CT based planning for transaxillary valve surgery

Clinical vignetteA 74-year-old woman with a cardiovascular history of dyslipidemia, type 2 diabetes mellitus, chronic atrial fibrillation, and a previous STEMI in 2022 treated with percutaneous coronary intervention (PCI) with a drug-eluting stent (DES) to a diagonal branch was admitted to the cardiology department for diagnostic evaluation.She presented with a recent onset of dyspnea on exertion [New York Heart Association (NYHA) functional class II-III] and echocardiographic assessment revealed a multivalvular disease involving mitral, aortic, and tricuspid valves, with surgical indication.Preoperative transesophageal echocardiography (TEE) revealed a preserved left ventricular ejection fraction (LVEF 62%) associated with severe aortic regurgitation, moderate-to-severe mitral regurgitation secondary to A2-P2 segment prolapse, and severe tricuspid regurgitation due to septal leaflet prolapse.Both the mitral and aortic valves showed rheumatic involvement of the leaflets.Invasive coronary angiography demonstrated patent coronary arteries without new significant obstructive lesions.Additionally, an angio-computed tomography (CT) scan was performed.Here we describe how to carefully analyze the CT scan to assess the feasibility of a minimally invasive approach to address the multivalvular disease. Choosing the right intercostal spaceBeyond general preoperative CT considerations-such as screening for aorto-coronary lesions, anatomical anomalies, coronary origin and course, or extensive valvular calcifications-the coronal view allows for precise assessments tailored specifically to the transaxillary approach (1-4).To do so, scrolling through the slices, we focused on the target valves to treat, and started by analyzing the fourth intercostal space, tracing a line between it and the valves.We analyzed the CT scan by carefully looking at: I. "Drop and scroll"• We first investigated the position of the valve inside the chest, in relation to the sternum, to be able to predict it before entering the chest-just looking at the patient's thorax.To do so, an easy technique we apply consists of dropping the pointer on the target valve on the CT-scan coronal view, and