Operative Techniques Accessing and Preserving the Heart

Partial or total median sternotomy is used for IE operations. In cases with previous coronary bypass surgery, right thoracotomy may be preferred to access the mitral valve, avoiding possible damage to patent grafts. Access to the mitral valve is excellent through right thoracotomy, although it does not allow easy access to the aortic root. For aortic IE complicated by an aortic root aneurysm or pseudo-aneurysms, particularly in redo operations, cardiopulmonary bypass is preferably established through the femoral vessels. Deep hypothermia may also be necessary and safer prior to repeat sternotomy. Myocardial protection is very important considering that surgery may involve long durations of cross-clamping and myocardial ischemia. With retrograde blood cardioplegia, excellent myocardial protection can be achieved by repeat injections (every 20 minutes) through the coronary sinus without interrupting the surgeon's work on the valve reconstruction. This technique avoids the manipulation of catheters and the need for direct antegrade root perfusion, which can cause migration of infected material into the coronary circulation in infected aortic root with severe aortic insufficiency. It also eliminates the need for cannulating possibly friable coronary ostia that might further complicate the operation.

Valves are accessed through usual approaches, such as left atriotomy for mitral valve or ascending aortotomy for aortic valve. However, more complex approaches may be required to evaluate all deformities and achieve optimal debridement of all infected tissues, including biatrial combined with aortic approach. More extensive cardiac incisions will require more time to repair and pose a higher intraoperative risk of bleeding, although they may occasionally be inevitable.

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