Preoperative pleural adhesion assessment using respiratory 4D CT for MICS-MVP

Unexpected pleural adhesion can increase operative difficulty and bleeding risk in minimally invasive cardiac surgery (MICS). Accurate preoperative evaluation for pleural adhesion is therefore crucial. Respiratory four-dimensional computed tomography (4D CT) enables visualization of pleural sliding and may help assess adhesion severity. We report a case in which 4D CT contributed to surgical planning for MICS–mitral valve plasty (MICS-MVP). An 80-year-old man was scheduled for MICS-MVP. Static CT suggested pleural thickening and calcification along the dorsal chest wall; however, the extent of adhesion at the anticipated thoracotomy site remained unclear. Respiratory 4D CT was performed, and analysis of the reconstructed dynamic images demonstrated synchronous motion between the dorsal pleura and ribs with red color-coding, indicating severe adhesion. In contrast, anterior–lateral regions showed asynchronous motion with blue-to-green color-coding, suggesting mild adhesion at most. Based on these findings, a right anterior thoracotomy through the 3rd–4th intercostal space was selected. Intraoperatively, only mild adhesion was encountered, and MICS-MVP was completed without complications. Respiratory 4D CT provided valuable information regarding the distribution of pleural adhesion, supporting safe surgical decision-making. This technique may serve as a useful adjunct to static CT for preoperative assessment in MICS.