Alternative approach for aortic valve replacement: in mediastinal deviation after right lobectomy.

A 71-year-old man on hemodialysis and with a history of right lobectomy was referred for aortic valve replacement. Chest computed tomography revealed counterclockwise rotation of the heart through its longitudinal axis.We approached the aortic valve through median sternotomy. Accordingly, we transected the sternum at the level of the 3rd intercostal space and extended the skin incision approximately 2 inches perpendicular to the midline. After partial transection of the sternum, 3 spreaders were placed: the 1st, in the upper sternum; the 2nd, in the lower sternum; and the 3rd, between the ribs. These devices yielded excellent exposure of the ascending aorta. In addition, the relatively central shift of the ascending aorta contributed to the exposure of the right atrium and the right upper pulmonary vein. Subsequently, aortic valve replacement was performed in the usual fashion, and the patient experienced no postoperative respiratory complications. Aortic valve surgery with T-shaped sternotomy and without thoracotomy is an alternative technique in a patient who has a secondary deviation after lobectomy.