Subaortic Stenosis Repair Using a Minimally Invasive Approach Via Right Anterior Thoracotomy

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The authors present a case of subaortic stenosis repair in a 47-year-old woman using a minimally invasive approach through the right anterior thoracotomy in the second intercostal space. The patient presented with progressive shortness of breath on minimal exertion. Subaortic stenosis had been known since childhood,  but surgery was postponed. Additionally, uterine fibroids were diagnosed in 2016. 

Preoperative Evaluation 

Transthoracic echocardiography demonstrated a fibrous membrane beneath the aortic valve, restricting leaflet mobility and causing significant left ventricular outflow tract obstruction, with a mean gradient of 35 mm of mercury and a maximum gradient of 75 mm of mercury.  

Whole-body computed tomography (CT) with contrast was performed to plan the minimally invasive strategy. No cardiovascular anomalies were detected; however, large uterine fibroids were noted.  

The surgical plan included: 

1. Right femoral cannulation for cardiopulmonary bypass (CPB) 
2. Right anterior thoracotomy in the second intercostal space 
3. Temporary transaction of the third costal cartilage at the sternal junction 
4. Transthoracic aortic cross-clamp 
5. Cold blood hyperkalemic antegrade cardioplegia via the aortic root 
6. Transverse aortotomy 
7. Excision of subaortic stenosis  

After cross-clamping and transverse aortotomy, standard exposure maneuvers were performed (1). Following the placement of commissural stay sutures, adequate exposure of the aortic valve and left ventricle outflow tract was obtained. It was determined that the aortic valve was tricuspid. A fibrous diaphragm, located approximately 1 cm below the aortic annulus and extending toward the anterior mitral leaflet, was identified. The remnants of the fibrotic diaphragm was bluntly dissected from the right coronary cusp and the anterior leaflet of the mitral valve. Additionally, some abnormal tissue was also excised from the right coronary cusp region. 

A sterile protective cuff was used to safeguard the aortic and mitral valve leaflets, chordae, and papillary muscles while enlarging the working space. The hypertrophic muscle bundles contributing to obstruction were resected. The aortotomy was then closed with a double-layer running suture. Temporary pacing wires were placed on the right ventricle, and VVI pacing at 80 beats pr minute (bpm) was initiated. With stable hemodynamics, the patient was weaned off CPB. The third rib was re-approximated to the sternum with a single wire suture, and one chest drain was placed in the right pleural cavity. 

Postoperative echocardiography demonstrated satisfactory left ventricular outflow trat (LVOT) flow with a residual mean gradient of 7 mm of mercury and a max gradient of 14 mm of mercury.  

Intraoperative Data 

The total operating time was 210 minutes, with CPB time of 101minutes and cross-clamp time of 48 minutes. The postoperative course was uneventful. Drain leakage was observed at 150 ml within the first 12 hours. The patient was discharged home after five days, which included one day spent in the intensive care unit. 

References

1. Babliak O, Babliak D. Surgical Maneuvers for Aortic Valve Exposure Through the Right Anterior Minithoracotomy. Innovations: Technology and Techniques in Cardiothoracic and Vascular Surgery. 2025 Mar 27; Available from: http://dx.doi.org/10.1177/15569845251326546

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