly used surgical techniques for experimental investigation of pressure overload-induced left ventricular hypertrophy (LVH) and its progression to heart failure. In the majority of the reported investigations, this procedure is performed with intubation and ventilation of the animal which renders it demanding and time-consuming and adds to the surgical burden to the animal. The aim of this protocol is to describe a simplified technique of minimally invasive TAC without intubation and ventilation of mice. Critical steps of the technique are emphasized in order to achieve low mortality and high efficiency in inducing LVH.
Male C57BL/6 mice (10-week-old, 25-30 g, n=60) were anesthetized with a single intraperitoneal injection of a mixture of ketamine and xylazine. In a spontaneously breathing animal following a 3-4 mm upper partial sternotomy, a segment of 6/0 silk suture threaded through the eye of a ligation aid was passed under the aortic arch and tied over a blunted 27-gauge needle. Sham-operated animals underwent the same surgical preparation but without aortic constriction. The efficacy of the procedure in inducing LVH is attested by a significant increase in the heart/body weight ratio. This ratio is obtained at days 3, 7, 14 and 28 after surgery (n = 6 - 10 in each group and each time point). Using our technique, LVH is observed in TAC compared to sham animals from day 7 through day 28. Operative and late (over 28 days) mortalities are both very low at 1.7%.
In conclusion, our cost-effective technique of minimally invasive TAC in mice carries very low operative and post-operative mortalities and is highly efficient in inducing LVH. It simplifies the operative procedure and reduces the strain put on the animal. It can be easily performed by following the critical steps described in this protocol.

The aim of this protocol is to describe step-by-step the technique of minimally invasive transverse aortic constriction (TAC) in mice. By elimination of intubation and ventilation which are mandatory for the commonly used standard procedure, minimally invasive TAC simplifies the operative procedure and reduces the strain put on the animal.

Transverse aortic constriction (TAC) in mice is one of the most commonly used surgical techniques for experimental investigation of pressure ...

Standardized Technique of Aortic Valve Re-implantation for Valve-sparing Aortic Root Replacement

Despite the obvious advantages of the preservation of a normal aortic valve during aortic root replacement, the complexity of valve sparing procedures prevents a number of cardiac surgeons from incorporating them into their practice. The aim of this protocol is to describe a simplified and user-friendly technique of an aortic valve-sparing root replacement (VSRR) procedure by re-implantation of the aortic valve. Proper selection of patients and limitations of the technique are discussed.
In 54 consecutive patients, normal appearing aortic valves were re-implanted in a commercially available polyester prosthesis with pre-shaped sinuses by a simplified and standardized technique. Placement of the first row of the proximal suture line, choice of the prosthesis size, and adjustment of the height of the commissures of the patient to the fixed height of the sinus portion of the prosthesis were slightly modified from the reference techniques with the aim of increasing its feasibility for use by other cardiac surgeons. Early mortality and morbidity as well as 5-year survival, freedom from aortic valve reoperation, and freedom from recurrent moderate regurgitation were collected in all patients.
Thirty-day mortality, re-sternotomy for bleeding, re-sternotomy for mediastinitis, and the incidence of stroke were very low, 1.8% for each (1 of 54). No patient required permanent pace-maker implantation. At 5 years, survival, freedom from aortic valve reoperation, and freedom from recurrent moderate regurgitation were 97.5%, 95.2%, and 91.6%, respectively.
Mid-term results of our standardized technique of re-implantation of the aortic valve for valve-sparing aortic root replacement are very good and compare with more complex techniques reported by experienced surgeons. By following the present protocol of the standardized re-implantation technique, a greater number of cardiac surgeons can perform this procedure with comparable good results.

Valve-sparing aortic root replacement has the advantage of preserving the patient&#39;s own aortic valve. The complexity of the reported techniques to date restricts their use to a limited number of cardiac surgeons. This protocol describes step-by-step a standardized technique reproducible by a greater number of cardiac surgeons.

Despite the obvious advantages of the preservation of a normal aortic valve during aortic root replacement, the complexity of valve sparing procedures ...

Improved Registration of 3D CT Angiography with X-ray Fluoroscopy for Image Fusion During Transcatheter Aortic Valve Implantation

The fusion of 3D anatomical models derived from high-fidelity pre-interventional computed tomography angiography (CTA), and x-ray (XR) fluoroscopy to facilitate anatomical guidance is of huge interest for complex cardiac interventions like TAVI procedures with cerebral protection. Co-registration of CTA and XR has been introduced either based on additional intraoperative non-/contrast-enhanced cone-beam computed tomography (CBCT) or two separate aortograms. With the related increase of radiation exposure and/or contrast agent (CA) dose, a potential additional risk for the patient is introduced. Here, we propose a modified co-registration approach making use of arteriograms of the iliofemoral arteries, routinely performed during the femoral puncture and sheath introduction. On-the-fly refinement of the co-registration during the on-going procedure enables accurate co-registration without any additional angiograms, thus reducing CA, XR dose and procedure time, while simultaneously improving operator confidence and procedure safety.

