Aortic Valve Replacement and Concomitant Right Coronary Artery Bypass Grafting Performed via a Right Minithoracotomy Approach Christos G. Mihos, DO,* Orlando Santana, MD,* Andres M. Pineda, MD,* Angelo La Pietra, MD,Þ and Joseph Lamelas, MDÞ Objective: We present our experience of concomitant right coronary artery bypass grafting (CABG) and aortic valve replacement performed via a right minithoracotomy in patients with coronary lesions not amenable to percutaneous intervention. Methods: A total of 17 patients underwent concomitant aortic valve replacement and right CABG between April 2008 and July 2013. A 5- to 6-cm minithoracotomy incision was made over the right second or third intercostal space, and the costochondral cartilage was transected. A saphenous vein bypass to the right coronary artery was then performed, initiating the anastomosis from the toe of the graft. Subsequently, the aortic valve was replaced using standard techniques. Results: There were 6 men and 11 women. The median European System for Cardiac Operative Risk Evaluation II score mortality risk was 5% [interquartile range (IQR), 2%-8%]. The mean (SD) age was 77 (10) years, the left ventricular ejection fraction was 59% (8%), and the New York Heart Association functional class was 2.4 (0.8). One patient had a history of CABG. The mean (SD) cardiopulmonary bypass time was 168 (57) minutes, and the aortic cross-clamp time was 133 (36) minutes. Three patients underwent concomitant mitral valve surgery (replace- ment, 2; repair, 1). The median intensive care unit and hospital lengths of stay were 47 hours (IQR, 24Y90) and 9 days (IQR, 5Y13), respectively. There was one reoperation for bleeding, and there was one postoperative stroke. All patients were alive at a mean (SD) follow-up of 2 (1.1) years. Conclusions: Aortic valve replacement with concomitant CABG performed via a right minithoracotomy approach is feasible. Key Words: Aortic valve replacement, CABG, Minimally invasive surgery, Minithoracotomy. (Innovations 2014;9:302Y305) V alvular heart disease is an important cause of cardiovas- cular morbidity, with a national prevalence of 8.5% by the sixth decade of life. 1 Approximately, 40% of patients with valvular heart disease are diagnosed with aortic stenosis or regurgitation, and upward of 200,000 aortic valve replacements (AVRs) are performed worldwide each year. 2 Because of overlapping risk factors such as advanced age, hypertension, dyslipidemia, and chronic kidney disease, clinically significant coronary artery disease is a common concurrent diagnosis in patients with aortic valve disease. 3 Thus, when not amenable to percutaneous coronary intervention, it is often necessary to perform combined AVR and coronary artery bypass grafting (CABG) surgery in this population, which, in many series, has been associated with higher risk for morbidity and mortality. 4Y6 First described by Cohn and colleagues 7 as well as Navia and Cosgrove, 8 minimally invasive valve surgery has become an acceptable alternative to conventional sternotomy and has been associated with lower morbidity, shorter hospital lengths of stay, and improved patient satisfaction, particularly among high-risk populations. 7Y14 Furthermore, staged hybrid pro- cedures, in which percutaneous coronary intervention is per- formed for significant coronary artery disease followed by minimally invasive valve surgery, have provided a safe and effective option for patients with concomitant valvular and coronary artery disease, which historically have been a con- traindication to minimally invasive surgery. 15Y17 Patients with concomitant aortic valve and coronary ar- tery disease, who are not candidates for a hybrid procedure, are typically referred for CABG and valve surgery via a conventional median sternotomy approach. However, when approaching aortic valve surgery via a right anterior minithoracotomy, ex- cellent exposure of the right coronary artery (RCA) is routinely obtained. In the present cohort, we examined the safety and the feasibility of a minimally invasive approach to combined aortic valve and single-vessel RCA bypass graft surgery, for patients in whom significant RCA obstructive disease was not amenable to percutaneous coronary intervention. MATERIALS AND METHODS After obtaining approval from the Mount Sinai Medical Center Institutional Review Board, which included waiver of patient consent, we retrospectively reviewed all heart opera- tions performed at our institution between September 2008 and April 2013 to identify patients who underwent concomitant minimally invasive AVR and RCA bypass grafting via a right anterior minithoracotomy approach. All patients had their valvular lesions documented by diagnostic catheterization and echocardiography, and all operative reports and echocardiograms were reviewed. The ORIGINAL ARTICLE 302 Innovations & Volume 9, Number 4, July/August 2014 Accepted for publication December 31, 2013. From the Divisions of *Cardiology, and †Cardiac Surgery, Mount Sinai Heart Institute, Columbia University, Miami Beach, FL USA. Disclosure: The authors declare no conflicts of interest. Address correspondence and reprint requests to Orlando Santana, MD, Echocardiography Laboratory, Division of Cardiology, Mount Sinai Heart Institute, Columbia University, 4300 Alton Rd, Miami Beach, FL 33140 USA. E-mail: osantana@msmc.com. Copyright * 2014 by the International Society for Minimally Invasive Cardiothoracic Surgery ISSN: 1556-9845/14/0904-0302 Copyright © 2014 by the International Society for Minimally Invasive Cardiothoracic Surgery. Unauthorized reproduction of this article is prohibited.