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Case Report *Corresponding author

Louay M. Habbab, McMaster University, Hamilton General Hospital, McMaster Clinic, 237 Barton Street Minimally Invasive Mitral East, Room 604, Hamilton, ON L8L 2X2, Canada, Tel: 1 (905) 521-2100; Email: Valve Repair Through Right Submitted: 08 July 2016 Accepted: 08 August 2016 Mini-Thoracotomy in a High Published: 09 August 2016 Copyright © 2016 Habbab et al.

Risk Patient with Previous OPEN ACCESS Aortocoronary Bypass Surgery Keywords • Minimally invasive • Mitral valve and Patent Grafts: A Case • Mini-thoracotomy • Redo surgery Presentation and Literature • CABG Review Louay M. Habbab* and F. Victor Chu Division of Cardiac Surgery, McMaster University, Canada

Abstract Redo mitral valve (MV) surgery via sternotomy in the presence of dense adhesions can be associated with significant complications:including injuries to the heart:great vessels and patent coronary artery grafts:that can increase morbidity and mortality. Although less likely to occur during minimally invasive MV surgery:adhesion-related injuries can be more difficult to repair because of limited surgical field. We report an 88-year-old obese male patient with sleep apnea and previous coronary artery bypass graft (CABG) surgery who presented with severe mitral regurgitation and patent grafts. He underwent minimally invasive mitral valve repair (MVr) through right mini-thoracotomy (RMT) under direct vision:during which the patent right coronary artery (RCA) graft the right atrial appendage and the aorta were injured and subsequently successfully repaired in a systematic fashion that did not preclude an adequate repair of the MV. We also summarize the results of reported redo MV surgery through RMT studies that included patients with previous CABG surgery to demonstrate that the performance of this procedure in a very elderly patient with multiple risk factors for redo cardiac surgery:not included in these studies:is challenging yet possible.

ABBREVIATIONS adhesion-related injuries during minimally invasive MV surgery

MV: Mitral Valve; CABG: Coronary Artery Bypass Graft; MVR: recognition of such complications is very important to prevent Mitral Valve Repair; RCA: Right Coronary Artery; P1: Lateral catastrophiccan be very difficult outcomes:especially because of the small in highincision. risk In patients.addition:quick We describe the management of adhesion-related injuries that Scallop Of Posterior Mitral Valve Leaflet; P2:Central Scallops Of occurred during minimally invasive MVr through RMT under PosteriorINTRODUCTION Mitral Valve Leaflet direct vision in an 88-year-old obese patient with previous aortocoronary bypass surgery and patent grafts:demonstrating As patients continue to live longer following cardiac surgery that the performance of this procedure in patients with multiple the number of patients with indications for redo surgery will risk factors for redo cardiac surgery is very challenging yet increase worldwide. Redo cardiac surgery represents a clinical possible. challenge due to an increased rate of perioperative morbidity and mortality especially in patients with other co-morbid conditions CASE PRESENTATION [1-4]. An 88-year-old male:known to have hypertension and Minimally invasive surgical approach through a RMT sleep apnea using continuous positive airway pressure represents a standard and valid alternative to a redo MV surgery by providing excellent exposure with less risk from re-entry had developed shortness of breath and visited the clinic for associated complications [5-10]. Nevertheless, the repair of checkups.device:who Upon underwent examination:he five graft wasCABG obese surgery with 10 ayears body before mass

Cite this article: Habbab LM, Chu FV (2016) Minimally Invasive Mitral Valve Repair Through Right Mini-Thoracotomy in a High Risk Patient with Previous Aortocoronary Bypass Surgery and Patent Grafts: A Case Presentation and Literature Review. J Cardiol Clin Res 4(4): 1070. Habbab et al. (2016) Email:

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Central Bringing Excellence in Open Access index of 35.6 and a loud systolic murmur was noted at the apical sinus rhythm by one cardio version. After that a saphenous area. Electrocardiogram showed normal sinus rhythm with left bundle branch block. Echocardiogram demonstrated normal anastomosed proximally onto the ascending aorta and distally to left ventricular size and function with an ejection fraction of 55- thevein end was of harvestedthe existing from RCA the vein right graft upper in an thighend-to- and end was fashion first

