Ann Thorac Surg 2006;82:733-735
© 2006 The Society of Thoracic Surgeons
Case report
Valvular Reoperations by Left Thoracotomy in Patients With Pectus Excavatum
Scott A. LeMaire, MDa,b,*,
Roderick G. MacArthur, MDb,
Joseph S. Coselli, MDa,b
a Cardiovascular Surgery Service, Texas Heart Institute at St. Luke's Episcopal Hospital Houston, Texas, USA
b Michael E. DeBakey Department of Surgery, Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Texas
Accepted for publication October 17, 2005.
* Address correspondence to Dr LeMaire, One Baylor Plaza, BCM 390, Houston, TX 77030 (Email: slemaire{at}bcm.tmc.edu).
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Abstract
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Several alternative approaches to the aortic and mitral valves have been reported recently. We describe a left anterior thoracotomy approach for valvular reoperations in 3 patients with Marfan syndrome and severe pectus excavatum.
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Introduction
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In the attempt to develop less invasive approaches for operations on the heart and great vessels, several alternative exposures have been reported recently, including limited upper median sternotomy and right parasternal minithoracotomy. Left thoracotomy is infrequently used for cardiac operations; this approach is usually used for myocardial revascularization and is only rarely used in valve replacement procedures [1–8]. The purpose of this report is to describe left anterior thoracotomy as a valuable approach to valvular reoperations in a unique patient population. In 3 patients with Marfan syndrome (MFS) and severe pectus excavatum, left thoracotomy avoided high-risk repeat sternotomy while providing excellent exposure for valve replacement.
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Case Reports
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A review of our patient database and records for this report, with a waiver of consent, was classified as exempt from formal review by the Institutional Review Board for Baylor College of Medicine and Affiliated Hospitals.
Patient 1
An 18-year-old man with MFS and severe pectus excavatum presented with severe aortic valvular insufficiency 5 years after homograft aortic root replacement. The patient had minimal symptoms attributable to his aortic valve disease, but surgery was recommended because he had progressive left ventricular enlargement (left ventricular end-diastolic dimension, 77 mm) and dysfunction (ejection fraction, 45%). A preoperative computed tomographic scan of the chest revealed dense adherence of the right atrium and ventricle to the posterior table of the sternum, displacement of mediastinal structures into the left chest, and calcification of the previously placed homograft (Fig 1).
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Fig 1. A computed tomographic scan shows severe pectus excavatum and adherence of the right atrium to the posterior table of the sternum.
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Given this anatomy, a left thoracotomy approach was selected to avoid high-risk repeat median sternotomy. General anesthesia with a single-lumen endotracheal tube was established, and the patient was placed supine with the left chest elevated approximately 30 degrees. The thorax was entered through the fifth intercostal space, and the left internal thoracic artery was divided. Pericardial retraction sutures held the left lung outside of the operative field. Exposure of the ascending aorta and aortic root was excellent (Fig 2), and cardiopulmonary bypass was established after left common femoral arterial and venous cannulation. A left atrial vent was placed through the left inferior pulmonary vein. The distal ascending aorta was clamped, and the heart was arrested with antegrade cardioplegia. The aortic root was replaced with a 23-mm St. Jude composite valve graft (St. Jude Medical, Inc, St. Paul, MN). The left main and right coronary buttons were directly reimplanted. The thoracotomy incision was closed in standard fashion.
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Fig 2. (A) Drawing, (B) intraoperative photograph, and (C) another drawing all illustrate the surgical approach to the aortic root at the time of surgery. (Ao = aorta; PA = pulmonary artery; RA = right atrium.)
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Patient 2
A 17-year-old Marfan patient was referred to our institution with symptomatic, severe mitral insufficiency 6 years after having his aortic root replaced with a 21-mm St. Jude composite valve graft. This patient had severe pectus excavatum with displacement of the heart into the left hemithorax. Therefore, a left anterior thoracotomy was used. The left common femoral vein and artery were cannulated for cardiopulmonary bypass. A cannula was placed in the superior vena cava, and a left ventricular sump was placed through the right superior pulmonary vein. The left atrium was very large and facilitated a standard left atriotomy approach to the mitral valve. A 33-mm St. Jude mechanical valve was inserted after the native valve was deemed irreparable.
