A Case of Beating Heart High Risk Aortic Valve Replacement in the Setting of Previous Bypass Graft Surgery

Conventional aortic valve replacement (AVR) surgery has been performed using cardioplegic cardio-respiratory arrest method. However this technique is often challenged when the surgeon is faced with a patient who has undergone previous coronary artery bypass grafting surgery (CABG), poor residual cardiac reserve and multiple comorbidities. Here the surgeon’s technical ability is challenged in performing careful dissection in order to preserve the integrity of the coronary artery grafts and to ensure myocardial protection from ischaemic damage.
Case and Operative Strategy: We present a case of a 76-year-old man with a past history of previous CABG surgery and severe peripheral vascular disease who presented with acute heart failure secondary to severe aortic stenosis requiring urgent AVR. Our safety surgical strategy included preoperative, prophylactic insertion of intra-aortic balloon pump and performing beating heart AVR in the setting of good bilateral arterial conduits and absence of the native coronary circulation. We also performed bi-caval cannulation to allow for potential fallback position of delivering retrograde cardioplegia into the coronary sinus under direct vision in case significant myocardial ischemia was encountered during cross clamping. The patient had an uneventful beating heart AVR surgery and remained asymptomatic on follow-up.
Beating heart AVR can be performed safely in the setting of good bilateral arterial conduits. Careful forward planning by prophylactic insertion of intra-aortic balloon pump and bi-caval cannulation allowing the option of delivering cardioplegia directly into the coronary sinus in case myocardial ischaemia was encountered during cross-clamping, would allow for beating heart AVR to be performed safely.