Minimally invasive aortic valve replacement (mini-AVR) has been established as a safe alternative to full sternotomy for isolated aortic valve pathology.1–13 Multiple authors have validated the right anterior thoracotomy as a safe and reproducible approach to the mini-AVR; however, the presence of coronary artery disease has excluded some patients from a minimally invasive approach. Some centers have used a hybrid approach, treating the coronary disease percutaneously and the aortic valve disease by limited access replacement. At our own institution, this is a common approach in carefully selected patients.
There are some patients whose coronary artery disease, although limited in extent, has excluded them from minimally invasive operations. Left and right main diseases are the most common examples. In this report, we describe a novel surgical approach in two patients with isolated, high-grade, ostial, right coronary artery (RCA) disease and severe aortic valve stenosis.
PATIENTS AND METHODS
Patient 1 was an 89-year-old man, and patient 2 was an 80-year-old woman. Both had been diagnosed with critical aortic stenosis secondary to senile calcific aortic disease and with high-grade calcified lesions in the ostium of the RCA.
Both patients underwent standard preoperative evaluation for right anterior thoracotomy for mini-AVR, including surface echocardiography, transesophageal echocardiogram (TEE), left-sided heart catheterization, and computed tomography angiography of the chest abdomen and pelvis.
For each patient, intraoperative monitoring and lines included TEE and a retrograde cardioplegia cannula, placed through a right internal jugular access under TEE guidance. A Swan-Ganz pacing catheter and a radial arterial line were placed. The right chest was elevated on a slight bump, and the chest and groins were prepared.
Endoscopic saphenous vein harvest and exposure of the right femoral vessels were performed through a 4-cm oblique groin incision, while the chest was opened. A 5-cm right anterior thoracotomy was made in the second intercostal space by dividing the right internal mammary artery and vein and then creating a “trap-door” in the third rib by shaving it off the sternum medially and dividing it laterally with an oscillating saw (Fig. 1). It should be noted that we now currently divide the third rib only at the sternum and leave it intact laterally for increased stability of the chest wall. A soft tissue retractor and small rib spreader were used to expose the upper mediastinum. A Blake drain (Ethicon, Somerville, NJ USA) was inserted over the sixth rib, initially for use as a port for CO2 infusion and then as a drain in the pericardium. Two 11-mm ports were created in the second and third intercostal spaces at the anterior axillary line. The superior port allowed placement of an aortic cross-clamp (Navarre vignette flexible clamp; Vitalitec, Plymouth, MA USA), and the inferior port was used for placement of a left ventricular vent. Thymic fat was removed, and the pericardium was opened vertically. Silk stay sutures were placed in the lateral edge of the pericardium and brought through the port incisions, and the aorta was pulled into the operative wound. After systemic heparinization, the femoral artery and vein were cannulated under TEE guidance using a Seldinger technique.
Cardiopulmonary bypass was initiated, and the ascending aorta circumferentially was mobilized. The Navarre clamp was introduced through the superior port and the aorta cross-clamped. The heart was arrested with 1-L blood cardioplegia, and the left ventricular vent was inserted through a purse string in the right superior pulmonary vein and brought out through the lower port. Subsequent doses of cardioplegia were then given through the neck (retrograde) and also down the vein graft. A suture passed around the RCA at the crux of the heart was used to retract the heart and to deliver the distal RCA into the operative field (Fig. 2). The distal RCA saphenous vein graft (SVG) was then performed with a standard, running polypropylene-suture anastomosis (Prolene; Ethicon, Somerville, NJ USA).
An oblique aortotomy was performed, and retraction sutures were placed at the commissures. The aortic valve was resected, and then, the prosthesis was sewn into place with noneverting pledgeted mattress sutures of polyester (Ethibond; Ethicon). The aortotomy was closed in two layers. A single aortotomy was then performed, and the proximal SVG anastomosis was created. This suture line was left open to aid in deairing the heart, and the cross-clamp was removed. The patients were weaned from bypass, and the thoracotomy was closed with a single figure-of-eight, using braided #2 polyglactin 910 (Vicryl; Ethicon). The rib was not repaired directly. The Blake drain was placed over the aortotomy, and a chest tube was placed high in the chest through the inferior port.
