A 76-year-old man presenting with severe AS was admitted to our hospital for investigation of a nodular shadow in the right upper lobe of the lung on computed tomography (CT) (Fig. 1A). Histopathological analysis by transbronchial biopsies demonstrated adenocarcinoma. Echocardiography showed a heavily calcified type 0 bicuspid aortic valve and severe AS with an orifice area, peak velocity, mean pressure gradient, and left ventricular ejection fraction of 0.59 cm2, 4.2 m/s, 47 mmHg, and 79%, respectively. Given the decreased potential risk of tumor metastasis and early recovery to normal work, a one-stage procedure was desirable. However, transcatheter aortic valve implantation (TAVI) was unsuitable due to severe calcifications around the aortic root and annulus, which included a relatively high potential risk of aortic root rupture (Fig. 1B). We considered that ND1b lymph node dissection would be enough because LC stage was relatively early. Therefore, we planned to perform concomitant MICS-AVR and right upper lobectomy through the same incision.
After general anesthesia and double-lumen tube intubation, the patient was placed in the left decubitus position. This concomitant surgery was performed using usual instruments by which we use MICS-AVR and VATS procedure. A 7.5-cm skin incision was made at the lateral edge of the pectoralis major muscle along the anterior axillary line, and a right lateral mini-thoracotomy was performed through the fourth intercostal space. A videoscope was inserted through the port at the fourth intercostal space on the midaxillary line. Cardiopulmonary bypass (CPB) was established via the right femoral artery and vein (19- and 25-Fr cannulas). Cold blood cardioplegia was administered antegrade for the first time and selective for the second and subsequent times. Aortotomy was performed 2 cm above the right coronary artery. The aortic valve was bicuspid, with severe calcifications (Fig. 2A). After removal of the valve, AVR was performed using a 23-mm Mosaic Ultra aortic valve (Medtronic, MN, USA). This valve was implanted in the supra-annular position with 15 pledgeted mattress sutures. The patient was easily weaned from CPB, and protamine was systemically administrated.
Subsequently, with the insertion of two additional ports for VATS, a right upper lobectomy was performed using a GIA (Covidien Inc., MA, USA). The pulmonary vein and artery were cut. The upper lobe bronchus was divided using a GIA (Fig. 2B). The right upper lobe and some lymph nodes (ND1b) were resected. The total operating time, CPB time, and MICS-AVR time were 513, 193, and 127 min, respectively. The postoperative blood loss was 1020 ml.
Postoperative histopathological analysis revealed adenocarcinoma with no lymph node metastases. The pathological stage was T1bN0M0 stage IA2. The postoperative course was uneventful. The intensive care unit stay and hospital stay were 1 and 12 days, respectively. He returned to normal work 24 days postoperatively.