1. Intuity Elite Valve Implantation Technique
Kyle W. Eudailey, MD, Michael A. Borger, MD, PhD 
Operative Techniques in Thoracic and Cardiovascular Surgery 
Volume 21, Issue 4, Pages (December 2016)
DOI: /j.optechstcvs
Copyright © 2017 Elsevier Inc. Terms and Conditions

2. Figure 1
A standard hemisternotomy or right lateral mini-thoracotomy approach is employed. We favor a midline skin incision starting at the sternomanubrial junction and extending 6-8 cm inferiorly. An inverted-T hemisternotomy through the fourth intercostal space is our preferred approach, as this usually provides optimal exposure for direct arterial and venous cannulation. A J-hemisternotomy or right anterolateral mini-thoracotomy approach is another commonly used technique. Six pericardial stay sutures are tied directly to the sternal periosteum or to the skin edges, and the retractor is replaced within retracted pericardium to pull the pericardial well up into the wound and maximize exposure. The pericardial well is flooded with CO2 during the entire procedure. We prefer to cannulate the right atrial appendage directly through the incision. In the case of difficult right atrial exposure, the venous cannula can be tunneled under the xyphoid and inserted into the right atrial appendage, or percutaneous femoral venous cannulation can be employed. The left ventricle is vented via the right superior pulmonary vein. In cases of difficult access to the pulmonary vein, the pulmonary artery or the roof of the left atrium between the superior vena cava and the aorta can serve as alternative venting sites. The placement and method of cardioplegia is at the discretion of the surgeon. Our preference is antegrade cardioplegia via the ascending aorta or directly via the coronary ostia in patients with aortic insufficiency. We administer approximately 1 L of del Nido cardioplegia, which safely allows more than 90 minutes of myocardial ischemia. We prefer to avoid retrograde delivery via this incision, although others have successfully used this technique. In patients with severe aortic insufficiency, we fibrillate the heart before performing the aortotomy to improve visualization and ensure rapid cannulation of the coronary ostia.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
Copyright © 2017 Elsevier Inc. Terms and Conditions

3. Figure 2
A hockey stick aortotomy incision greatly facilitates the exposure and seating of the Intuity Elite valve system before deployment. The aortotomy is made in a standard position, that is, starting 5-10 mm below the Rindfleisch fold, extending leftward to the level of the pulmonary artery and right and downward into the middle of the non-coronary sinus. The aortotomy should stop 10-15 mm above the non-coronary annulus.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
Copyright © 2017 Elsevier Inc. Terms and Conditions

4. Figure 3
Careful excision and debridement of the aortic valve and surrounding calcification is strongly recommended, but excessive decalcification with resultant annular defects should be avoided. If an annular defect occurs, repair stitches with or without a pericardial patch should be placed before the seating of the Intuity Elite valve. If multiple annular defects occur, a conventional AVR using pledgeted sutures and a stented bioprosthesis should be performed. An important consideration during annular debridement is that a markedly non-cylindrical annulus will not conform to the Intuity Elite as with a conventional stented bioprosthesis, because of the absence of annular sutures. In such cases, the surgeon should also consider a conventional bioprosthesis. Finally, care should be taken to remove large calcifications just below the annulus, as the sealing zone of the valve is just below the annulus at the level of the stent.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
Copyright © 2017 Elsevier Inc. Terms and Conditions

5. Figure 4
Proper sizing is crucial for procedural success and to minimize paravalvular leak with the Intuity Elite valve. The cylindrical end of the sizer is first inserted through the annulus. The proper valve size is one in which the operator feels some resistance when inserting the cylinder through the annulus, without being able to pass the flange portion of the sizer through the annulus. We strongly recommend testing 1-size smaller and larger sizer to ensure the appropriate valve choice. When the measured annulus is somewhere between 2 different valve sizers, then the surgeon should insert the smaller valve size.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
Copyright © 2017 Elsevier Inc. Terms and Conditions

6. Figure 5
Once the proper valve size is chosen, valve preparation involves two 1-minute washes in saline solution.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
Copyright © 2017 Elsevier Inc. Terms and Conditions

7. Figure 6
Three braided 2-0 non-pledgeted sutures are placed at the nadir of each aortic sinus, making sure that the sutures exit 5-8 mm above the annulus on the aortic wall to facilitate seating of the valve system. Care should be taken to place these stitches equidistant from each commissure.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
Copyright © 2017 Elsevier Inc. Terms and Conditions

8. Figure 7
Each suture needle, which exits below the annulus, is then passed through the sewing ring of the Intuity Elite valve at the black markers and snared with a tourniquet. In the case of a bicuspid aortic valve, the sutures may need to be placed slightly away from the black markers to compensate for the asymmetrical bicuspid annulus. The Intuity Elite valve should not be inserted in patients with a true bicuspid valve without a raphe (ie, Sievers type 0).
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
Copyright © 2017 Elsevier Inc. Terms and Conditions

9. Figure 8
The valve is then lowered down to the annulus and a standard shoehorn manipulation is employed to seat the valve. Gentle upward traction can be placed on the annular sutures to help guide the valve down.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
Copyright © 2017 Elsevier Inc. Terms and Conditions

10. Figure 9
Once the surgeon is able to visualize the annular sutures exiting the aortic wall, the tourniquets are tightened sequentially. The snares must be positioned flush on the sewing cuff of the valve without entrapping the valve frame. Care should be taken to limit rocking of the valve system once the tourniquets have been tightened.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
Copyright © 2017 Elsevier Inc. Terms and Conditions

11. Figure 10
(A, B) Once the valve system is seated, the balloon catheter is advanced into the valve holder and the inflation device is attached to the proximal end of the balloon catheter. Although the surgeon maintains gentle downward pressure on the valve system, the balloon is inflated with saline by the assistant. The correct target inflation pressure is written on the valve holder handle and is maintained for 10 seconds.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
Copyright © 2017 Elsevier Inc. Terms and Conditions

12. Figure 10
(A, B) Once the valve system is seated, the balloon catheter is advanced into the valve holder and the inflation device is attached to the proximal end of the balloon catheter. Although the surgeon maintains gentle downward pressure on the valve system, the balloon is inflated with saline by the assistant. The correct target inflation pressure is written on the valve holder handle and is maintained for 10 seconds.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
Copyright © 2017 Elsevier Inc. Terms and Conditions

13. Figure 11
The balloon is then fully deflated with negative pressure, and the inflation device is locked. The 3 polypropylene sutures on the valve holder are cut at the level of the stent posts and the entire valve system is gently removed.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
Copyright © 2017 Elsevier Inc. Terms and Conditions

14. Figure 12
The surgeon and assistant should stabilize at least 2 stent posts with forceps while removing the balloon. The 3 annular guide sutures are then tied and cut. Proper seating and deployment of the valve is confirmed by ensuring patency of the coronary ostia in addition to visual inspection of the annulus. It is important to understand that the zone of seal for the valve is just below the sewing cuff, and the valve is not circumferentially fixed at the annular level like standard surgical valves.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
Copyright © 2017 Elsevier Inc. Terms and Conditions

15. Figure 13
The aortotomy is closed in a usual fashion. Standard de-airing maneuvers are employed and cardiopulmonary bypass is weaned. Post-bypass transesophageal echocardiography is performed to rule out paravalvular leak and to measure transvalvular gradients. The sternum and incision are closed in the usual fashion.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
Copyright © 2017 Elsevier Inc. Terms and Conditions