Letter to the Editor | 73 International Cardiovascular Forum Journal 4 (2015) DOI: 10.17987/icfj.v4i0.149 Direct Aortic CoreValve implantation via right anterior thoracotomy in a patient with patent bilateral mammary artery grafts and aortic arch chronic dissection Giuseppe Bruschi, Pasquale Fratto, Paola Colombo, Alberto Barosi, Luca Botta, Stefano Nava, Francesco Soriano, Maria Pia Gagliardone, Claudio Francesco Russo, Silvio Klugmann Cardiology & Cardiac Surgery Department, Niguarda Ca’ Granda Hospital Introduction Transcatheter aortic valve implantation (TAVI) is widely used to treat patients with aortic stenosis who are at increased risk for surgical aortic valve replacement due to multiple comorbidities. Numerous observational clinical studies, national registries 1 and controlled randomized clinical trials 2,3 demonstrated the safety and effectiveness of transcatheter valve implantation. The first access for TAVI was the retrograde approach from the femoral artery, today several choices for access route are available, the subclavian access 4 , the transapical or direct aortic approaches 5,6,7 . Direct aortic trans-catheter aortic valve implantation should be performed via a mini-sternotomy or right thoracotomy, in both cases in patients with patent bilateral mammary artery grafts the procedure should be considered more challenging and careful computed tomography evaluation is needed. We describe the case of a 78 year-old male that underwent retrograde CoreValve direct aortic implantation after two coronary artery bypass grafting operations with bilateral mammary artery grafts and chronic aortic arch dissection. A 78 year-old male (165 cm, 110 Kg) affected by severe aortic stenosis was admitted to our hospital. The patient was affected by severe renal failure, peripheral vascular disease, and severe chronic obstructive pulmonary disease. The patient had previously undergone emergency coronary artery bypass grafting (CABG) in 1993 with saphenous vein grafts. He subsequently underwent eleven different percutaneous coronary interventions (PCIs) on native coronary arteries and saphenous vein grafts. In 2005 the patient underwent re-do emergency CABG with bilateral mammary arteries graft and saphenous vein grafts and subsequently other two PCIs. Echocardiographic evaluation evidenced a severe aortic stenosis with a mean gradient of 45 mmHg; at coronary angiography mammary artery grafts were patent. An ECG-gated multi slides computed tomography (MSCT) was performed and evidenced chronic dissection of aortic arch with extension to the brachiocephalic trunk and left subclavian artery (Figure 1 A). After Heart Team evaluation taking in consideration patient’s prior CABG and comorbidities (Euroscore II: 37.2%; STS score Mortality: 25%) a TAVI was preferred, patient’s written informed consent was obtained. Due to chronic aortic arch dissection and peripheral vasculopathy, a direct aortic access was chosen. On the basis of 3-d CT scan images right mammary artery course was evaluated, entry site on the ascending aorta was selected and right anterior thoracotomy was preferred (Figure 1 B, C), a Medtronic CoreValve 29 mm valve was preferred considering annulus size. The procedure was performed, under general anesthesia, in a hybrid OR by our heart team. A temporary pacing lead was advanced in the right ventricle through the right femoral vein. A right radial access was performed in order to inject directly the right mammary artery and a femoral access was gained to advance a pigtail catheter in the non-coronary cusp. Right anterior thoracotomy was performed in the 2nd intercostal space as evaluated by MSCT, mammary artery graft course was visualized by contrast injection (Figure 1 D). A basal ascending aorta aortography was performed to evaluate location of proximal graft anastomosis before opening the pericardium and to measure the distance between the aortic annulus and ISSN: 2410-2636 © Barcaray Publishing * Corresponding author. E-mail: giuseppe.bruschi@fastwebnet.it Abstract Direct aortic trans-catheter aortic valve implantation is an alternative approach to treat high risk for surgery patients affected by severe aortic stenosis and concomitant peripheral vascular disease. We describe a case of direct aortic CoreValve implantation made via a right anterior thoracotomy in a 78-year-old male affected by severe aortic stenosis and severe peripheral vasculopathy, who previously underwent coronary artery bypass grafting, with patent bilateral mammary artery grafts and chronic aortic arch dissection. Key words: Aortic stenosis; Transcatheter Valve Replacement; Direct Aortic; Aortic Valve Citation: Bruschi G., Fratto P., Colombo P., et. al. Direct Aortic CoreValve implantation via right anterior thoracotomy in a patient with patent bilateral mammary artery grafts and aortic arch chronic dissection. International Cardiovascular Forum Journal. 2015;4:73-74. DOI: 10.17987/icfj.v4i0.149