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Combined Aortic Valve Replacement and Coronary Artery Bypass Graft without a Sternotomy-Early Experience with Eleven Cases
Zhandong Zhou1, Michael Hodell1, Ahmed Nazem1, Gary R. Green1, Charles Lutz1, Feng Gao2.
1St. Joseph Hospital, Syracuse, NY, USA, 2An Zheng Hospital, Beijing, China.

OBJECTIVE: Patients with aortic valve stenosis who need coronary artery bypass graft (CABG) were not candidate for minimally invasive approach in the past. With the development of new technologies, we were able to perform combined aortic valve replacement (AVR) and single vessel CABG without a sternotomy in selected patients.
METHODS: Patients who need AVR and single vessel CABG were selected for either a mini-right thoracotomy or bilateral mini-thoracotomy approach depending on the location of the graft. For patients with left anterior descending coronary artery (LAD) disease, Da Vinci robot was used to takedown the left internal mammary artery (LIMA) first. Then AVR was performed through a right mini-thoracotomy. With aorta still clamped, the LIMA to LAD anastomosis was performed through a mini left thoracotomy. For patients with circumflex or diagonal artery disease, a small left thoracotomy was performed after AVR was completed. A saphenous vein/radial artery graft was then anastomosed to the target artery with the aorta still clamped. The graft was then tunnelled to the right side for anastomosis to the aorta. For patients with right coronary artery disease, the distal and proximal anastomosis can usually be performed through the same incision.
RESULTS: Total eleven patients had combined AVR and CABG through a right thoracotomy or bilateral mini thoracotomy approach. Average age was 74±2.6 year, with 6 male and 5 female patients. Other demographics include 3 patients with COPD, 10 patients with diabetes, and 2 patients had previous congestive heart failure. All patients successfully completed the surgery without conversion to sternotomy and stay alive in 30 days. Average aortic clamp time was 127±11 minutes and cardiopulmonary bypass time was 169 ± 12 minutes. No early post operative complications were noticed. One patient developed endocarditis and died three months later. All patients are in class I or II in follow-up.
CONCLUSIONS: To our knowledge, this is the first reported series that combined AVR and single vessel CABG were performed without a sternotomy to all territories of the coronary artery distribution. It is especially valuable in patients who need to return to full activity sooner with little restrictions.


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