The aim of this study was to improve the co-registration for image fusion (IF) of pre-interventional CT data with real-time x-ray (XR) fluoroscopy during transfemoral transcatheter aortic valve implantation (TAVI).

The fusion of 3D anatomical models derived from high-fidelity pre-interventional computed tomography angiography (CTA), and x-ray (XR) fluoroscopy to ...

Murine Cervical Aortic Transplantation Model using a Modified Non-Suture Cuff Technique

With the introduction of powerful immunosuppressive protocols, distinct advances are possible in the prevention and therapy of acute rejection episodes. However, only minor improvement in the long-term results of transplanted solid organs could be observed over the past decades. In this context, chronic allograft vasculopathy (CAV) still represents the leading cause of late organ failure in cardiac, renal and pulmonary transplantation.
Thus far, the underlying pathogenesis of CAV development remains unclear, explaining why effective treatment strategies are presently missing and emphasizing a need for relevant experimental models in order to study the underlying pathophysiology leading to CAV formation. The following protocol describes a murine heterotopic cervical aortic transplantation model using a modified non-suture cuff technique. In this technique, a segment of the thoracic aorta is interpositioned in the right common carotid artery. With the use of the non-suture cuff technique, an easy to learn and reproducible model can be established, minimizing the possible heterogeneity of sutured vascular micro anastomoses.

Here, we present a protocol of heterotopic aortic transplantation in mice using the non-suture cuff technique in a cervical murine model. This model can be used to study the underlying pathology of chronic allograft vasculopathy (CAV) and can help evaluate new therapeutic agents in order to prevent its formation.

With the introduction of powerful immunosuppressive protocols, distinct advances are possible in the prevention and therapy of acute rejection episodes. ...

Four-Dimensional Computed Tomography-Guided Valve Sizing for Transcatheter Pulmonary Valve Replacement

The measurements of the right ventricle (RV) and pulmonary artery (PA), for selecting the optimal prosthesis size for transcatheter pulmonary valve replacement (TPVR), vary considerably. Three-dimensional (3D) computed tomography (CT) imaging for device size prediction is insufficient to assess the displacement of the right ventricular outflow tract (RVOT) and PA, which could increase the risk of stent misplacement and paravalvular leak. The aim of this study is to provide a dynamic model to visualize and quantify the anatomy of the RVOT to PA over the entire cardiac cycle by four-dimensional (4D) cardiac CT reconstruction to obtain an accurate quantitative evaluation of the required valve size. In this pilot study, cardiac CT from sheep J was chosen to illustrate the procedures. 3D cardiac CT was imported into 3D reconstruction software to build a 4D sequence which was divided into eleven frames over the cardiac cycle to visualize the deformation of the heart. Diameter, cross-sectional area, and circumference of five imaging planes at the main PA, sinotubular junction, sinus, basal plane of the pulmonary valve (BPV), and RVOT were measured at each frame in 4D straightened models prior to valve implantation to predict the valve size. Meanwhile, dynamic changes in the RV volume were also measured to evaluate right ventricular ejection fraction (RVEF). 3D measurements at the end of the diastole were obtained for comparison with the 4D measurements. In sheep J, 4D CT measurements from the straightened model resulted in the same choice of valve size for TPVR (30 mm) as 3D measurements. The RVEF of sheep J from pre-CT was 62.1 %. In contrast with 3D CT, the straightened 4D reconstruction model not only enabled accurate prediction for valve size selection for TPVR but also provided an ideal virtual reality, thus presenting a promising method for TPVR and the innovation of TPVR devices.

This study assessed a new methodology with a straightened model generated from the four-dimensional cardiac computed tomography sequence to obtain the desired measurements for valve sizing in the application of transcatheter pulmonary valve replacement.

The measurements of the right ventricle (RV) and pulmonary artery (PA), for selecting the optimal prosthesis size for transcatheter pulmonary valve ...

