Minimally Invasive Pulmonary Valve Replacement in Reoperative Settings

The authors present a case of reoperative settings using a minimally invasive approach in an 11-year-old girl with a complex congenital heart defect.

The procedure consisted of pulmonary valve replacement via a left anterior minithoracotomy in the second intercostal space, indicated for severe pulmonary valve insufficiency.

The patient was born with a complex congenital heart defect, including pulmonary atresia type I, patent foramen ovale (PFO), ventricular septal defect (VSD), and major aortopulmonary collateral arteries (MAPCAs).

At six months of age, she underwent a single-stage complete anatomical repair, which included unifocalization of MAPCAs, patch closure of the VSD, and right ventricle-to-pulmonary artery reconstruction using a transannular pericardial patch to create a neopulmonary valve. At three years of age, balloon angioplasty of the left pulmonary artery branch was performed.

By the age of 11 years, transthoracic echocardiography revealed dilation of the pulmonary valve annulus up to 19 mm, with a peak transvalvular gradient of 10 mmHg and severe pulmonary regurgitation. A patent foramen ovale persisted. Moderate tricuspid regurgitation was present, with an estimated right ventricular systolic pressure of 40 mmHg. Left ventricular systolic function was preserved, with a normal ejection fraction. The aortic valve demonstrated trivial regurgitation.

Preoperative whole-body contrast-enhanced computed tomography (CT) was performed to plan the minimally invasive strategy.

The surgical plan included:

1. Right femoral cannulation for cardiopulmonary bypass
2. Left anterior thoracotomy in the second intercostal space
3. Longitudinal incision of the main pulmonary artery
4. Pulmonary valve replacement using a bioprosthetic valve
5. Pulmonary artery augmentation with a xenopericardial patch

Following a left anterior minithoracotomy in the second intercostal space, the lung was partially mobilized from the mediastinum. Cardiopulmonary bypass was established via femoral cannulation. The main pulmonary artery was opened longitudinally. Both the right and left pulmonary artery branches accommodated an 11 mm Hegar dilator, consistent with the expected anatomical dimensions.

A 23 mm bioprosthetic valve was implanted in the pulmonary position using a continuous 3-0 Prolene suture. The main pulmonary artery was subsequently augmented with a xenopericardial patch measuring 3 × 1.5 cm.

The postoperative course was uneventful and included one day in the intensive care unit. The patient was discharged home on postoperative day five.

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