Transaxillary direct-vision valve surgery: operative technique and technical principles

Figures

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  Figure 1. Operating room ergonomics and direct-vision setup. The operating table is tilted to elevate the right hemithorax, and the primary surgeon stands immediately adjacent to the lateral chest wall, minimizing the distance between the surgeon and the operative target. The procedure is performed under direct three-dimensional vision without an endoscope. A head-mounted camera transmits the surgeon’s view to a monitor positioned behind the surgeon, allowing the operating room team to follow the procedure without altering the surgeon’s visual axis.

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  Figure 2. Target-specific patient and arm positioning. For mitral and tricuspid valve surgery, atrial septal defect closure, and intracardiac mass excision, the right arm is positioned alongside the body and slightly displaced caudally to improve exposure of the axillary region (A). For aortic valve replacement and combined aortic-mitral procedures, the arm is elevated above the head to reproduce the thoracic configuration used during preoperative CT (B). This consistency is particularly important because the intercostal space is selected on CT and precise alignment with the relatively small aortic root and valve is required. Arm elevation is also used in patients with obesity or abundant breast tissue because it flattens the axillary and periaxillary soft tissues, reducing the distance between the skin and chest wall. All pressure points are padded, and excessive shoulder or brachial plexus traction is avoided. CT, computed tomography.

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  Figure 3. Incision planning and initial thoracic exposure. A 4–6 cm incision runs along the right anterior axillary line and is centered over the selected third or fourth intercostal space (A). Whenever anatomy permits, it follows the lateral extension of the natural inframammary crease (B). The pleural cavity is entered without rib division, and carbon dioxide is insufflated at 2 L/min. Limited intercostal spreading is used only during pericardial opening and is discontinued once adequate cranial and caudal exposure has been obtained.

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  Figure 4. High longitudinal pericardial opening. The pericardium is opened longitudinally, extending cranially high over the ascending aorta and caudally toward the diaphragm while preserving the phrenic nerve. The high cranial extension creates a posterior pericardial curtain that permits placement of posterior stay sutures away from the phrenic nerve and keeps the right lung separated from the operative field after ventilation is resumed.

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  Figure 5. Seven pericardial stay sutures. Seven stay sutures are distributed around the pericardial opening and secured directly to the skin edges of the thoracotomy. The anterior sutures elevate the anterior pericardium and right ventricular surface, whereas the posterior sutures draw the heart toward the lateral chest wall. Direct fixation to the incision preserves the traction vector toward the access, reduces the working distance, and centers the operative target. SVC, superior vena cava.

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  Figure 6. Central exposure of the cardiac anatomy. After pericardial traction, the ascending aorta, superior and inferior venae cavae, right atrium, right superior pulmonary vein, interatrial groove, transverse sinus, and left atrial appendage are accessible through short working trajectories. This central exposure forms the anatomical basis of the unified transaxillary platform and permits access to all three valves and associated atrial structures without changing the incision or surgeon position. IVC, inferior vena cava; RA, right atrium; RSPV, right superior pulmonary vein; SVC, superior vena cava.

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  Figure 7. Flexible aortic cross-clamp. A low-profile flexible aortic clamp is introduced directly through the main thoracotomy without an additional port and passed around the ascending aorta under direct vision. Rotation of the clamp toward the assistant produces slight leftward displacement of the ascending aorta, facilitates left atrial retraction during mitral surgery, and widens access to the transverse sinus when left atrial appendage occlusion is planned.

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  Figure 8. Direct mitral valve exposure. The left atrium is opened through the interatrial groove, and a dedicated atrial retractor elevates the interatrial septum. Posterior and anterior annular sutures are placed, tensioned, and secured on external suture organizers. This brings the annulus approximately 4–5 cm closer to the surgeon, centers the valve, and stabilizes the annular plane before valve analysis. The posterolateral trajectory provides an almost perpendicular view of the leaflets and commissures and direct central access to both papillary muscles, with particularly favorable exposure of the posteromedial commissure and papillary muscle.

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  Figure 9. Right atrial, tricuspid, and septal exposure. After bicaval control, a longitudinal right atriotomy is performed parallel to the atrioventricular groove and appears almost horizontal within the operative field (A). An inferior stay suture is secured to an external organizer, whereas a superior stay suture is exteriorized transthoracically to stabilize the atrial wall. A right atrial retractor then exposes the tricuspid annulus, leaflets, commissures, subvalvular apparatus, coronary sinus, atrioventricular node region, and interatrial septum (B). The same exposure permits tricuspid repair or replacement, atrial septal defect closure, and transseptal removal of intracardiac masses.

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  Figure 10. Aortotomy and aortic valve exposure. After aortic cross-clamping and cardioplegic arrest, a standard aortotomy is performed (A). Aortic stay sutures draw the root toward the thoracotomy and center the valve. The short working distance and near-perpendicular trajectory provide a uniform en face view of the annulus across all three sinuses (B). The native leaflets are excised, the annulus is debrided and sized, and a sutured, rapid-deployment, or sutureless prosthesis is delivered and seated perpendicularly under direct vision, with continuous visualization of the annulus, prosthetic components, and coronary ostia.

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  Figure 11. Left atrial appendage occlusion. Rotation of the flexible aortic clamp toward the assistant opens the transverse sinus. A caudally directed right atrial suspension suture and a flexible plastic retractor further expose the appendage to its base. A traction suture is placed at the appendage apex, and the epicardial clip delivery system is advanced along this suture to the base. Before deployment, complete inclusion of the appendage base and its relationship to the left superior pulmonary vein and left circumflex coronary artery are verified. The same exposure also permits surgical excision and direct polypropylene closure using a cut-and-sew technique. LAA, left atrial appendage.