Afterwards the patient was weaned off cardiopulmonary bypass right60%: ventricle:flail central biatrial (P2) enlargement:scallops of posterior mild tricuspid mitral regurgitation valve leaflet using running 7-0 Prolene sutures and an excellent flow achieved. andcausing pulmonary severe eccentric hypertension mitral with regurgitation a pulmonary (Figure artery 1): systolicdilated in place. Protamine was given:all cannulae were removed and hemostasiswithout any wasdifficulty. secured The anddrain the and mediastinum temporary wires was irrigated.were left The thoracotomy was closed using interrupted heavy vicryl pressure of 52 mmHg. Coronary angiography demonstrated that sutures and skin and subcutaneous tissue were closed using all bypass grafts were patent (Figure 2). Calculated EuroSCORE running sutures. Transesophageal echo showed no residual II wasWritten 6.95%. informed consent was obtained from the patient and his family and the patient was taken to the operating room the MV and well preserved left and right ventricular function. for a corrective surgery. The patient was intubated with a Themitral patient regurgitation tolerated and the less procedure than 2 wellmmHg and of was gradient transferred across double-lumen endotracheal tube and was positioned in a supine position with the right side of the chest slightly elevated with the right arm above the head. A right lateral mini thoracotomy back to the Cardiac Intensive Care Unit in a stable condition. was performed and the right pleural space was entered via the Before discharge:transthoracic echo confirmed that the MV was fourth intercostal space. Dissection was carried out to free the DISCUSSIONcompletely competent (Figure 3). pericardium from severe adhesion in the anterior portion of the right atrium. The right femoral vein and artery were exposed invasive mitral surgery through RMT has emerged as a good alternativeSince its to firstthe conventional introduction full in sternotomy the mid-1990s:minimally approach with cannulaand the the Seldinger femoral technique vein with a under 30/33 direct two-stage vision femoral was usedvenous to similar perioperative outcome and favorable resource-related cannulacannulate and the cardiopulmonary femoral artery withbypass a 21was French initiated femoral after systemic arterial outcomes [11-14]. Recently:outcomes of minimally invasive mitral surgery in high risk patients were studied in relation to heparinization. The patient was then cooled towards 25 and the acceptable early and long-term results:indicating that minimally EuroSCORE II [15]. Patients with EuroSCORE II ≥ 6 - <9% had dissectionheart actually was fibrillated carried outat 24 to and gain the better rest of exposure. the procedure The RCAwas invasive mitral surgery may be considered as an at least graftperformed was severely under fibrillatory adherent to arrest the pericardium without cross and clamp. right Furtheratrium. Because of dense adhesions:attempt to free this graft from the equivalent alternative to standard sternotomy in these patients. surrounding tissue was unsuccessful and resulted in injuring the henceHowever:patients maybe potentially with EuroSCORE candidates for II ≥ alternative 9% showed procedures a high right atrial appendage. Again:right atrial appendage was further operative mortality and significantly reduced survival time:and adherent underneath to the aorta:which was injured during the such as catheter-based interventions. attempted repair of the right atrial appendage. The aorta was A redo cardiac surgery:particularly for the MV position is generally associated with a higher risk of morbidity and and the right atrium was repaired with multiple 3-0 prolene pledgetedfirst repaired sutures with as interruptedwell. During 3-0this proleneprocess and pledgeted because sutures of the to major vascular structures or patent coronary grafts during severe adhesions the RCA vein graft was injured and it was felt sternalmortality reentry: than the especially first operation in the mainly presence due to risk of extensive of injury that it is not feasible to free the vein graft from the surrounding pericardial adhesions [1-3]. Also previously implanted aortic tissue without causing further damage to the atrial and aortic valve prosthesis can make the exposure of the MV through tissue. Therefore:the proximal end of the vein graft was ligated years:as well as:other co-morbid conditions such as congestive proceeded with MVr portion of the surgery. CO hearta sternotomy failure:chronic particularly kidney difficult disease:diabetes [3]. In addition:age mellitus:chronic >80 to be repaired by an interposition graft eventually. We first initiated. The left atrium was entered via the intra-atrial2 groove lung disease and morbid obesity can further increase the rate and the MV and its subvalvular apparatus were insufflation inspected. wasThe of perioperative morbidity and mortality in these patients [4]. Several studies have documented the utility and highlighted its valve a myxomatous-type with prolapsed lateral (P1) scallops of 10]. andposterior were mitralreapproximated valve leaflet with and multiple P2 causing interrupted severe regurgitation. 4-0 Tycron advantages in reoperative mitral valve procedures (Table 1) [5- sutures.Both P1and At thisP2 were stage first the repaired regurgitation by a quadrangular was only central resection and Onnasch et al. reported 39 series of patients who underwent the MV became completely competent after inserting a 32 mm theredo 11 MV patients surgery with through prior a RMT CABG using the operationthe port-access was performed technique and videoscopic assistance and femoro-femoral cannulation. In de-airingCE Physio the 2 left annuloplasty atriotomy was ring closed (Edwards using Lifesciences:running 3-0 prolene Irvine: suturesCalifornia) and using the patienta total ofwas ten rewarmed 2-0 Tycron towards mattress 34 sutures. and further After authors demonstrated in this study that redo MV surgery can beusing performed deep hypothermia safely using a and RMT ventricular in patients fibrillation. with a previous The sternotomy with a mortality of 5.1% [5]. Similarly:Thompson rewarming was continuing. At this stage the patient defibrillated himself into atrial fibrillation rhythm which was converted to and colleagues reported 125 patients (mean age 63 range: 30– J Cardiol Clin Res 4(4): 1070 (2016) 2/5 Habbab et al. (2016) Email:

