Simultaneous beating-heart mitral valve replacement and aortic repair following Bentall procedure via double right mini-thoracotomies: a case report

Background: Redo mitral valve surgery by re-sternotomy approach has challenges such as bleeding and organ injury due to adhesion dissection, sternal bone infection, and poor field of view of mitral valve. On the other hand, redo mitral valve surgery via a right mini-thoracotomy approach appears to address these challenges. We successfully performed a double right mini-thoracotomies approach for mitral valve replacement and pseudoaneurysm repair under the beating-heart condition. Herein, we report the effectiveness and the safety of this technique and detailed procedure.

Case presentation: The patient is a 71-year-old man with a history of Bentall procedure using a mechanical valve at another hospital 30 years ago. He developed acute heart failure due to severe mitral valve regurgitation. After medication, he was referred to our department for the purpose of surgery for mitral valve regurgitation. Preoperative transesophageal echocardiography showed extensive degenerative change of the both leaflets and chordae tendineae rupture at the P3 segment. Both left atrium and ventricle dilated, and left ventricle contractility reduced. Aortic mechanical valve had no problem. In addition, preoperative contrast enhanced computed tomography revealed a pseudoaneurysm at the distal anastomotic site of Bentall procedure. We performed mitral valve replacement by mechanical valve and repair of distal anastomotic cite under beating heart condition, utilizing a double right mini-thoracotomies approach for mitral valve and ascending aortic pseudoaneurysm respectively. The postoperative course was uneventful, the patient was discharged without complications.

Conclusion: The right mini-thoracotomies approach efficiently accessed mitral valve and ascending aorta in reoperations, reducing the adhesion dissection risks and ensuring clear exposure. Moreover, concomitant use of beating-heart technique minimized adhesion dissection for aortic cross-clamp, preserved cardiac function.