Transcatheter Pulmonary Valve Replacement from Autologous Pericardium with a Self-Expandable Nitinol Stent in an Adult Sheep Model

Transcatheter pulmonary valve replacement has been established as a viable alternative approach for patients suffering from right ventricular outflow tract or bioprosthetic valve dysfunction, with excellent early and late clinical outcomes. However, clinical challenges such as stented heart valve deterioration, coronary occlusion, endocarditis, and other complications must be addressed for lifetime application, particularly in pediatric patients. To facilitate the development of a lifelong solution for patients, transcatheter autologous pulmonary valve replacement was performed in an adult sheep model. The autologous pericardium was harvested from the sheep via left anterolateral minithoracotomy under general anesthesia with ventilation. The pericardium was placed on a 3D shaping heart valve model for non-toxic cross-linking for 2 days and 21 h. Intracardiac echocardiography (ICE) and angiography were performed to assess the position, morphology, function, and dimensions of the native pulmonary valve (NPV). After trimming, the crosslinked pericardium was sewn onto a self-expandable Nitinol stent and crimped into a self-designed delivery system. The autologous pulmonary valve (APV) was implanted at the NPV position via left jugular vein catheterization. ICE and angiography were repeated to evaluate the position, morphology, function, and dimensions of the APV. An APV was successfully implanted in&#160;sheep J. In this paper, sheep J was selected to obtain representative results. A 30 mm APV with a Nitinol stent was accurately implanted at the NPV position without any significant hemodynamic change. There was no paravalvular leak, no new pulmonary valve insufficiency, or stented pulmonary valve migration. This study demonstrated the feasibility and safety, in a long-time follow-up, of developing an APV for implantation at the NPV position with a self-expandable Nitinol stent via jugular vein catheterization in an adult sheep model.

This study demonstrates the feasibility and safety of developing an autologous pulmonary valve for implantation at the native pulmonary valve position by using a self-expandable Nitinol stent in an adult sheep model. This is a step toward developing transcatheter pulmonary valve replacement for patients with right ventricular outflow tract dysfunction.

Transcatheter pulmonary valve replacement has been established as a viable alternative approach for patients suffering from right ventricular outflow ...

Guided Endodontics: Three-Dimensional Planning and Template-Aided Preparation of Endodontic Access Cavities

Pulp canal obliterations (PCO) are often a consequence of dental trauma, such as luxation injuries. Even though dentin apposition is a sign of vital pulp, pulpitis or apical periodontitis may develop in the long term. Root canal treatment of teeth with severe PCO and pulpal or periapical pathosis is challenging for general practitioners and even for well-equipped endodontic specialists. To ensure detection of the calcified root canal and avoid excessive loss of tooth structure or root perforation, static navigation using templates ("Guided Endodontics") was introduced a few years ago. The general workflow includes three-dimensional imaging using cone-beam computed tomography (CBCT), a digital surface scan, and superimposition of both in a planning software. This is followed by virtual planning of the access cavity and the design of a template that will guide the drill to the desired target point. To do this, a true-to-scale virtual image of the drill must be placed in a way that the tip of the drill reaches the orifice of the calcified root canal. Once the template has been fabricated using computer-aided design and computer-aided manufacturing (CAD/CAM) or a 3D printer, guided preparation of the access cavity can be performed clinically. For research purposes, a postoperative CBCT image can be used to quantify the accuracy of the access cavity performed. This work aims to present the technique of static guided endodontics from imaging to clinical implementation.

Guided endodontics describes a template-aided approach for access cavity preparation. The procedure requires cone-beam computed tomography and a surface scan to produce a template. An incorporated sleeve guides the drill to the target point. This allows the preparation of minimally invasive endodontic access cavities in calcified teeth.

Pulp canal obliterations (PCO) are often a consequence of dental trauma, such as luxation injuries. Even though dentin apposition is a sign of vital pulp, ...

A Murine Model of Hemodialysis Access-Related Hand Dysfunction

Chronic kidney disease is a major public health problem, and the prevalence of end-stage renal disease (ESRD) requiring chronic renal replacement therapies such as hemodialysis continues to increase. Autogenous arteriovenous fistula (AVF) placement remains a primary vascular access option for ESRD patients. Unfortunately, approximately half of the hemodialysis patients experience dialysis access-related hand dysfunction (ARHD), ranging from subtle paresthesia to digital gangrene. Notably, the underlying biologic drivers responsible for ARHD are poorly understood, and no adequate animal model exists to elucidate the mechanisms and/or develop novel therapeutics for the prevention/treatment of ARHD. Herein, we describe a new mouse model in which an AVF is created between the left common iliac artery and vein, thereby facilitating the assessment of limb pathophysiology. The microsurgery includes vessel isolation, longitudinal venotomy, creation of arteriovenous anastomosis, and venous reconstruction. Sham surgeries include all the critical steps except for AVF creation. Iliac AVF placement results in clinically relevant alterations in central hemodynamics, peripheral ischemia, and impairments in hindlimb neuromotor performance. This novel preclinical AVF model provides a useful platform that recapitulates common neuromotor perturbations reported by hemodialysis patients, allowing researchers to investigate the mechanisms of ARHD pathophysiology and test potential therapeutics.

This protocol details the surgical steps of murine common iliac arteriovenous fistula creation. We developed this model to study hemodialysis access-related limb pathophysiology.