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Table 1: Main data of the reported studies of minimally invasive redo mitral valve surgery through right mini-thoracotomy in patients with previous CABG. In- CABG in Type of hospital/ Patients Mean age previous surgery Author Year 30-day Conclusion surgery MVr/MVR mortality (n) (years) (%) (% / %) Re-operative MV surgery can be performed safely Onnasch et al. 5.1(%) using a right mini-thoracotomy in patients with a previous sternotomy. 2001 39 59 ± 13 28.2 51/49 MVR via a right thoracotomy on beating heart 63 under normothermic bypass offers a safe Thompson et al. 16.6 0/100 6.4 alternative to redo median sternotomy in this high- 2003 125 (range: risk group. 30–80) Right video-assisted minimal access correction 45/50 of atrioventricular valve disease after previous Casselman et al. 80 3.8 cardiac surgery is not only feasible but had lower 2007 65 ± 12 29.0 than predicted mortality. (TVR 5%) Right-sided lateral minithoracotomy approach

a MV procedure after a previous cardiac Seeburger et al. 181 51 60/40 6.6 operation:particularlyis a useful alternative for in patients withrequiring patent 64.5 ± 12 2009 coronary bypass grafts or previous aortic valve replacement. Minimally invasive right thoracotomy without aortic cross-clamping is safe and effective Umakanthan et al. 73 in reducing operative mortality in patients 2010 90 66 ± 9 11/89 2 undergoing reoperative cardiac surgery.

right thoracotomy to treat mitral pathology while Confirmed the effectiveness of minimally invasive Arcidi et al. 167 71 3.0 and cardioplegic arrest methods were found to be avoiding reoperative sternotomy risk. Fibrillatory 2012 66.9 ± 9 62/38 safe myocardial preservation strategies with this approach. Redo right thoracotomy mitral valve surgery on the beating heart is associated with shorter Romano et al. 450 74.7 65/35

2012 63 ± 15 6.9 postoperative ventilation:and lower mortality. bypass time:less transfusion requirements:shorter Abbreviations: CABG: Coronary Artery Bypass Graft; MV: Mitral Valve; Mvr: Mitral Valve Repair; MVR: Mitral Valve Replacement; TVR: Tricuspid Valve Replacement

and endoaortic clamping were routinely used. Procedures operations. Twenty-two had also undergone previous CABG. The operation80 years) waswho carried had undergone out on a beating previous heart minimally using normothermic invasive MV included MVr (45%):replacement (50%) and tricuspid valve achieved via the femoral artery or ascending aorta and venous 181replacement consecutive (5%) minimallywith a total invasiveoperative MV mortality operations:though of 3.8% [7]. drainagebypass without with bi-cavalcross-clamping cannulae. the aorta.Complication Arterial rates inflow were was RMTBetween with March femoral 1999 cannulation to January 2008, for cardiopulmonary Seeburger et al. performed bypass:in

