Redo mitral surgery via sternotomy can be associated with significant complications, including injuries to the heart, great vessels and patent coronary artery grafts, especially internal mammary artery leading to excessive blood loss, and may increase morbidity and mortality in these patients(1). The right antero-lateral thoracotomy offers excellent exposure with less risk from re-entry associated complications. This approach is particularly valuable in patients with patent coronary bypass grafts avoiding the risk of perioperative graft injury. Resternotomy after coronary artery bypass grafting (CABG) is a technically challenging situation, especially in the presence of patent grafts. In this case report we present a case with a previous coronary bypass grafting along with mitral valve repair 15 years back,and stenting to left anterior descending artery (LAD) 2 years ago. Patient underwent on-pump beating heart normothermic mitral valve replacement without cross-clamping the aorta through right anterolateral thoracotomy.
Keywords: Redo mitral valve; beating heart; right thoracotomy
A 58 year old female presented with increasing shortness of breath. Patient had history of coronary bypass surgery and mitral valve repair 5 year back.The patient had New York Heart Association class 4 symptoms. Transthoracic echocardiography showed severe mitral regurgitation. Coronary angiography and CT cardiac showed patent saphenous vein graft to diagonal and posterior descending artery and atretic and thinned out LIMA graft, patent LAD stent (Figure 1, 2). Patient had right anterolateral thoracotomy through 4th intercostal space. Left atrium was opened through sulcus of sondergord. The ascending aorta and right atrium was used for cannulation. The ascending aorta and right superior pulmonary vein was vented for deairing and to maintain a bloodless surgical field. The surgery was performed under normothermic cardiopulmonary bypass without aortic cross clamping
The mitral valve was thickened fibrotic appeared to be rheumatic, and was not suitable for repair. Annuloplasty ring and anterior leaflet of the mitral were valve excised (Figure 3, 4, 5). The mitral valve replacement was done with 25 hancock 2 bioprosthetic valve using interrupted pledgeted sutures. (Figure 6)The CPB time was 68 minutes. Postoperative bleeding was 250 ml and patient was extubated after three hours. Post-operative period was uneventful and the patient was discharged on the sixth postoperative day.