Name: A Surgical Method for Subvalvular Structure Intervention Through a Transaortic Approach in Normal Bama Pigs (Video) | JoVE Journal
Uploaded: 2026-03-13T13:45:00.000+00:00
Duration: 7 min 24 s
Description: Learn a reproducible transaortic surgical method for subvalvular structure intervention in Bama miniature pigs. This technique enables controlled remodeling of left ventricular outflow tract structures for cardiovascular research.

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This work was supported by the National Key Research and Development Program of China (2023YFF0724701).

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<li>Guo, H. C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Comparison+of+clinical+effects+between+percutaneous+transluminal+septal+myocardial+ablation+and+modified+morrow+septal+myectomy+on+patients+with+hypertrophic+cardiomyopathy%5BTitle%5D)+AND+%22Chin+Med+J+%28Engl%29%22%5BJournal%5D)">Comparison of clinical effects between percutaneous transluminal septal myocardial ablation and modified morrow septal myectomy on patients with hypertrophic cardiomyopathy.</a> Chin Med J (Engl). 131 (5), 527-531 (2018).</li>
<li>Li, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Mir-30d+regulates+cardiac+remodeling+by+intracellular+and+paracrine+signaling%5BTitle%5D)+AND+%22Circ+Res%22%5BJournal%5D)">Mir-30d regulates cardiac remodeling by intracellular and paracrine signaling.</a> Circ Res. 128 (1), e1-e23 (2021).</li>
<li>Lv, Q., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Proline+metabolic+reprogramming+modulates+cardiac+remodeling+induced+by+pressure+overload+in+the+heart%5BTitle%5D)+AND+%22Sci+Adv%22%5BJournal%5D)">Proline metabolic reprogramming modulates cardiac remodeling induced by pressure overload in the heart.</a> Sci Adv. 10 (19), eadl3549(2024).</li>
<li>Schauer, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Empagliflozin+improves+diastolic+function+in+HFpEF+by+restabilizing+the+mitochondrial+respiratory+chain%5BTitle%5D)+AND+%22Circ+Heart+Fail%22%5BJournal%5D)">Empagliflozin improves diastolic function in HFpEF by restabilizing the mitochondrial respiratory chain.</a> Circ Heart Fail. 17 (6), e011107(2024).</li>
<li>Yang, P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Engineered+model+of+heart+tissue+repair+for+exploring+fibrotic+processes+and+therapeutic+interventions%5BTitle%5D)+AND+%22Nat+Commun%22%5BJournal%5D)">Engineered model of heart tissue repair for exploring fibrotic processes and therapeutic interventions.</a> Nat Commun. 15 (1), 7996(2024).</li>
<li>Fang, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Transapical+septal+myectomy+in+the+beating+heart+via+a+minimally+invasive+approach%3A+A+feasibility+study+in+swine%5BTitle%5D)+AND+%22Interact+Cardiovasc+Thorac+Surg%22%5BJournal%5D)">Transapical septal myectomy in the beating heart via a minimally invasive approach: A feasibility study in swine.</a> Interact Cardiovasc Thorac Surg. 30 (2), 303-311 (2020).</li>
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The authors of this manuscript have no conflicts of interest to declare.

Subvalvular structure abnormalities of the left ventricle represent critical anatomical changes in patients with hypertrophic cardiomyopathy (HCM), leading to impaired ventricular compliance, elevated diastolic pressure, and left ventricular outflow tract (LVOT) obstruction. These structural abnormalities constitute major pathological bases for clinical cardiac dysfunction and adverse outcomes10,11 . In this study, we established a surgical method in normal Bama ...

