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There are fewer than 100 reported cases of congenital left main coronary artery atresia. In this report, we present an adolescent male presenting with exertional syncope in the setting of this rare coronary defect, and review important diagnostic and therapeutic considerations imperative to obtain a favorable outcome., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Revascularization of the coronary arteries, via open sternotomy and on cardiopulmonary bypass, remains the most common cardiac surgical procedure in the United States. Patients, and cardiologists, seek an alternative to dividing the sternum while reaping the advantages of left internal mammary artery (LIMA) revascularization of the diseased left anterior descending (LAD) coronary artery. We describe a strictly transxiphoid mammary artery liberation with anastomosis to the anterior descending (TRAX CABG) without sternal division. Of the 26 patients who underwent attempted TRAX CABG, 18 had nonsternotomy LIMA-to-LAD revascularization with completion angiogram to document bypass patency. TRAX CABG offers surgeons a minimally invasive alternative to trans-sternal LIMA-to-LAD in select patients. Conversion to traditional sternotomy has limited unanticipated morbidity and completion angiogram confirms procedural success.

BioGlue is a surgical adhesive widely used to help reinforce complex cardiac and vascular repairs. Since its introduction, several case reports have emerged revealing complications that all providers should be mindful of whenever the product is used. This report considers a unique situation where BioGlue was used after double cardiac valve repair that resulted in adhesion of the new mechanical aortic valve leaflets and was difficult to visualize with transesophageal echocardiography.

Objective: Recently, the PARTNER 2A trial reported results of transcatheter aortic valve replacement versus surgical aortic valve replacement in 2032 intermediate-risk patients at 2 years. Two hundred thirty-six patients (24%) required an access route other than transfemoral. Compared with transfemoral and surgical aortic valve replacement, nontransfemoral transcatheter aortic valve replacement was associated with a numerically higher rate of death and disabling stroke at 30 days. This underscores the need for a better alternative surgical approach for patients with marginal femoral access. We reviewed our multicenter experience with minimally invasive suprasternal transcatheter aortic valve replacement., Methods: Consecutive patients with symptomatic severe aortic stenosis at high or intermediate risk for surgical aortic valve replacement underwent suprasternal transcatheter aortic valve replacement. A commercially available transcatheter heart valve was deployed under fluoroscopic guidance through the innominate artery or ascending aorta. Using a 3-cm skin incision just above the sternal notch, the Aegis Transit System (Aegis Surgical Ltd, Galway, Ireland) provided illuminated access to the mediastinum without bone disruption. Through a purse-string suture placed in the innominate artery or ascending aorta, transcatheter aortic valve replacement proceeded similarly to the direct aortic approach., Results: Thirty patients at six medical centers successfully underwent suprasternal transcatheter aortic valve replacement. Implanted valves included 2 CoreValve and 12 Evolut-R (Medtronic, Inc, Minneapolis, MN USA), as well as 10 SAPIEN 3 and 6 SAPIEN XT (Edwards Lifesciences, Corp, Irvine, CA USA) with sizes ranging from 23 to 31 mm. Median procedure time was 90 minutes and median hospital stay was 4 days. Postoperatively, new permanent pacemaker (n = 3) was the most common Vascular Academic Research Consortium 2 complication., Conclusions: These data demonstrate the early clinical feasibility of suprasternal transcatheter aortic valve replacement. Key advantages of this approach include direct access to the innominate artery and ascending aorta, precise sheath control, and confident arterial closure. Additional experience is warranted to confirm these favorable results.