Another approach for aortic valve replacement through left thoracotomy

Right Parasternal Approach for Aortic Valve Replacement After Presternal Gastropexy

Due to bicuspid aortic valve aortic stenosis, a 78-year-old man with a history of esophagectomy and presternal gastric tube reconstruction required aortic valve replacement (AVR). AVR with a bioprosthetic valve was performed through a right parasternal thoracotomy. Despite the unfavorable conditions for conventional median sternotomy, AVR was successfully performed through an alternate approach. The right parasternal approach was excellent for AVR in patients with presternal gastric tube reconstruction for esophageal cancer (EC).

Left Anterior Thoracotomy Minimally Invasive Aortic Valve Replacement Following Left Pneumonectomy

We report the case of a 59-year-old man referred for aortic valve replacement for severe, symptomatic aortic insufficiency who underwent a minimally invasive left anterior thoracotomy aortic valve replacement. This approach was facilitated by his history of a left pneumonectomy for lung cancer 7 years prior to presentation, which resulted in a significant left mediastinal shift. The cannulation strategy and exposure were analogous to what would be expected from a standard right anterior thoracotomy minimally invasive aortic valve replacement. The minimally invasive approach allowed for early extubation and mobilization in a patient with moderate baseline pulmonary dysfunction.

Aortic valve replacement via right anterolateral thoracotomy in the case of a patient with extreme mediastinal right-shift following pneumonectomy

We report on the case of a 68-year-old male patient with the history of right pneumonectomy due to bronchial carcinoma, who was referred for aortic valve replacement due to severe calcified aortic stenosis. Pre-operative chest X-ray and computed tomography (CT) revealed an unusually pronounced mediastinal shift to the right. Despite this unusual anatomy, we decided to perform surgery using the right anterolateral thoracotomy following thorough pre-operative planning using 3D-volume rendering of the CT data-set. This approach yielded excellent exposure of the aortic root and the ascending aorta, respectively. Following an uneventful operative and post-operative course the patient could be discharged on post-OP day 6.Although only occasionally described for aortic valve replacement a right anterolateral thoracotomy may represent a valuable surgical approach, particular in patients with unusual anatomy, e.g. a mediastinal right-shift. However, thorough pre-operative planning, i.e. using visualization and planning techniques such as 3D-volume rendering should be mandatory as it provides information crucial to facilitate surgical steps and thus, may help avoid severe surgical complications.

Aortic valve replacement after esophagectomy with substernal gastric tube and total laryngectomy with tracheostoma

A 77-year-old man successfully underwent aortic valve replacement with a bioprosthesis through a right thoracotomy. Right thoracotomy was utilized because the patient had previously undergone esophagectomy with reconstruction of a substernal gastric tube for esophageal cancer as well as total laryngectomy with tracheostoma formation for laryngeal cancer. Thus, even in a situation in which conventional median sternotomy was difficult, a good outcome for aortic valve replacement was achieved through an alternate approach. This case highlights the need to consider patient history when selecting a surgical approach.

Aortic valve replacement in a patient with a retrosternal gastric tube

A 65-year-old male with a history of a total thoracic esophagectomy with a retrosternal gastric tube reconstruction required aortic valve replacement for aortic valve stenosis due to a bicuspid aortic valve. Preoperative multidetector computed tomography demonstrated that the gastric tube occupied the retrosternal space and the gastroepiploic artery was located on the left side of the gastric tube. Aortic valve replacement was performed through a median sternotomy approach. Blunt dissection on the anterior and right side of the gastric tube was performed without injury, and we could then perform cardiac surgery with the standard surgical view. 

Aortic valve replacement through left thoracotomy after esophageal operation

A 67-year-old man was referred for aortic valve surgery due to aortic valve regurgitation. He underwent an aortic valve replacement through a left thoracotomy, since he had a history of esophageal surgery with substernal gastric tube reconstruction and lymph node dissection through a right thoracotomy 14 years ago. The aortic valve was successfully replaced with excellent visualization using vacuum-assisted venous drainage on a cardiopulmonary bypass. Although exposing the aortic valve through a left thoracotomy is difficult, the application of vacuum-assisted venous drainage helps visualize the aortic valve in this approach.

