Hypertrophic aortic branches can potentially cause critical problems during minimally invasive cardiac surgery

Here we present two cases in which hypertrophic aortic branches caused trouble during minimally invasive cardiac surgery. We performed mitral valvuloplasty with the Maze procedure in Case 1 and mitral valvuloplasty with aortic valve replacement in Case 2 via mini-thoracotomy. In preoperative computed tomography scan, we did not note a hypertrophic bronchial artery in Case 1 or a dilated intercostal artery in Case 2. The right atrium was distended after aortic cross-clamping and perioperative myocardial infarction occurred in Case 1. Whereas, we could effectively deal with this situation in Case 2. The increased pulmonary blood flow can potentially cause critical problems during minimally invasive surgery. Sufficient venting of the right ventricle and secure myocardial protection is the key to perform safe surgery in the presence of dilated aortic branches. However, surgeons should not hesitate to convert to sternotomy under poor surgical exposure despite sufficient venting.