Quadrivalvular Aortic Valve Replacement Through Ministernotomy Incision
Carlos Manuel de Almeida Brandão, Elinthon Tavares Veronese, Márcio S. M. Lima, Cassio Carvalho Soeiro Machado, Pablo Maria Alberto Pomerantzeff, Fábio Biscegli Jatene.
Heart Institute - University of São Paulo Medical School, São Paulo, Brazil.
OBJECTIVE: Describe a case of quadrivalvular aortic valve replaced through ministernotomy.
METHODS: A 51-year-old female diagnosed with severe aortic regurgitation was admitted to our institution for elective aortic valve surgery. She had been presenting progressive worsening of symptoms of fatigue and dyspnea on exertion in the last 12 months. Her blood pressure at admission was 142/50 mmHg. Transthoracic echocardiogram confirmed severe aortic regurgitation and normal systolic left ventricular (LV) function. End-diastolic LV diameter was 56 mm. Intraoperative transesophageal echocardiography revealed a quadrivalvular aortic valve (QAV) with a clear cusps malcoaptation and severe regurgitation (Figure 1).
RESULTS: She was submitted to a minimally invasive aortic valve surgery through right ministernotomy by "L Inverted" incision in the fourth right intercostal space. The extracorporeal circulation was placed in the right femoral artery and vein. The aortic valve was replaced for a Braile 23 bovine pericardium bioprosthesis. Procedure was successful with a short postoperatory recover (6 days). After 6 months of the procedure she remains asymptomatic.
CONCLUSIONS: QAV is a rare cardiac malformation, with an incidence between 0.003 and 0.043% of all congenital heart defects. Many cases are diagnosed incidentally on aortic surgeries or autopsies. It is not known exactly the mechanism responsible for this abnormality, but the strongest hypothesis is abnormal septation of embryologic truncus arteriosus. Functionally, QAV tends to evolve with progressive regurgitation for decades (rarely before adulthood), due to the asymmetry in the distribution of transvalvular flow and inequality of valvular coaptation. The minimally invasive aortic surgery is an excelent option to selected patients with both clinical and cosmetic results.
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