Abnormalities in the subvalvular structures of the left ventricle play a crucial role in various cardiovascular diseases, particularly in patients with hypertrophic cardiomyopathy (HCM), where subvalvular anomalies contribute to left ventricular outflow tract (LVOT) obstruction and interventricular septal hypertrophy1. These structural changes not only impair ventricular filling and ejection but may also lead to severe complications such as ventricular arrhythmias, sudden cardiac death, and chronic heart failure2. Clinically, transaortic surgical resection of left ventricular tissues is often employed in such patients to relieve LVOT obstruction and improve prognosis3. However, only a few studies have systematically investigated the physiological changes and ventricular remodeling processes following this surgical intervention, limiting its application in basic research and translational therapeutic development.
Various animal models have been widely employed to study subvalvular structural changes and intervention strategies. These models have significantly contributed to understanding molecular and tissue-level mechanisms; however, they show notable limitations in simulating clinical cardiac surgical procedures, particularly in achieving precise exposure and targeted tissue cutting of the left ventricle. Problems such as anatomical distortion, insufficient surgical precision, and limited tissue sampling remain4,5,6,7. These deficiencies hinder the broader application of such models in research on surgical intervention mechanisms, postoperative structural intervention, and biomaterial evaluation.
In recent years, animal models simulating left ventricular subvalvular structure intervention via a transaortic approach have remained extremely limited. Existing studies are primarily restricted to modifications of current surgical techniques, attempting to intervene in localized ventricular tissue structures through minimally invasive pathways or energy-based methods. However, these approaches significantly differ from clinical surgical practices in terms of surgical pathways, intraoperative cardiac conditions, and tissue intervention strategies, making it difficult to accurately reproduce the structural, hemodynamic, reperfusion, and mechanical stress responses induced by surgical interventions8,9. Therefore, in this study, we established a reproducible large animal surgical model by performing a median sternotomy and an anterior aortic wall incision under cardiopulmonary bypass (CPB) support in normal Bama pigs. This model enables direct exposure of the left ventricular outflow tract and the subvalvular region, followed by controlled tissue cutting to promote subvalvular structure intervention, providing a clinically relevant platform for future research.
Specifically, this model was designed to replicate the procedural pathway and operative environment of clinical transaortic septal myectomy used in patients with hypertrophic obstructive cardiomyopathy (HOCM). It is not intended to recapitulate HOCM pathophysiology or serve as a disease model, but rather to reproduce the operative conditions under which subvalvular intervention is performed.
This model serves as a standardized surgical framework for studying subvalvular structural interventions, evaluating novel cardiac surgical devices, and providing a reproducible training platform for experimental cardiac surgery, including surgical training in transaortic LVOT exposure and controlled subvalvular resection, as well as acute tissue-level and histologic studies following defined structural interventions.

<table><tbody><tr><td>0.9% Sodium Chloride Injection</td><td>-</td><td>-</td><td>Used for irrigation and solution dilution</td></tr><tr><td>Anesthesia Machine</td><td>-</td><td>-</td><td>Delivers inhaled anesthetics and respiratory support</td></tr><tr><td>Anesthetics (Propofol, Fentanyl, Atracurium)</td><td>-</td><td>-</td><td>Used for anesthesia induction and maintenance</td></tr><tr><td>Aortic Retractor</td><td>SINOVIEW</td><td>RT37008-25</td><td>Used to retract the aorta and improve visibility</td></tr><tr><td>Atraumatic Forceps</td><td>SINOVIEW</td><td>FC22500-24</td><td>Used to grasp tissue while minimizing trauma</td></tr><tr><td>Cardioplegia Solution (St. Thomas)</td><td>-</td><td>-</td><td>Used for cardiac arrest and protection</td></tr><tr><td>Cardiopulmonary Bypass Machine and Tubing</td><td>-</td><td>-</td><td>Used for maintaining circulation during CPB</td></tr><tr><td>Central Venous Catheter Kit</td><td>-</td><td>-</td><td>Establishes central venous access</td></tr><tr><td>Endotracheal Intubation Set and Ventilator</td><td>-</td><td>-</td><td>Maintains airway during surgery</td></tr><tr><td>Flat Hook Retractor</td><td>SINOVIEW</td><td>RT37000-00</td><td>Used for tissue retraction in thoracic cavity</td></tr><tr><td>General Retractor</td><td>-</td><td>-</td><td>Used to retract tissue and expose surgical area</td></tr><tr><td>Hemostatic Forceps</td><td>-</td><td>-</td><td>Used to clamp blood vessels or tissue for hemostasis</td></tr><tr><td>Heparin Sodium Injection</td><td>-</td><td>-</td><td>Used for anticoagulation</td></tr><tr><td>IV Catheter&amp;middot;Radiopaque 22 GA &amp;times; 1.00 in</td><td>BD Angiocath</td><td>381123</td><td>Used to establish venous access</td></tr><tr><td>Microsurgical Instrument Basket</td><td>SINOVIEW</td><td>90X0003</td><td>Used to store and transport microsurgical instruments</td></tr><tr><td>Minimally Invasive Curved Scissors</td><td>SINOVIEW</td><td>SC40230-25</td><td>Used in minimally invasive procedures for curved cutting</td></tr><tr><td>Minimally Invasive Double-joint Scissors</td><td>SINOVIEW</td><td>SC55001-29</td><td>Used for precise cutting in deep operative fields</td></tr><tr><td>Needle Holder</td><td>-</td><td>-</td><td>Used to hold suture needles during stitching</td></tr><tr><td>Scalpel Handle and Blade</td><td>-</td><td>-</td><td>Used to incise skin and tissues</td></tr><tr><td>Sterile Drapes, Sutures, Gloves, Masks</td><td>-</td><td>-</td><td>Used to maintain a sterile surgical field</td></tr><tr><td>Sterilization Box for Precision Instruments</td><td>SINOVIEW</td><td>90X0401</td><td>Used for cleaning and sterilizing surgical instruments</td></tr><tr><td>Tissue Forceps (Toothed/Non-toothed)</td><td>-</td><td>-</td><td>Used to grasp tissue</td></tr><tr><td>Tissue Scissors</td><td>SINOVIEW</td><td>SC35101-25SC</td><td>Used for general tissue cutting</td></tr><tr><td>Triple-joint Microforceps</td><td>SINOVIEW</td><td>FC17010-301</td><td>Used in microsurgery for delicate manipulation</td></tr><tr><td>Ultra-sharp Scissors</td><td>SINOVIEW</td><td>SC35101-23UC</td><td>Used for precise tissue dissection</td></tr><tr><td>Urinary Catheter and Drainage Bag</td><td>-</td><td>-</td><td>Used for urine drainage and monitoring</td></tr><tr><td>Vital Signs Monitor</td><td>-</td><td>-</td><td>Monitors ECG, blood pressure, SpO&lt;sub&gt;2&lt;/sub&gt;, temperature</td></tr></tbody></table>

