Mission Re-Op Impossible
João Pedro Monteiro, Sara Costa, Nelson Santos, Daniel Martins, Rodolfo Pereira, Luís Vouga.
CHVNG/E, Vila Nova de Gaia, Portugal.
BACKGROUND: Right anterolateral minithoracotomy approach for mitral valve repair and replacement is a well established minimally invasive technique. In this re-operation case report, the surgeon allied this approach to a ventricular fibrillation without aortic cross clamping technique in order to be able to replace the mitral valve safely, by avoiding secondary injuries associated to a re-sternotomy and the presence of an aneurysmatic patent bypass graft. METHODS: A 56-year-old woman entered the emergency department due to worsening dyspnea. Severe mitral regurgitation and pulmonary artery dilation with a flow compatible with fistula were observed by transthoracic and transesophageal echocardiography. The patient had history of an ALCAPA (Anomalous Left Coronary Artery from Pulmonary Artery) syndrome having undergone coronary artery bypass grafting (saphenous venous graft to left anterior descending artery) 30 years before. Coronary angiography and computed tomography revealed patency of the graft, with the dilated vein running across the front of the ascending aorta and being responsible for the perfusion of the left anterior descending artery and circumflex artery. To avoid injuring the patent graft, minimally invasive mitral valve replacement under ventricular fibrillation without aortic cross clamping was performed through a right anterolateral minithoracotomy approach. RESULTS: The postoperative course was uneventful, and she was discharged in an improved state on hospital day 7. Follow-up transthoracic echocardiography reveals a functioning mitral prothesis. CONCLUSIONS: Minimally invasive mitral valve replacement under ventricular fibrillation without aortic cross clamping through a right anterolateral minithoracotomy approach appears to be safe, effective and useful for avoiding secondary injuries in patients with severe mitral regurgitation, previous sternotomy and patent bypass grafts.LEGEND: Pre-operative chest computed tomography revealing the patent and aneurysmatic saphenous venous graft to the left anterior descending artery, running across the front of the ascending aorta and close to the sternum, thus increasing the risk of a possible re-sternotomy
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