Both patients had uncomplicated AVR and coronary artery bypass grafting through a 5-cm right anterior thoracotomy, as described earlier. Cross-clamp times were 93 and 75 minutes for patients 1 and 2, respectively, and cardiopulmonary bypass times were 130 and 117 minutes, respectively. Porcine supraannular valves sizes 25 and 21 mm were implanted into the aortic position, and SVGs were placed to the RCA just proximal to its bifurcation. The patients were discharged home on postoperative days 9 and 7. Both patients received intraoperative blood transfusions for preexisting anemia. Patient 2 received a permanent pacemaker for postoperative tachy-brady syndrome. Both were alive and well at intermediate follow-up (25 and 31 months).
The right anterior thoracotomy for AVR has been accepted in some centers as a safe and reliable approach to isolated aortic valve disease,1–13 but the presence of concomitant coronary artery disease has excluded some patients from consideration of a minimally invasive approach. Hybrid strategies are now being used by a number of surgeons to increase the volume of patients who can be considered for a non–full-sternotomy approach, whether that be a J-sternotomy or a limited right anterior thoracotomy. Indeed, this approach is being used with the newer transcatheter valves. Even with an aggressive hybrid approach, there are still some patients who will require concurrent coronary artery bypass grafting. We have successfully treated two elderly patients, each of whom had high-grade ostial RCA disease and severe aortic stenosis, by concurrent RCA SVG bypass and mini-AVR through a 5-cm right anterior thoracotomy, and demonstrated excellent results in these carefully selected patients.
The authors thank Jeanne McAdara-Berkowitz, PhD, for the expert assistance with the manuscript preparation.
1. Glauber M, Miceli A, Gilmanov D, et al. Right anterior minithoracotomy versus conventional aortic valve replacement
: a propensity score matched study. J Thorac Cardiovasc Surg
. 2013; 145: 1222–1226.
2. Pineda AM, Santana O, Reyna J, Sarria A, Lamas GA, Lamelas J. Outcomes of reoperative aortic valve replacement
via right mini-thoracotomy versus median sternotomy. J Heart Valve Dis
. 2013; 22: 50–55.
3. Murzi M, Cerillo AG, Bevilacqua S, Gilmanov D, Farneti P, Glauber M. Traversing the learning curve in minimally invasive heart valve surgery: a cumulative analysis of an individual surgeon’s experience with a right minithoracotomy approach for aortic valve replacement
. Eur J Cardiothorac Surg
. 2012; 41: 1242–1246.
4. Pineda AM, Santana O, Lamas GA, Lamelas J. Is a minimally invasive approach for re-operative aortic valve replacement
superior to standard full resternotomy? Interact Cardiovasc Thorac Surg
. 2012; 15: 248–252.
5. Brinkman WT, Hoffman W, Dewey TM, et al. Aortic valve replacement
surgery: comparison of outcomes in matched sternotomy and PORT ACCESS groups. Ann Thorac Surg
. 2010; 90: 131–135.
6. Brown ML, McKellar SH, Sundt TM, Schaff HV. Ministernotomy versus conventional sternotomy for aortic valve replacement
: a systematic review and meta-analysis. J Thorac Cardiovasc Surg
. 2009; 137: 670.e5–679.e5.
7. Murtuza B, Pepper JR, Stanbridge RD, et al. Minimal access aortic valve replacement
: is it worth it? Ann Thorac Surg
. 2008; 85: 1121–1131.
8. Bakir I, Casselman FP, Wellens F, et al. Minimally invasive versus standard approach aortic valve replacement
: a study in 506 patients. Ann Thorac Surg
. 2006; 81: 1599–1604.
9. Doll N, Borger MA, Hain J, et al. Minimal access aortic valve replacement
: effects on morbidity and resource utilization. Ann Thorac Surg
. 2002; 74: S1318–S1322.
10. Bonacchi M, Prifti E, Giunti G, Frati G, Sani G. Does ministernotomy improve postoperative outcome in aortic valve operation? A prospective randomized study. Ann Thorac Surg
. 2002; 73: 460–466.
11. Mächler HE, Bergmann P, Anelli-Monti M, et al. Minimally invasive versus conventional aortic valve operations: a prospective study in 120 patients. Ann Thorac Surg
. 1999; 67: 1001–1005.
12. Benetti F, Rizzardi JL, Concetti C, Bergese M, Zappetti A. Minimally aortic valve surgery avoiding sternotomy. Eur J Cardiothorac Surg
. 1999; 16(suppl 2): S84–S85.
13. Minale C, Reifschneider HJ, Schmitz E, Uckmann FP. Minimally invasive aortic valve replacement
without sternotomy. Experience with the first 50 cases. Eur J Cardiothorac Surg
. 1998; 14(suppl 1): S126–S129.