I had always thought that this pathology required a full sternotomy, until now. This patient has a sinus venosus ASD with drainage of the right superior pulmonary veins into the SVC and a secundum ASD.  A minimally invasive option was proposed. I percutaneously placed a 16 FR arterial cannula into the right IJ after drapping the patient. Femoral  arterial and venous cannulation were also performed in the routine fashion. The incision in the chest is that of a double valve incision. It is a mini-thoracotomy incision  in the 2-3rd ICS and approximately 6cm in length (This is the same exact incision that I use for my mini aortic cases). Once on bypass, I encircled both the SVC and IVC with vessel loops. I also pull the femoral venous cannula into the IVC before snarring both cava’s. As you can see in the pictures, the incision starts over the SVC and extends onto the right atrium.  Once in the atrium, a baffle is created with pericardium, directing the right SPV blood flow into the left atrium via the ASD. Then to avoid stenosis of the SVC a pericardial patch is utilized to close the right atriotomy.  I have enclosed pictures.

I have another case exactly like this in 2 weeks.  I will let you know if I encounter anything different.

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.