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Background: Although right parasternal approach (RPA) decreases the incidence of mediastinal infection, this approach is associated with lung hernia and flail chest. Our RPA employs thoracotomy with bending rib cartilages and wound closure performed by repositioning the ribs with underlying sheet reinforcement. Methods: We evaluated 16 patients who underwent aortic valve replacement via the RPA from January 2010 to August 2013. We compared outcomes of 15 male patients had the RPA with 30 male patients had full median sternotomy. Results: One patient with a history of radical breast cancer treatment underwent RPA with concomitant right coronary artery bypass grafting. No hospital deaths occurred. Four patients developed hospital-associated morbidity (re-exploration for bleeding, prolonged ventilation, cardiac tamponade, and perioperative myocardial infarction). There were no conversions to full median sternotomy, mediastinal infections, and lung hernias. Preoperative computed tomography showed that the distance from the right sternal border to the aortic root was significantly associated with operation times. With RPA, there was no significant difference in outcomes, despite significantly longer operation times compared with full median sternotomy. Conclusion: Our RPA provides satisfactory outcomes without lung hernia, especially in patients unsuitable for sternotomy. Preoperative computed tomography is useful for identifying appropriate candidates for the RPA.

A 26-year-old man presented chest oppression. He had pectus excavatum associated with Loeys-Dietz syndrome and a history of redo aortic root replacement with the modified Bentall technique using an 8-mm long interposed graft to the left coronary ostium. Coronary angiography revealed severe stenosis of both left coronary ostium and proximal left anterior descending artery, which was supposed to be resulted from thrombosis in the interposed graft. The left coronary system was bypassed through a left thoracotomy, which was suitable in this patient because the pectus excavatum would prevent harvest of the left internal thoracic artery through re-median sternotomy and to avoid potential sternal reentry injury of the heart. Although the left anterior descending artery was easily accessed under off-pump technique, exposure and anastomosis of the circumflex coronary artery was more difficult than expected without cardiopulmonary bypass as the pectus excavatum and adhesion of the heart prevented anterior shift and rotation of the heart.