This is an elderly obese, wheelchair bound patient who had a bleeding disorder and did not qualify for a TAVR.  A CT Scan was performed for TAVR screening.  When she disclosed the bleeding disorder (hyper-coagulable state), she was turned down.  She ultimately had a mini thoracotomy AVR, uneventfully.

I have been told that a contraindication for a mini thoracotomy AVR is if the aorta is displaced to the left side of the chest by CT Scan or lies to the left of an imaginary line drawn from the mid portion of the sternum straight back to the vertebral column.  I believe that this is definitely NOT the case.

The mini AVR in this particular obese patient,  with a “left sided” aorta,  was extremely easy.  I would venture to say that I have had very skinny patients with the aorta lying just underneath the sternum to be the more challenging cases.

I have provided intra operative pictures of the exposure as well as the CT Scan for you to be the judge of this falsely claimed contraindication.

I constantly hear that obese patients are not candidates for Minimally Invasive Surgery.  I truly believe that these are the ones that benefit the most. They ambulate sooner  due to improved chest wall stability. Physical therapy as well as pulmonary toilet is facilitated. In addition, the risk of sternal complications does not exist. I also have heard that the CT scan is essential in determining who is a candidate for a minimally invasive AVR. This is NOT true. I have enclosed a CT scan on a patient that I recently operated upon.( I do not order CT scans, but since she was being evaluated for a TAVR, it was performed).  As you can clearly see, her aorta on the the left side of the chest. Some would say that this is a contraindication. Some even draw a line from the mid portion of the sternum and trace it back to the spine. If the aorta is to the left, then this is an exclusion criteria for a mini AVR. This is absolutely WRONG!!!  In my experience, if the heart is further away from the chest wall, the visualization will be better. I have operated on many very obese patients, and the surgery has been easier than in some very slender patients. 

This is an 83 y/o very obese ,wheelchair bound, O2 dependent female with multiple hematologic problems (which excluded her from being Corevalve candidate) as well as pulmonary issues and an IVC filter which was crossed with the 25 Fr. Biomedicus venous cannula. (FYI, I have been able to cross all but one of 12 Vena cava filters!) who have critical AS.