Fifth Sternotomy for Triple Valve Replacement via Combined Extended Manouguian and Guiraudon Vertical Transseptal Approach

This is the case of a 65-year-old woman who presented with exertional dyspnea, fatigue, and a long history of chronic hemolytic anemia. She had a complex cardiac surgical history with four previous sternotomies to address mitral valve (MV) pathology. The patient had three previous MV replacements with mechanical prostheses (St. Jude twice and Starr Edwards once). She also had previous repair of periprosthetic mitral regurgitation and tricuspid DeVega annuloplasty. Due to recurrent periprosthetic mitral regurgitation, transcatheter device closure was attempted but was unsuccessful. Other significant medical history included: rheumatic fever at age 16, chronic atrial fibrillation, hypertension, pectus excavatum, and chronic hepatitis C.

Preoperative studies included routine chest X-ray, CT scan, echocardiography, and hemodynamic cardiac catheterization. Major findings were cardiomegaly, with severely dilated left atrium, severe mitral annular calcifications (MAC), aortic arch calcifications with close proximity of both innominate vein and ascending aorta to the back of the sternum, severe periprosthetic mitral regurgitation, combined aortic valve (AV) regurgitation and stenosis, and recurrent severe tricuspid valve (TV) regurgitation. On hemodynamic catheterization, there were markedly elevated right-sided pressure with elevated pulmonary vascular resistance, which responded favorably to oxygen and sodium nitroprusside.

The procedure was performed through a fifth time sternotomy, with right axillary artery cannulation. Using a combined extended Manouguian posterior aortic root enlargement and Guiraudon extended vertical transseptal approaches, the authors were able to have adequate exposure to explant the previously placed Starr-Edwards prothesis, decalcify the posterior mitral annulus, enlarge both aortic and mitral valves annuli, and place adequate size mechanical aortic and mitral prostheses (25 mm and 29 mm St. Jude mechanical prostheses). A concomitant tricuspid valve replacement was also performed using a leaflet-sparing approach and a 29 mm St. Jude Epic Bioprosthesis was placed.

The postoperative course was uneventful. Delayed sternal closure was performed 48 hours later. She was discharged home two weeks later and did not require pacemaker placement. Follow-up echocardiography demonstrated well-functioning prostheses with single digit gradient across all prostheses. She continued to do well at her last follow-up.

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