Transaxillary triple valve surgery and left atrium appendage occlusion

Clinical vignetteWe present the case of a 66-year-old female presenting with severe rheumatic mitral valve stenosis, moderate aortic regurgitation and moderate tricuspid regurgitation.She presented with exertional dyspnea [New York Heart Association (NYHA) functional class II], with a history of previous mitral commissurotomy in 1995; in addition, she had previous episodes of paroxysmal atrial fibrillation. Preoperative evaluation and surgical planningPreoperative transesophageal echocardiography (TEE) demonstrated a preserved left ventricular ejection fraction (LVEF) of 60%, severe mitral stenosis (mean gradient 16 mmHg), moderate aortic regurgitation (vena contracta 5 mm), moderate tricuspid regurgitation with a tricuspid annular diameter of approximately 41 mm, and a dilated left atrium (left atrial volume index 83 mL/m 2 ).A contrast-enhanced computed tomography (CT) angiography confirmed adequate iliofemoral vessel diameters (>6 mm) without severe calcification or tortuosity, making peripheral cannulation safe.CT also confirmed favorable chest wall anatomy and an ascending aorta free from calcifications.After meticulous preoperative imaging evaluation, a minimally invasive approach through a right transaxillary incision was selected to perform triple valve surgery and left atrial appendage occlusion.Based on valvular orientation and distance from the access, the fourth intercostal space was chosen as the best access site.Given the rheumatic morphology of the mitral valve and the history of previous commissurotomy, mitral valve replacement was favored over repair.