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OBJECTIVE: Use of a minimally invasive partial sternotomy approach for aortic valve replacement in patients with a prior sternotomy has been well described. However, combining this approach with an aortic root enlargement is a newer technique to avoid patient-prosthesis mismatch. We present a case to highlight several technical details that are critical to the success of this procedure.
METHODS: Chart review was performed of a 63-year old patient who underwent reoperation for minimally invasive aortic valve replacement after prior sternotomy and coronary artery bypass grafting.
RESULTS: Surgical access was achieved using an inverted T-incision. Cardiopulmonary bypass was established through the ascending aorta and the right femoral vein. No attempt was made to isolate the patent left internal mammary artery. Systemic cooling to 25° was performed. Single-shot Custodiol ®HTK was used for induction and maintenance cardioplegia. Given the 18 mm aortic annulus, a Nicks aortic root enlargement using a CorMatrix® extracellular matrix patch was performed, allowing implantation of a 21 Magna pericardial valve. Cross-clamp and cardiopulmonary bypass times were 68 and 111 minutes, respectively. TEE revealed good valve function and seating, with a mean gradient < 10. The patient recovered uneventfully, was discharged on postoperative day 3, and remains asymptomatic at short-term follow-up.
CONCLUSIONS: The minimally invasive partial sternotomy approach, particularly using an inverted T incision, gives excellent exposure to the ascending aorta in the reoperative setting, avoiding the need for significant cardiac dissection. Cardioplegia with single-shot Custodiol ® HTK is a useful adjunct. The addition of an aortic root enlargement is a feasible extension in selected cases of minimally invasive aortic valve replacement in the reoperative setting.