cardiac surgery. Previous CABG was reported in 51% of these low: pleuro-pulmonary: 30 patients (24%): re-operation for patients (mean age 64.5 ± 12 years) who had undergone previous authorsbleeding:four concluded patients that (3.2%) mitral andprosthetic cerebrovascular replacement accident: via a right two thoracotomypatients (1.6%). on beatingEight patients heart under (6.4%) normothermic died within bypass30 days. offers The cases. MVr was performed in 109 patients and MV replacement a safe alternative to redo median sternotomy in this group with in 72. Operations were performed during ventricular fibrillation wasin 140 6.6% (77%):transthoracic and it was concluded aortic that cross-clampRMT approach in is 31 a (17%)useful later:Casselman et al. showed that right video-assisted minimal and beating heart in 10 patients (6%). Perioperative mortality accesslow complication correction ratesof atrioventricular and perioperative valve mortality disease after[6]. Few previous years previous cardiac operation particularly in patients with patent cardiac surgery is not only feasible but had lower than predicted coronaryalternative bypass for patients grafts or requiring previous a aortic MV procedure valve replacement after a underwent reoperative surgery using a video-assisted approach mortality. They studied 80 adults (mean age 65 ± 12 years) who [3]. Also Umakanthan et al. performed 90 consecutive minimally hadinvasive undergone MV operations previous viacardiac right surgery:including thoracotomy:between 73% as January CABG. without rib spreading. Previous CABG was performed in 29% of 2006 and August 2008 in patients (mean age 66 ± 9 years) who these patients. Mean preoperative Euroscore was 9.0 ± 2.7 and predicted mortality was 16.0 ± 14.2%. Femoral vessel cannulation Of these patients:89% underwent MV replacement and 11% J Cardiol Clin Res 4(4): 1070 (2016) 3/5 Habbab et al. (2016) Email:

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Central Bringing Excellence in Open Access through axillary:femoral:or direct aortic cannulation and the MVr with fibrillation. Cardiopulmonary bypass was instituted andoperative effective mortality alternative was to 2%. conventional The findings redo-sternotomy demonstrated for that re- operativesurgery through MV surgery a right [8]. thoracotomy with fibrillation is a safe

andArcidi peripheral et al. reported cannulation their for fifteen-year reoperations experience involving (from the June MV 1996 to April 2010) with minimally invasive right thoracotomy in 167 patients (mean age 66.9 ± 9 years):71% of whom had Figure 3 proceduresundergone previouswere performed CABG. Fibrillatory with robotic arrest assistance. was used Thirty-day in 77% and aortic clamping and root cardioplegia in 23%. Nineteen completely Postoperative competent repaired transthoracic mitral valve. echocardiographic image (A) Abbreviations:and Color Doppler LA: Left image Atrium; (B):recorded LV:Left Ventricle. during systole (*):showing mortality was 3.0% and from 2005-2010 that was decreased

minimally invasive right thoracotomy to treat mitral pathology whileto no avoiding mortalities. reoperative These results sternotomy confirmed risk: as the well effectiveness as: the safety of

period:Romanoof fibrillatory and and cardioplegic colleagues reviewed arrest methods the outcomes as myocardial of 450 preservation strategies with this approach [9]. During the same

patients (mean age 63 ± 15 years) who underwent redo MV 316surgery patients via aunderwent RMT from beating 1996 toheart 2011. surgery. Of these:134 74.7 % patientsof these underwent redo MV surgery with ventricular fibrillation:and Figure 1 Preoperative transesophageal echocardiographic image patients had undergone CABG. Although the 30-day mortality was

tricuspid(A):recorded regurgitation. during systole (*):showing prolapse of P2 (arrow) and similar for both (6.9% for beating heart and 7.4% for ventricular Color Doppler image (B) showing sever mitral regurgitation and mild ventilation.fibrillation):the The beating authors heart concluded surgery that was reoperative associated withMV surgeryshorter bypass time:less transfusion requirements:shorter postoperative Abbreviations: LA: Left Atrium; LV: Left Ventricle; P2: Central Scallops via a right thoracotomy on the beating heart is a safe effective and of Posterior Mitral Valve Leaflet; RA: Right Atrium; RV: Right Ventricle reliable procedure [10]. The results of these studies demonstrated that minimally invasive redo MV surgery through a RMT could be safely performed with a low incidence of major vascular injury and perioperative mortality. Also they documented the utility and highlighted the advantages of this approach in reoperative mitral valve procedures. The right thoracotomy was highly suitable to

exposure to the MV which could be easily approached in all cases. observe valve pathology and function and facilitated efficient enter the right atrium for additional right heart procedures such In addition:through the same approach it was also possible to

as tricuspid valve repair/replacement:atrial fibrillation ablation or atrial septal defect or patent foramen ovale closure [9,10]. demonstrating that minimally invasive MVr through RMT under directIn thisvision case could presentation be performed we addedin a high to theserisk patient advantages for redo by cardiac surgery. The patient in our report had an EuroSCORE

II of 6.95% with multiple risk factors for redo cardiac surgery graftincluding CABG age 10 years of 88 before years (olderwith patent than grafts patients [11-15]. included These in risk the factorsprevious and studies):obesity the extensive adhesions with sleep put apnea the patient and history in a high of risk five Figure 2 Coronary angiography demonstrating patent bypass grafts category for redo cardiac surgery. The occurrence of adhesion- related injuries during the minimally invasive MVr via RMT in coronary arteries. to right (A): intermediate (B): diagonal (C) and obtuse marginal (D) our patient was recognized and dealt with quickly as detailed J Cardiol Clin Res 4(4): 1070 (2016) 4/5 Habbab et al. (2016) Email:

