CARDIOVASCULAR JOURNAL OF AFRICA • Volume 34, No 1, January–April 2023 AFRICA 57 outcome, decreasing the degree of invasiveness during aortic root surgery allows significantly shortened postoperative rehabilitation, reduces the risk of infectious complications in the surgical wound and improves the patient’s quality of life.4 Therefore, state-of-the-art surgical techniques allow surgeons to perform correction of almost all abnormalities of the thoracic aorta without using the conventional sternotomy approach. At the same time, there are a number of clinical situations when alternative access during aortic root and ascending aorta surgery is a necessity, not a bonus, as it decreases the degree of peri-operative invasiveness. About two-thirds of all the people suffering from MS exhibit chest deformations, such as pectus excavatum or pectus carinatum, which constitute a serious problem for selecting an optimal and safe surgical approach.5 In the case of patients with pectus excavatum, as described in our clinical report, the dislocation of the heart to the left hemithorax and the sternum to the posterior is a factor making surgical access twice as difficult. Conducting a median sternotomy in such cases is associated with a high risk of iatrogenic damage to the cardiac structures, while alternative approaches can limit the surgery-related exposure, which is especially relevant for patients with aortic dissection and vast aneurysms.6 A thorough analysis of surgical risks and anticipated visualisation of the field of operation have defined our choice of using left-sided thoracotomy. Such a surgical approach, combined with peripheral CPB, allowed for extensive visualisation of the aortic root and ascending aortic structures, as well as decreasing the risk of damage to the right heart, which is associated with a median sternotomy. In the case of the second patient with a history of previous surgery (supra-coronary prosthetic replacement of the aorta, significant adhesion combined with pectus excavatum, which significantly complicated the task of safe access to the cardiac structures), left-sided thoracotomy allowed for precise visualisation of the surgical area of operation, not limiting the surgeon in his activities. In addition, with such an approach, it is important to turn off the left lung due to selective intubation of the right main bronchus, ensuring full access to the aortic root without increasing the risk of pulmonary complications. Furthermore, the shortening of the postoperative hospital stay to six days in both patients, as well as an absence of any pulmonary complications, is comparable to the only published case found in the literature, when Turkish colleagues successfully used an upper-median sternotomy combined with left-sided thoracotomy in a MS patient with acute aortic dissection (type A, Stanford).5 It is worth noting that, having reviewed the articles on aortic surgery published in international journals, we found data on the successful use of left-sided thoracotomy for aortic arch and descending aorta surgery, as well as cases of a dextralateral aortic arch combined with a vascular ring.7,8 Despite these limited reports on the satisfactory results of a single-surgery treatment of cardiac abnormalities and chest deformation,6 we assume that such an approach could significantly increase the duration of surgery and the extent of peri-operative injury, thus increasing the risk of haemorrhage and pulmonary complications. Conclusion Left-sided thoracotomy combined with peripheral CPB allows for full-scale and safe visualisation of the aortic root and ascending segment of the aorta in patients with MS and significant pectus excavatum, decreasing the risks of intraoperative damage to the cardiac structures adjacent to the sternum. Also, left thoracotomy can be used not only for patients with MS, but also for patients with aortic arch pathology. Left thoracotomy provides excellent visualisation and does not require thoracoscopic techniques and special equipment. We consider this surgical access reproducible for most surgeons. Fig. 3. Appearance of the patient on the sixth postoperative day. Fig. 4. A. Three-dimensional CT before the operation reveals an aortic root aneurysm. B. Postoperative threedimensional CT shows the success of the procedure.
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