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A 71-year-old man on hemodialysis and with a history of right lobectomy was referred for aortic valve replacement. Chest computed tomography revealed counterclockwise rotation of the heart through its longitudinal axis.
We approached the aortic valve through median sternotomy. Accordingly, we transected the sternum at the level of the 3rd intercostal space and extended the skin incision approximately 2 inches perpendicular to the midline. After partial transection of the sternum, 3 spreaders were placed: the 1st, in the upper sternum; the 2nd, in the lower sternum; and the 3rd, between the ribs. These devices yielded excellent exposure of the ascending aorta. In addition, the relatively central shift of the ascending aorta contributed to the exposure of the right atrium and the right upper pulmonary vein. Subsequently, aortic valve replacement was performed in the usual fashion, and the patient experienced no postoperative respiratory complications. Aortic valve surgery with T-shaped sternotomy and without thoracotomy is an alternative technique in a patient who has a secondary deviation after lobectomy.
Although aortic valve replacement (AVR) is a well-known surgical procedure, AVR in a patient with secondary displacement has rarely been reported. Herein, we present an alternative surgical approach for surgery in the case of a patient with mediastinal deviation.
In March 2009, a 71-year-old man on hemodialysis presented with chest pain and ST changes during electrocardiography after colectomy. Echocardiographic investigation revealed severe aortic valve stenosis (pressure gradient, 100 mmHg). The patient had undergone a right upper lobectomy for lung carcinoma 3 years earlier. The lobectomy had been performed through a right thoracotomy. Chest computed tomography revealed counterclockwise rotation of the heart through its longitudinal axis, with left pleural effusion (Fig. 1). Although right thoracotomy seemed to be a good approach for the displaced heart, adhesion in the right thoracic cavity was predicted. The patient's pulmonary function was poor because of chronic obstructive pulmonary disease. In order to protect the right lung, we decided to perform AVR through a complete median sternotomy.
After the pericardium was opened, only the main pulmonary artery and right ventricle were revealed. The ascending aorta and right atrial appendage were not visible. Accordingly, we transected the sternum at the level of the 3rd intercostal space and extended the skin incision approximately 2 inches perpendicular to the midline. The right internal thoracic artery was ligated and divided, and care was taken not to incise the pleura. After partial transection of the sternum, 3 spreaders were placed. The 1st spreader was placed in the upper sternum; the 2nd, in the lower sternum; and the 3rd, between the ribs. The use of these devices enabled excellent exposure of the ascending aorta. In addition, the relatively central shift of the ascending aorta contributed to the exposure of the right atrium and the right upper pulmonary vein.
Cardiopulmonary bypass was established via the ascending aorta with venous drainage through a 2-stage cannula in the right atrial appendage. After a cannula was inserted from the right atrium into the coronary sinus for retrograde cardioplegia, a vent tube was placed through the right upper pulmonary vein into the left ventricle in standard fashion. The ascending aorta was clamped, and retrograde cold-blood cardioplegic solution was delivered. A transverse aortotomy was performed at the level of the sinotubular junction. Subsequently, the severely calcified native aortic valve was excised and replaced with a 19-mm Carpentier-Edwards bioprosthetic valve (Edwards Lifesciences LLC; Irvine, Calif). The patient's postoperative recovery was uneventful, with no respiratory complications. He remains under observation as an outpatient.
Several approaches to aortic valve surgery have been used, including median sternotomy, right or left thoracotomy, and various minimally invasive approaches; however, the most common is median sternotomy.1–5 The procedures other than median sternotomy have been used for reoperation for cosmetic reasons, or when the patient had patent internal thoracic artery grafts or mediastinal displacement.1,2,5
A thoracotomy approach to valve surgery involves technical difficulties. Svensson and colleagues3 found a higher incidence of stroke in cases of right thoracotomy than in those of median sternotomy. They underlined the importance of the cannulation approach in order to reduce the risk of embolic stroke. Our patient had undergone dialysis for 20 years. Computed tomography showed severe calcification and arteriosclerosis in the descending aorta and femoral artery. In previous patients who also had arteriosclerosis, we used axillary artery cannulation. This was not possible in our patient, who had a dialysis shunt on his arm. Moreover, the adhesion between the 3rd and 4th intercostal spaces added to the difficulty of performing a right thoracotomy or using the right parasternal approach.
Several authors have reported AVR through left thoracotomy.2,4 Barreda and colleagues4 described this approach to valve surgery for the treatment of mediastinal displacement after pneumonectomy. Their patient had experienced a severe shift of the mediastinum into the left lung; hence, they could perform aortic valve surgery through a left thoracotomy. In our patient, left thoracotomy was undesirable because of the counterclockwise rotation of the mediastinum through its longitudinal axis.
In order to avoid embolic stroke and lung injury in our patient, we planned to expose the aortic valve through a median sternotomy; however, in order to achieve exposure, the sternum at the 3rd intercostal space had to be partially transected. Then, the 3 spreaders yielded excellent exposure of the ascending aorta and valve. In addition, the relatively central shift of the ascending aorta contributed to the exposure of the right atrium and the right upper pulmonary vein. The surgery was straightforward, and the patient experienced no postoperative respiratory dysfunction or other sequelae.
We conclude that aortic valve surgery with T-shaped sternotomy and without thoracotomy is an alternative technique in a patient who has a secondary deviation after lobectomy.
Address for reprints: Koji Ueyama, MD, PhD, Department of Cardiovascular Surgery, Kitano Hospital, 2-4-20 Ogimachi, Kita-ku, Osaka City, Osaka 530–8480, Japan