a surgical method for subvalvular structure intervention through a transaortic approach in normal bama pigs

A Surgical Method for Subvalvular Structure Intervention Through a Transaortic Approach in Normal Bama Pigs

Subvalvular structure abnormalities leading to left ventricular outflow tract (LVOT) alterations and myocardial hypertrophy are characteristic anatomical features of structural heart diseases such as hypertrophic cardiomyopathy (HCM). This study establishes a surgical method for aortic subvalvular structure intervention through a transaortic approach in normal Bama pigs. Animals were obtained from a certified experimental pig supplier in Beijing (Licence No. SCXK (Jing) 2018-0008).This method was validated in three healthy female Bama miniature pigs aged approximately 33-35 weeks, weighing 30-35 kg at the time of surgery. The procedure involves a median sternotomy and an anterior aortic wall incision, performed under cardiopulmonary bypass (CPB) support, hypothermic cardiac arrest, and direct visualization of the LVOT and subvalvular regions. Targeted tissue traction, localization, and cutting are utilized to remodel the subvalvular structure.
The complete surgical process includes anesthesia induction, placement of a central venous catheter and urinary catheter, surgical site disinfection and draping, median sternotomy, pericardial incision, and cardiac mobilization. CPB is established through right atrial drainage and retrograde coronary sinus perfusion. Following an anterior aortic wall incision, the left ventricle is accessed across the aortic valve, and subvalvular tissue intervention is performed under cardiac arrest. The procedure concludes with aortic closure, cardiac resumption of beating, CPB withdrawal, and thoracic closure. Throughout the procedure, hemodynamic stability was maintained, and the animal remained in good condition without intraoperative mortality. After surgery, the cut surfaces were smooth, and the surrounding structures remained intact.
This method demonstrates high reproducibility and procedural controllability, providing a stable surgical intervention model for studying subvalvular structure intervention. It also offers a technical platform for conducting histological analysis, surgical validation, and intervention strategy evaluation.

This surgical protocol enables stable exposure and controlled cutting of the subvalvular structures within the left ventricle. During the procedure, the aortic incision was accurately positioned, and entry through the aortic opening allowed clear visualization of the left ventricular outflow tract and the associated subvalvular region. The surgeon localized the cutting area by applying traction on the pre-placed suture and completed targeted subvalvular tissue cutting under direct vision using small, curved scissors. Pos...

This study presents a surgical method for subvalvular aortic valve structure intervention using targeted tissue cutting via a transaortic approach in normal Bama pigs.

Subvalvular structure abnormalities leading to left ventricular outflow tract (LVOT) alterations and myocardial hypertrophy are characteristic anatomical ...

