Ann Thorac Surg 2008;86:1668-1670. doi:10.1016/j.athoracsur.2008.04.059
© 2008 The Society of Thoracic Surgeons
Case Reports
Aortic Valve Replacement Through Left Thoracotomy After Esophageal Operation
Satoru Wakasa, MD, PhD*,
Tomonori Ooka, MD, PhD,
Suguru Kubota, MD, PhD,
Norihiko Shiiya, MD, PhD,
Toshifumi Murashita, MD, PhD,
Yoshiro Matsui, MD, PhD
Department of Cardiovascular Surgery, Hokkaido University Hospital, Sapporo, Japan
Accepted for publication April 16, 2008.
* Address correspondence to Dr Wakasa, Department of Cardiovascular Surgery, Hokkaido University Hospital, Kita-14, Nishi-5, Kita-ku, Sapporo, 060-8648, Japan (Email: wakasa{at}med.hokudai.ac.jp).
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Abstract
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A 67-year-old man was referred for aortic valve surgery due to aortic valve regurgitation. He underwent an aortic valve replacement through a left thoracotomy, since he had a history of esophageal surgery with substernal gastric tube reconstruction and lymph node dissection through a right thoracotomy 14 years ago. The aortic valve was successfully replaced with excellent visualization using vacuum-assisted venous drainage on a cardiopulmonary bypass. Although exposing the aortic valve through a left thoracotomy is difficult, the application of vacuum-assisted venous drainage helps visualize the aortic valve in this approach.
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Introduction
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Median sternotomy is the standard approach in cardiac operations; it is unsafe in patients who have previously undergone an esophagectomy with substernal gastric tube reconstruction. We report a case of successful aortic valve replacement through a left anterolateral thoracotomy.
A 67-year-old man was referred for treatment of aortic valve regurgitation. He had a history of surgery for esophageal carcinoma with substernal gastric tube reconstruction through a right thoracotomy 14 years ago. He presented with anterior exertional chest pain without angiographically significant lesions in the coronary arteries. A chest roentgenogram showed no pulmonary congestion with a cardiothoracic ratio of 64%. An echocardiogram demonstrated an aortic valve regurgitation of grade III/IV, mild ventricular dilatation with a left ventricular diastolic diameter of 65 mm, and preserved left ventricular systolic function with an ejection fraction of 60%. Computed tomography showed that the ascending aorta was located just beneath the sternum, not on the right side, whereas the gastric tube occupied the right anterolateral space of the ascending aorta and was close to the back surface of the upper and lower parts of the sternum (Fig 1). In addition, a three-dimensional, computed tomographic image clearly demonstrated the gastroepiploic artery running across the sternum, which implicated the risk of injury during a sternotomy (Fig 2). Accordingly, approaching the aortic valve seemed difficult through either a sternotomy or a right thoracotomy, including a right parasternal approach; the latter was also contraindicated due to a history of right thoracotomy with lymph node dissection. Therefore, the operation was performed through a left anterolateral thoracotomy. The patient was placed in a 45° semi-oblique right lateral decubitus position, and the surgeon was on the left side of the patient. The pleural cavity was opened through the fourth intercostal space, with a division of the fourth and fifth costal cartilages. Pericardiotomy was made and the ascending aorta, the pulmonary artery, and the right atrial appendage were revealed, but the gastric tube was not visualized. After general heparinization, a cardiopulmonary bypass was commenced through the right femoral artery and vein. A vent tube was placed through the left atrial appendage into the left atrium. Right heart decompression by vacuum-assisted venous drainage made the aortic root well visible, which simplified the approach (Fig 3). The ascending aorta was clamped, and cardioplegia was administered directly into the left and right coronary ostia after an ordinary horizontal aortotomy. At this point, the surgeon moved to the right side and continued the procedure, because the aortic valve was clearly seen from the patient's right side. Then the aortic valve was removed and replaced with a 23-mm Carpentier-Edwards Perimount valve (Edwards Lifescience, Irvine, CA) without any difficulty, using interrupted pledgeted everting mattress sutures of 2-0 braided polyester. The aortic incision was closed, and the aorta was de-clamped after the air was removed from the left ventricle through an aortic-root-vent tube. The patient was smoothly weaned from the cardiopulmonary bypass. The postoperative course was uneventful.
