Mini-PVR in a Child (Left Anterior Minithoracotomy)

Left anterior minithoracotomy represents a good alternative for pulmonary valve replacement via a minimally invasive technique. This minimal access approach can be performed safely in both primary and repeat operations on the right ventricular outflow tract (RVOT). An important prerequisite is the absence of intracardiac shunts and other concomitant cardiac pathology due to the limitations of the access.

General anesthesia and monitoring are similar to a full sternotomy approach. The patient is positioned supine, prepped, and draped from chin to knees in the standard fashion. The left chest and both groins are marked. Arterial and venous accesses are obtained in both groins (usually the artery on one side and the venous on the other) under ultrasound guidance and a smaller vascular sheath is placed in each vessel so it can be exchanged easily when the need for cardiopulmonary bypass (CPB) comes. An alternative is a cut-down.

The left chest is entered through a 6 cm transverse anterior minithoracotomy along the left third intercostal space. A rib spreader is placed and the left lung is retracted to allow visualization of the pericardium, which is then opened by electrocautery. Pericardial stay sutures are placed.

Once the RVOT is visualized, heparin is administered systemically and the left femoral artery followed by the right femoral veins are cannulated percutaneously using the modified Seldinger technique and under transesophageal echocardiographic guidance. In the current case, the authors used 15 Fr. arterial and 23 Fr. multistage venous cannulae. CPB was initiated without difficulty and the RVOT was decompressed. Stay sutures were placed in the RVOT to facilitate exposure.

Pulmonary arteriotomy is then created and extended to the RVOT, and valve leaflets are excised. The neopulmonary annulus is sized. Using a running 3/0 prolene suture, the neopulmonary prosthesis is secured to the RVOT. In the current case, the authors used a 25 mm bioprosthesis. A bovine pericardial patch is then tailored and used to augment the RVOT. The heart is subsequently de-aired and the patient is ventilated and weaned of CPB without difficulty. 

Post-bypass transesophageal echocardiography demonstrated well-seated prosthesis with no periprosthetic regurgitation.

The femoral venous followed by the femoral arterial cannulae were removed and manual compression on the groin for 45 minutes was maintained to achieve hemostasis during administration of protamine. A single chest drain is placed, and the pericardium is closed partially followed by closure of the incision in layers. 

The patient tolerated the procedure well and was extubated in the operating room and received no transfusions. The rest of the hospital stay was uneventful.

References 

1. Ramman TR, Chowdhuri KR, Raja N, Girotra S, Azad S, Iyer PU, et al. Pulmonary valve replacement in repaired tetralogy of Fallot through limited left anterolateral thoracotomy: an alternative to repeat sternotomy. World J Pediatr Congenit Heart Surg. 2020 May;11(3):346-349.
2. Henaine R, Yoshimura N, Di Filippo S, Ninet J. Pulmonary valve replacement in repaired tetralogy of Fallot by left thoracotomy avoid ascending aorta injury. J Thorac Cardiovasc Surg. 2011;141(2):590-592.

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