The incidence of concomitant cardiovascular diseases and LC is increasing.
[[1]] The surgical strategy for each case needs to be considered based on the severity of AS, curability of LC, and patient safety. Lung surgery 4–6-week after AVR may lead to unreliability or metastasis. Conversely, lung surgery before AVR significantly increases the risks associated with anesthesia and death.
[[4]] Prior AVR for AS with lung cancer was often performed to avoid sudden hemodynamic change due to AS, but there was a report that showed prior lobectomy has been performed to avoid the risk of bleeding, even with protamine administration, and the risk of cellular immune dysfunction due to cardiopulmonary bypass which is associated with cancer progression.
[[5]] However, there is no significant evidence on the risk of cancer progression due to cardiopulmonary bypass, which is controversial. The concomitant procedure is not without limitations, such as the risk of dissemination due to the manipulation of the lung, inability to perform lymph node dissection, and excessive blood loss due to heparinization. We used the following points for the patient selection. Firstly, preoperative respiratory function is enough to tolerate to lung resection. Secondly, lung cancer is in the right lung. Finally, lung resection was limited to lobectomy or segmentectomy. A recent study revealed that TAVI for AS complicated with early cancer was effective and provided promising early results.
[[2]] Furthermore, some reports suggested that TAVI with simultaneous lung resection has good long-term results.
[[2, 6]] However, not every patient with AS can undergo TAVI due to a lack of anatomical suitability which includes severity and location of calcification etc. In this case, it was not appropriate owing to the anatomical morphology of the aortic valve. Considering the patient’s recovery and avoiding potential tumor dissemination, we decided to perform a one-stage minimally invasive surgery for AS and LC. We considered lobectomy before heparinization can increase the risk of pulmonary hemorrhage. In addition, taking into account the risk of hemodynamic collapse caused by AS during lobectomy, we performed AVR firstly. To the best of our knowledge, this is the first successful case of simultaneous MICS-AVR for severe AS and VATS oncologic resection via right mini-thoracotomy.
Conventional concomitant valve replacement and lung resection are usually performed with median sternotomy. However, lobectomy through median sternotomy is more difficult than the thoracotomy approach in terms of lymph node resection. If the surgery uses two different approaches, the patient will experience more postoperative discomfort. Conversely, minimally invasive valve surgery can be performed for valve diseases under CPB via a right mini-thoracotomy. Fujii et al. studied MICS-AVR under CPB via the femoral artery and femoral vein in Japan and reported no cases with postoperative neurological complications.
[[7]] Durdu et al. reported the efficacy of MICS-AVR with sutureless valve for bicuspid AS.
[[8]] We could not use sutureless valve in our institution, the sutureless valve can be an effective option. When the pulmonary nodule is located on the right lung, we can use the same incision on the right side to complete the lobectomy. Therefore, concomitant minimally invasive cardiac surgery and VATS lobectomy via right mini-thoracotomy are beneficial for and do not affect the safety of the operation while possessing cosmetic benefits. Furthermore, avoiding a sternum incision can reduce bleeding and the risk of wound infection, mediastinal infection,
[[9]] and sternal osteomyelitis.