A 46-year-old male was referred to the authors’ unit with severe symptomatic pulmonary valve regurgitation, which caused severe right ventricular dilatation. The patient had a history of tetralogy of Fallot repair with a transannular patch performed at the age of three.
The pulmonary annulus was severely dilated (> 40 mm). Therefore, as previously described by the authors, they implanted a bioprosthetic mitral valve instead of a bioprosthetic aortic valve to replace the pulmonary valve. This was necessary because no available bioprosthetic aortic valve was large enough to match the patient’s pulmonary annulus.
Pulmonary valve replacement (PVR) was performed via an L-shaped upper ministernotomy in the second intercostal space. Cardiopulmonary bypass was established between the right femoral vein and the ascending aorta. The procedure was performed on a beating heart, thanks to a negative bubble contrast study. A 31 mm mitral valve was implanted. The diameter of its external sewing ring was 42 mm, which matched the patient’s annulus almost perfectly. The cardiopulmonary bypass time, intubation duration, and hospital stay were 27 minutes, five hours, and six days respectively.
Discussion
In cases of isolated pulmonary valve intervention, there are many advantages to performing a redo ministernotomy.
Compared to a redo full sternotomy, a redo ministernotomy offers the following benefits:
- There is no risk of injury to the right atrium or right ventricle on re-entry.
- The risk of intraoperative oozing, bleeding, and the need for transfusion is decreased.
- There is virtually no risk of postoperative pericardial effusion or tamponade because adhesions facing the atria and ventricles are not dissected.
- Patient satisfaction is high, even with the presence of a previous scar, which is often an unexpected finding in patient feedback.
Compared to a redo left anterior minithoracotomy, a redo ministernotomy provides these advantages:
- It allows for safe and straightforward access to the ascending aorta if cross-clamping is necessary (i.e., residual intracardiac shunt).
- It enables safe and straightforward cannulation of the ascending aorta, allowing for the use of a larger cannula, ensuring forward flow, and eliminating the risk of femoral artery injury.
- It requires no additional incisions or scars.
Limitations
In general, minimally invasive approaches are not appropriate if multiple procedures are indicated, such as PVR combined with tricuspid valve intervention or pacing leads implantation.
This approach should also be avoided if the ascending aorta is positioned very close to the sternum or in cases requiring complex right ventricle-to-pulmonary artery (RV-PA) conduit replacement. In these instances, a redo full sternotomy is preferred.
References
- Soquet J, Loobuyck V, Longere B, Godart F, Vaksmann G, Moussa MD, Juthier F. Pulmonary Valve Replacement and Redo Pulmonary Valve Replacement via Ministernotomy. Heart Lung Circ. 2022 Jan;31(1):e1-e4. doi: 10.1016/j.hlc.2021.09.003. Epub 2021 Sep 30. PMID: 34600813.
- Soquet J, Rajamanickam CS, Hardikar A. Feasibility of minimally invasive pulmonary valve replacement with a novel mitral bioprosthetic valve associated with left atrial appendage resection. JTCVS Tech. 2025 Apr 9;31:72-74. doi: 10.1016/j.xjtc.2025.04.006. PMID: 40641783.
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