Combined Aortic Valve and Coronary Surgery via Left Anterior Minithoracotomy: Clinical Experience With Sutureless Bioprosthesis

Combined aortic valve replacement (AVR) and coronary artery bypass grafting (CABG) are predominantly performed via full sternotomy. The authors present an innovative sternum-sparing technique using a left anterior minithoracotomy (LAmT) for concomitant AVR and multivessel CABG. In this case, the implantation of a sutureless bioprosthesis facilitated rapid valve replacement and compensated for the limited exposure inherent to minimally invasive approaches. The procedure enabled complete revascularization with a radial artery (RA) sequential graft to the posterior descending and obtuse marginal branches, as well as a left internal mammary artery (LIMA) graft to the left anterior descending artery (LAD). This approach reduces surgical trauma, preserves sternal integrity, and promotes faster recovery. The authors’ clinical experience demonstrates the feasibility and safety of this technique, complementing recent publications on minimally invasive combined AVR and CABG via LAmT (1, 2). 

Surgical Technique

The procedure commenced with endoscopic RA harvesting from the nondominant arm. A left anterior minithoracotomy was performed through the third intercostal space to provide access for both coronary and valvular procedures. 

Cannulation and LIMA Harvesting 

Simultaneously, the right axillary artery was surgically exposed and cannulated using the Seldinger technique, while the femoral vein was cannulated percutaneously under ultrasound guidance. The LIMA was harvested under direct vision in a pedicled fashion, beginning at its bifurcation. Following systemic heparinization, cardiopulmonary bypass (CPB) was initiated. 

Myocardial Protection and Exposure 

The pericardium was opened longitudinally toward the ascending aorta, which was mobilized, separated from the pulmonary artery, and encircled with a tape. A purse-string suture was placed for the insertion of a cardioplegia and venting cannula. A transthoracic cross-clamp was introduced via the second intercostal space, and cold blood cardioplegia was administered into the aortic root. Exposure tapes were positioned around the left pulmonary veins and the inferior vena cava to optimize visualization of the coronary targets. 

Coronary Revascularization (Right Coronary Artery, Obtuse Marginal) 

The posterior descending artery (PDA) was exposed, and a distal anastomosis between the RA and PDA was performed using standard coronary techniques. This configuration allowed the graft to serve as a conduit for intermittent cardioplegia delivery and intraoperative flow assessment. The exposure tapes were then repositioned to reveal the circumflex artery, where a sequential anastomosis of the RA to an obtuse marginal branch was completed. 

Aortic Valve Replacement 

After both distal anastomoses were completed, the apex of the heart was gently displaced into the left pleural cavity to improve access to the ascending aorta. An oblique aortotomy was performed, and several stay sutures were placed to enhance visualization. The calcified native cusps were excised, followed by annular debridement. Annular sizing indicated suitability for a 23 mm sutureless bioprosthesis. Three guiding sutures were placed equidistantly at the nadirs of the native cusps and passed through the sewing ring of the prosthesis. The valve was parachuted into the annulus under counter-traction, secured with snares, and stabilized by balloon inflation to 4.5 ATM for 10 seconds according to manufacturer instructions. After balloon deflation, the delivery system was removed, and the guiding sutures were tied using Cor-Knot devices. The aortotomy was then closed in a two-layer running fashion. 

Final Coronary Revascularization 

Following valve implantation, a LIMA-to-LAD anastomosis was performed. A T-shunt was created between the LIMA and the RA graft to ensure optimal myocardial perfusion and flow distribution. 

Completion 

The cross-clamp was removed, hemostasis was verified, and the patient was successfully weaned from CPB. Intraoperative assessment confirmed satisfactory valve function and graft flow. 

References

1. Demianenko V, Dörge H, Grossmann M, Sellin C. Minimally Invasive Combined Aortic Valve Replacement and Coronary Artery Bypass Grafting Through Left Anterior Minithoracotomy. Innovations. 2025;20(4):419-421. doi:10.1177/15569845251339187.
2. Babliak O, Demianenko V, Babliak D, Marchenko A, Melnyk Y, Stohov O. New approach for combined aortic valve and coronary procedures through the left anterior minithoracotomy. Interdiscip Cardiovasc Thorac Surg. 2024 Jan 2;38(1):ivad214. doi:10.1093/icvts/ivad214. PMID: 38175780; PMCID: PMC10903181.

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