This study develops a reproducible transaortic surgical method to study subvalvular interventions under clinically relevant conditions. This protocol can be applied to surgical training, histological analysis, and evaluation of subvalvular intervention strategies. After preparing the animal, make a midline incision along the sternum, extending from the suprasternal notch to approximately two centimeters below the xiphoid process.Using an electrocautery device, incise the skin and subcutaneous tissues while maintaining an incision length of approximately 20 centimeters. Continue to separate the pectoralis major muscles and the periosteum of the sternum. Fully expose the anterior surface of the sternum.Gently retract the lateral tissues with the help of an assistant to maintain a clear surgical field. After exposing the sternum, insert a Lebsche knife beneath the xiphoid process and apply upward traction. Using a small hammer, carefully and evenly tap the proximal end of the Lebsche knife.Gradually split the sternum along the midline, proceeding cranially until the thoracic cavity is opened. Maintain continuous upward traction throughout the process to avoid deviation or injury to the pericardium. After completing the sternal division, place a Finochietto rib retractor.Slowly expand the thoracic cavity bilaterally to widen the operative field, while avoiding excessive retraction to prevent pleural injury or rib fractures. Perform blunt dissection bilaterally to separate the pericardium from the mediastinal pleura and adjacent connective tissues. After completing the dissection, expose the heart under direct visualization.Confirm clear identification of key anatomical structures, including the aorta, pulmonary artery, right atrial appendage, cardiac apex, and coronary sinus. Once adequate cardiac exposure is achieved, place a purse-string suture at the base of the right atrial appendage. Make a small incision within the suture loop and insert a venous drainage cannula obliquely downward along the axis of the right atrial appendage to establish the venous return pathway for cardiopulmonary bypass.Advance the cannula approximately three to four centimeters to ensure that its tip enters the right atrial cavity and secure the cannula to the atrial appendage using silk sutures to prevent slippage or leakage. Insert a perfusion cannula through the right atrial appendage region into the coronary sinus to serve as the inflow pathway for cardioplegia delivery and myocardial perfusion. Activate the venous return pump to initiate partial venous drainage.Gradually open the arterial pump to maintain perfusion pressure at 60 to 80 millimeters of mercury. Infuse cooled high potassium cardioplegia via the coronary sinus to induce cardiac arrest and record the arrest time. Apply pre-prepared sterile ice saline slush over the cardiac surface to further reduce myocardial temperature, decrease metabolic demand, and enhance myocardial protection.After achieving cardioplegic arrest and hypothermic protection, make a transverse incision approximately one to 1.5 centimeters in length on the anterior wall of the ascending aorta. Position the incision approximately 1.5 to two centimeters above the aortic valve annulus and orient it perpendicular to the long axis of the aorta. Insert two curved sheet hooks into the aortic incision from the left dorsal and ventral sides and gently retract the incision laterally to open the aortic root and expand the surgical field.Now, advance small curved scissors through the aortic incision along the axis of the aorta toward the left ventricular chamber. Use the traction suture to expose the target subvalvular region. Under direct visualization, orient the scissors horizontally and cut the designated subvalvular structures in a controlled manner.Remove the resected tissue and hand it to the assistant. Finally, close the aortic incision using continuous absorbable sutures. Begin at one end of the incision and sequentially pass the needle through the intima and media using evenly-spaced stitches to ensure complete watertight closure.Following aortic incision closure, restore cardiac perfusion and observe spontaneous cardiac rebeating. After placement of the closed drainage tubes, close the sternum with interrupted stainless steel wires and perform routine layered closure of the thoracic wall. The total operation time was approximately 2.5 to three hours.Cardiopulmonary bypass was maintained for about 60 to 71 minutes. After restoration of cardiac perfusion, spontaneous cardiac rebeating was observed in all animals with a stable sinus rhythm. No apparent complications or adverse events were observed after the procedure.The key challenge is achieving adequate exposure and precise resection while avoiding damage along the surgical access pathway. Following intervention, animals can undergo echocardiography, CMR, and other hemodynamic assessments to evaluate cardiac function. Future studies can explore long-term functional outcomes, optimize resection strategies, and investigate mechanisms underlying subvalvular intervention effects.

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Learn a reproducible transaortic surgical method for subvalvular structure intervention in Bama miniature pigs. This technique enables controlled remodeling of left ventricular outflow tract structures for cardiovascular research.

A Surgical Method for Subvalvular Structure Intervention Through a Transaortic Approach in Normal Bama Pigs

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