Patient 3
A 28-year-old woman with MFS presented with severe symptomatic aortic insufficiency after a prior homograft aortic root replacement. A left anterior thoracotomy was used because the patient had severe pectus excavatum with leftward displacement of the heart. Techniques for cannulation and exposure were similar to those used in patient 1. Although the homograft aortic valve was regurgitant, the aortic root was not calcified. The valve leaflets were excised, and the valve was replaced with a 23-mm St. Jude mechanical valve.
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Comment
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We performed 3 valvular reoperations through limited left anterior thoracotomies. Each patient had MFS, severe pectus excavatum, displacement of mediastinal structures into the left chest, and right-sided heart chambers that were adherent to the sternum. Operative exposure was excellent in all 3 patients. All patients did well postoperatively and were discharged from the hospital after a satisfactory recovery.
Although the left thoracotomy was used in the past to access the mitral valve, contemporary reports describing the use of the left thoracotomy approach for valve replacement are rare [1–8]. Three of these reports describe first-time valve replacements in patients who had previously undergone esophageal resection and reconstruction with substernal gastric conduits [2, 3, 5]. Others describe mitral valve replacements with concomitant patent ductus arteriosus ligation [1], left atrioplasty [6], or transmyocardial laser revascularization [4]. Van Nooten and colleagues [8] combined the left anterior thoracotomy with endoluminal balloon occlusion of the aorta as a strategy for approaching mitral valve procedures in patients who had previously undergone coronary artery bypass grafting. The patients in these prior reports did not have pectus deformities, and most were not undergoing aortic valve procedures.
This report highlights the difficulties associated with repeat median sternotomy in patients with chest wall deformities. In patients with pectus excavatum who have not had prior cardiac surgery, we generally perform valve operations through a median sternotomy, which allows concomitant chest wall repair. Circulatory arrest probably would have been required if a median sternotomy approach had been selected in these reoperative cases. Avoiding a high-risk repeat sternotomy is the primary benefit of the left thoracotomy approach; this strategy allowed us to open the chest and divide mediastinal adhesions before heparinization and cardiopulmonary bypass without compromising exposure. It also avoided potentially difficult wound closure. Our patients' chest wall deformities did not cause symptoms significant enough to warrant the increased risk of concomitant pectus repair.
Given MFS patients' lifelong risk of aneurysm formation and dissection, arguments can be made for bioprosthetic valves in this patient population. Nonetheless, each of these 3 patients chose to accept the risks associated with anticoagulation in order to decrease the risk of a third complex valvular procedure; therefore these patients received mechanical valves. We advocate meticulous monitoring of anticoagulation and generally suggest that patients' international normalized ratios be kept in the low therapeutic range.
In conclusion, left anterior thoracotomy is a valuable option for approaching cardiac operations when there are major obstacles to safe sternotomy. This technique should be considered for valvular reoperations in patients with severe pectus excavatum.
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Acknowledgments
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The authors gratefully acknowledge Scott Weldon, MA, for creating the illustrations and Stephen N. Palmer, PhD, ELS, for editorial support.
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References
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- Hughes GC, Donovan CL, Lowe JE, Landolfo KP. Combined TMR and mitral valve replacement via left thoracotomy Ann Thorac Surg 1998;65:1141-1143.[Abstract/Free Full Text]
- Pratt JW, Williams TE, Michler RE, Brown DA. Current indications for left thoracotomy in coronary revascularization and valvular procedures Ann Thorac Surg 2000;70:1366-1370.[Abstract/Free Full Text]
- Serra AJ, McNicholas KW, Lemole GM. Giant left atrium as cause of left pulmonary artery obstruction Ann Thorac Surg 1987;43:329-331.[Abstract]
- Balasundaram SG, Duran C. Surgical approaches to the mitral valve J Card Surg 1990;5:163-169.[Medline]
- Van Nooten G, Van Belleghem Y, Van Overbeke H, et al. Redo mitral surgery using the Estech endoclamp Heart Surg Forum 2001;4:31-33.[Medline]
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Abstract
Introduction
