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Beyond The Midline: Mitral Valve Repair Via Left Mini Thoracotomy In Patient With Severe Pectus Excavatum
Borko Ivanov, Sami Sirat, Katja Bohmann, Josepha Köhne, Tanja Josic, Mirko Doss.
Helios Hospital Siegburg, Department of Cardiothoracic Surgery, Siegburg, Germany.
Background Pectus excavatum is the most common congenital chest wall deformity and may be associated with cardiac compression and valvular pathology. In patients with advanced deformity, conventional mitral valve surgery via median sternotomy or right-sided minimally invasive approaches may be technically challenging or contraindicated due to leftward displacement of the heart. We report a case demonstrating the feasibility of minimally invasive mitral valve repair via left thoracotomy in severe pectus excavatum. Case Presentation A 74-year-old male presented with a six-month history of progressive dyspnea on exertion and reduced exercise tolerance. Transesophageal echocardiography revealed severe mitral regurgitation caused by prolapse of the posterior leaflet (P3 segment) with a flail leaflet and significant left atrial dilatation. Computed tomography demonstrated pronounced pectus excavatum with elongation of the right atrium adjacent to the sternum and marked leftward displacement of the heart. The distance between the mitral valve and the sternum was approximately 8 cm. Based on these anatomical findings, median sternotomy and right-sided minimally invasive thoracotomy were considered unfavorable. Therefore, a minimally invasive left thoracotomy approach was chosen as an alternative strategy. Surgical Technique The patient underwent surgery under general anesthesia and cardiopulmonary bypass. A 5-cm left minithoracotomy was performed in the fourth intercostal space at the left anterior midclavicular line, providing excellent exposure of the left-sided cardiac structures. After aortic cross-clamping and cardioplegic arrest, the right atrium was opened under total bypass followed by transseptal access to the left atrium. Intraoperative inspection showed elongated and ruptured chordae of the P2 and P1 segments. Two neochordae loops were implanted in P2 and three in P1. An indentation in the A1 segment was closed, followed by annuloplasty using a 36-mm ring. Results The postoperative course was uneventful. Predischarge echocardiography showed no residual mitral regurgitation. The patient was asymptomatic and discharged on postoperative day six. Conclusion Minimally invasive mitral valve repair via left thoracotomy is a safe and effective alternative in selected patients with severe pectus excavatum and leftward cardiac displacement, offering excellent valve exposure and favorable clinical outcomes.
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