Mitral re-repair and right coronary fistula closure: advantage of minimally invasive approach.

A 51-year-old man developed severe mitral regurgitation 10 years after previous mitral valve repair; the echocardiographic images showed a remarkable eccentric jet toward posterior wall of left atrium associated with a high degree of pulmonary vein retrograde flow. The coronary arteriography pointed out no pathologic lesions but a coronary fistula from the proximal right coronary to the right atrium. The standard approach was avoided, and a right anterolateral minithoracotomy was chosen, providing an excellent view. Under cardiopulmonary bypass and mild hypothermia, the mitral valve was re-repaired, and a new ring was implanted. After aortic cross-clamp release, the right coronary fistula was closed through the right atrium. The postoperative course was uneventful, and the patient was discharged on the fourth postoperative day. In such a high-risk reintervention and concomitant procedure, we think that this different approach may represent a feasible and reliable alternative.