After acquiring a significant amount of experience with redo sternotomy surgery and redo minimally invasive MV surgery, I decided to embark on redo minimally invasive Aortic Valve surgery. I have performed more than 50 of these cases.  Most have been in patients with a patent LIMA +/- patent SVG’s (one was a 3rd time redo with 2 previous CABG’s).  I was always hesitant to operate on patients who had bilateral IMA’s. Well the time came, and I did my first patient with a LIMA to the LAD and a RIMA to the RCA.  The RIMA was never clearly visible , although there was a fibrotic band which I assumed was the RIMA.  So therefore, these patients are candidates for a mini-thoracotomy AVR.

Then came the case which you can see in the enclosed pictures. This patient has a RIMA via the transverse sinus to the first OM.  My concern was whether I could clearly visualize the aorta and then clamp the aorta with the RIMA coursing behind it.   Since it is difficult to see the RIMA, I have enclosed duplicate pictures with one highlighting the RIMA in blue.  In general it is very common to encounter the least amount of adhesions over the greater curvature of the aorta in any redo operation, so therefore I believe that this allows this procedure to be performed via a mini-thoracotomy approach.

When performing a redo mini AVR with a patent LIMA (+/- RIMA), I usually cool the patients to 28C and give continuous cold blood cardioplegia.  I never attempt to identify nor clamp the IMA’s.  I truly believe that the redo mini AVR’s are the most challenging for the surgeon,  but are the subgroup that truly recover quicker.  These are cases that require experience.