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Fig 1. Chest computed tomography displaying relationship among the ascending aorta (Ao), the sternum (St), the gastric tube (GT), and the gastroepiploic artery (GEA) at the level of the (A) upper, (B) middle, and (C) lower sternum.
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Fig 2. Three-dimensional image demonstrates gastroepiploic artery (GEA) running across the sternum. (Ao = aorta; GT = gastric tube.)
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Fig 3. Surgical view of aortic root through the left anterolateral thoracotomy after establishment of cardiopulmonary bypass with vacuum-assisted venous drainage. (Ao = ascending aorta; RV = right ventricle.)
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Comment
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Approaches to the aortic valve in patients with a history of esophageal surgery with substernal gastric tube reconstruction remain challenging. To avoid injury to the reconstructed substernal tube and the surrounding tissues, a route to approach the aortic valve must be selected, depending on the situation of each case, such as a history of thoracotomy, concomitant procedure, or previous cardiac operation. Several authors have reported their techniques of approach including standard sternotomy [1, 2], right thoracotomy [3], right parasternal incision [4, 5], and left thoracotomy [6, 7].
A left thoracotomy approach to the aortic valve contains technical difficulties, such as obstruction by the main pulmonary artery and the right ventricular outflow tract, and the direction of the aortic valve faces the right side of the patient. Hirose and colleagues [6] first reported a successful aortic valve replacement through a left thoracotomy after an esophageal operation. They opened the fourth intercostal space and established a cardiopulmonary bypass through the right femoral artery and vein as we did. In addition to the insertion of another drainage cannula into the right atrium by the right atrial appendage to acquire adequate venous drainage, they divided both the ascending aorta and the main pulmonary artery and then retracted them using reinforced stay sutures to visualize the aortic valve. Takahara and colleagues [7] also published their technique using the same approach, in which they required neither division of the two great arteries nor particular retraction sutures. In our case, although we were even prepared to divide both great arteries, we obtained excellent exposure of the aortic valve using vacuum-assisted venous drainage, which permitted adequate right heart decompression without additional drainage through the right atrial appendage. Indeed, the relatively central location of the ascending aorta may contribute to the exposure.
Although the techniques required for visualization of the aortic valve through a left thoracotomy might depend on a variety of cases, successful venous drainage is one essential factor. Utilization not only of the additional drainage by right atrial appendage or the division of the great arteries, or both, but also the vacuum-assisted venous drainage could encourage performance of aortic valve replacement or even another type of cardiac operation through the left thoracotomy in patients under particular conditions.
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References
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- Matsuda H, Okada M, Yamashita C, Sugimoto T, Watanabe Y. Aortic valve replacement after retrosternal gastric tube reconstruction for esophageal cancer Jpn J Thorac Cardiovasc Surg 1999;47:234-236.[Medline]
- Tobinaga S, Tayama K, Kawano H, et al. Aortic valve replacement after esophagectomy with substernal gastric tube reconstruction Ann Thorac Cardiovasc Surg 2006;12:213-215.[Medline]
- Rao PN, Kumar AS. Aortic valve replacement through right thoracotomy Tex Heart Inst J 1993;20:307-308.[Medline]
- Gillinov AM, Casselman FP, Cosgrove 3rd DM. Aortic valve replacement after substernal colon interposition Ann Thorac Surg 1999;67:838-839.[Abstract/Free Full Text]
- Mazzitelli D, Bedda W, Petrova D, Lange R. Right parasternal approach for aortic valve replacement after retrosternal gastropexy Eur J Cardiothorac Surg 2004;25:290-292.[Abstract/Free Full Text]
- Hirose H, Umeda S, Mori Y, Murakawa S, Azuma K, Hashimoto T. Another approach for aortic valve replacement through left thoracotomy Ann Thorac Surg 1994;58:884-886.[Abstract/Free Full Text]
- Takahara Y, Sudo Y, Nakazima N. Aortic valve replacement via left thoracotomy after an esophageal operation Ann Thorac Surg 1997;63:225-227.[Abstract/Free Full Text]
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Abstract
Introduction
