Mini-Bentall Procedure and Hemiarch Replacement:Graft Anastomosis and Mini-Sternotomy Closure

<div><p>In this video, the final episode in a seven-part series, Tristan Yan demonstrates how to anastomose the Ante-Flo graft to the Valsalva graft, wean the patient off bypass, and close the mini-sternotomy incision.</p><p></p></div><ol><li>Once the root procedure is completed, the proximal valve conduit is trimmed just above the Valsalva portion of the graft.</li><li>The distal Ante-Flo graft is put under a stretch and cut to an appropriate length.</li><li>A graft-to-graft anastomosis is performed using a continuous 3-0 running prolene suture. The spacing between the adjacent stitches needs to be narrow and precise when doing a graft-to-graft anastomosis, usually only a couple of millimeters apart.</li><li>The aortic root vent is inserted, the aortic cross clamp is slowly released, and a 21-gauge needle is used to de-air the graft. In order to ensure an absolute hemostasis, pledgeted 4-0 prolene sutures are applied to reinforce the proximal anastomosis.</li><li>A bi-polar temporary pacing wire is inserted in the epicardium over the right ventricle.</li><li>Two 28 Fr soft drains are inserted and brought out below the xiphoid cartilage.</li><li>Hemostasis is carefully checked and the patient is weaned from cardiopulmonary bypass.</li><li>Protamine is given to reverse the Heparin effect. Topical Floseal Hemostatatic Matrix (Baxter Healthcare, Zurich, Switzerland) is applied around the anastomotic sites.</li><li>Once the hemostasis is deemed satisfactory, two stainless steel double wires are used to approximate the sternum.</li></ol><p>This completes the Mini-Bentall procedure and hemiarch replacement. As shown in this video series, the fundamental principles of a traditional aortic root replacement must be respected. It also cannot be emphasized enough that a meticulous surgical technique to ensure absolute hemostasis is of utmost importantance in minimally invasive surgery. This results in a complete aortic repair via a minimal access incision, and successful treatment in selected patients with aortic root and/or ascending aortic aneurysm.</p>