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Central Bringing Excellence in Open Access in the report. This demonstrates that the performance of this SS,Thompson A,et al. Minimally invasive right lateral thoracotomy procedure in patients with multiple risk factors for redo cardiac without aortic cross-clamping, an attractive alternative to repeat possible. sternotomy for reoperative mitral valve surgery. J Heart Valve Dis. surgery and a EuroSCORE II ≥ 6 - <9% is very challenging yet 2010; 19: 236-243. REFERENCES 9. Arcidi JM Jr,Rodriguez E,Elbeery JR,Nifong LW,Efird JT,Chitwood WR 1. Jr. Fifteen-year experience with minimally invasive approach for . Morales D,Williams E, John R. Is resternotomy in cardiac surgery still a reoperations involving the mitral valve. J Thorac Cardiovasc Surg. 10. 2012; 143:1062-1068. problem? Interact Cardiovasc Thorac Surg. 2010; 11: 277-286 right thoracotomy for reoperative mitral valve surgery, a safe and 2. Botta L, Cannata A, Fratto P,Bruschi G,Trunfio S,Maneggia C,et al. The Romano MA,Haft JW,Pagani FD,Bolling SF. Beating heart surgery via role of the minimally invasive beating heart technique in reoperative 3. valve surgery. J Card Surg. 2012; 27: 24-28. effective operative alternative. J Thorac Cardiovasc Surg. 2012; 144: Minimally invasive mitral valve surgery after previous sternotomy, 11. 334-339. Seeburger J, Borger MA, Falk V, Passage J, Walther T, Doll N, et al. Ward AF,Grossi6 EA,Galloway AC. Minimally invasive mitral surgery 4. experience in 181 patients. Ann Thorac Surg. 2009; 87: 709-714. through right mini-thoracotomy under direct vision. J Thorac Dis. 2013; 5: 673- 79. O’Brien SM,Shahian DM, Filardo G, Ferraris VA, Haan CK, Rich JB, et al. The Society of Thoracic Surgeons 2008 cardiac surgery risk models, 12. Mariscalco G,Musumeci F. The minithoracotomy approach, a safe and 5. part 2--isolated valve surgery. Ann Thorac Surg. 2009; 88: 23-42. effective alternative for heart valve surgery. Ann Thorac Surg. 2014; Minimally invasive approach for redo mitral valve surgery, a true 13. 97:Sü 356-364. Onnasch JF,Schneider F,Falk V,Walther T,Gummert J and Mohr FW. ndermann SH,Sromicki J,Rodriguez Cetina Biefer H,Seifert B,Holubec 6. benefit for the patient. J Card Surg. 2001;17:14-19. T,Falk V, et al. Mitral valve surgery, right lateral minithoracotomy or sternotomy? A systematic review and meta-analysis. J Thorac Thompson MJ,Behranwala A,Campanella C,Walker WS,Cameron EW. 14. Cardiovasc Surg. 2014; 148: 1989-1995. Immediate and longterm results of mitral prosthetic replacement invasive mitral valve surgery via minithoracotomy and direct using a right thoracotomy beating heart technique. Eur J Cardiothorac Nezafati MH,Nezafati P,Hosseinzadeh M,Tehrani SO. Minimally 7. Surg. 2003; 24: 47-51. 15. cannulation. Asian Cardiovasc Thorac Ann. 2015; 23: 271-274. Casselman FP,La Meir M,Jeanmart H,Mazzarro E,Coddens J,Van Praet R, et al. Minimally invasive mitral valve surgery in high-risk patients, F,et al. Endoscopic mitral and tricuspid valve surgery after previous Moscarelli M, Cerillo A, Athanasiou T, Farneti P, Bianchi G, Margaryan 8. cardiacUmakanthan surgery. R,PetracekCirculation. 2007; MR,Leacche 116: 270-275. M,Solenkova NV,Eagle 761. operating outside the boxplot. Interact Cardiovasc Thorac Surg. 2016; 22: 756-

Cite this article Habbab LM, Chu FV (2016) Minimally Invasive Mitral Valve Repair Through Right Mini-Thoracotomy in a High Risk Patient with Previous Aortocoronary Bypass Surgery and Patent Grafts: A Case Presentation and Literature Review. J Cardiol Clin Res 4(4): 1070.

J Cardiol Clin Res 4(4): 1070 (2016) 5/5