Valvular Reoperations by Left Thoracotomy in Patients With Pectus Excavatum

Several alternative approaches to the aortic and mitral valves have been reported recently. We describe a left anterior thoracotomy approach for valvular reoperations in 3 patients with Marfan syndrome and severe pectus excavatum.

Aortic valve replacement for a patient with porcelain aorta and retrosternal gastric tube reconstruction after esophageal resection

A 67-year-old woman with congestive heart failure due to aortic stenosis and regurgitation needed aortic valve replacement. She had undergone right radical mastectomy 23 years before, and total thoracic esophagectomy with retrosternal gastric tube reconstruction 11 years before. Plain computed tomography showed coincident porcelain aorta. Aortic valve replacement was performed through a median sternotomy approach. Blunt dissection on anterior and right side of the gastric tube could be done with minimal injury, and the heart was exposed as in usual cardiac surgery. Preoperative multi-detector computed tomography revealed inhomogeneous and patchy distribution of calcification in the ascending aorta, and was helpful to decide aortotomy site. Aortic valve replacement was done and aortotomy was closed with felt strip buttressed running suture. Postoperative course was uneventful.

Alternative approach for angioplasty of stenosed left pulmonary artery following intracardiac repair of tetralogy of Fallot

A 5-year-old boy with stenosed left pulmonary artery following total correction of tetralogy of Fallot underwent surgical pulmonary arterioplasty through a left anterolateral thoracotomy on a normothermic perfused heart under cardiopulmonary bypass. We found this to be a convenient approach, and recommend it for correction of this lesion in the absence of gross pulmonary regurgitation and right ventricular outflow tract dilatation.

Current indications for left thoracotomy in coronary revascularization and valvular procedures

BACKGROUND

Left thoracotomy is infrequently used for cardiac procedures, but its application in reoperative and minimally invasive coronary revascularization and in valvular procedures has been reported recently.

METHODS

Three case reports and a review of the current literature illustrate the unique benefits of this approach for myocardial revascularization and valve replacement.

RESULTS

Reoperative coronary revascularization of the left anterior descending and circumflex coronary arteries was performed off-pump via a left posterolateral thoracotomy. For the second case, this approach was used for coronary artery bypass grafting of the right coronary and left anterior descending arteries with femoral-femoral cardiopulmonary bypass in a patient with congestive heart failure and coronary artery disease who also required closure of a patent ductus arteriosus. In the third case, mitral valve replacement using femoral venous and aortic cannulation for cardiopulmonary bypass was performed via a left thoracotomy to avoid a retrosternal gastric conduit in a patient with severe mitral stenosis and congestive heart failure. All patients returned to normal activity and are asymptomatic.

CONCLUSIONS

These case reports and a comprehensive review of the literature demonstrate the utility of left thoracotomy as an alternative approach to standard median sternotomy in selected cases of revascularization and valvular procedures.

Aortic valve replacement after retrosternal gastric tube reconstruction for esophageal cancer

A 59-year-old man with a history of the thoraco-abdominal esophagus resection with retrosternal gastric tube reconstruction for esophageal cancer complicated by anastomosis leakage and purulent pericarditis was admitted for aortic regurgitation due to infective endocarditis. Floppy vegetation and worsening cardiac failure indicated aortic valve replacement. In a median sternotomy approach, the thickest adhesion between the cervical esophagus and posterior surface of the manubrium sternae was freed using an ultrasonic osteotome. Severe adhesions in the pericardium due to purulent pericarditis were found. Median sternotomy enabled minimal exposure of the aortic root, upper right atrium, and right superior pulmonary vein for instituting extracorporeal circulation and replacing the aortic valve. The patient's postoperative course was uneventful. For cardiac surgery in patients with a retrosternal gastric tube, left anterior or right thoracotomy may be considered to avoid gastric tube injury. Median sternotomy, however, is an alternative enabling safe heart exposure, and the ultrasonic osteotome was very useful in incising the sternum without injuring the cervical esophagus, which had no serosa.