Modified Bentall procedure is a gold standard technique for aortic root dilatation supported by long term data [1]. However, proximal coronary artery complications are well documented. Proximal coronary aneurysms are common in the late postoperative period [2]. The incidence may be as high as 50% in younger patients with Marfan’s syndrome [3]. Stenosis or narrowing in the proximity of neo coronary ostium is not uncommon. Turbulent blood flow between the Dacron graft and the native coronary artery may contribute to the stenosis. Tension free anastomosis respecting the anatomical orientation is a prerequisite for laminar blood flow.

The incidence of coronary artery stenosis after aortic root replacement reported in literature is 0.3 − 5% [4]. Various mechanisms contribute to this sequel such as a stretched graft, mechanical injury during manipulation of cardioplegia cannula, high infusion pressure during transfusion of cardioplegia solution and inadequate mobilisation the left main stem during the Bentall procedure. Inappropriate tissue handling results in inflammatory reaction and stenosis and fibrous tissue formation in the proximity of the coronary ostia. Surgical correction is the definitive treatment.

Resternotomy is associated with a substantial risk of mortality and morbidity and this is most pronounced within 12 months of primary surgery. Mini-OPCABG is an ideal approach in suitable cases [5, 6]. It eliminates the risk of full redo sternotomy which can be potentially hazardous. Avoidance of extensive adhesiolysis, aortic manipulation and cardiopulmonary bypass is beneficial [7, 8]. This case illustrates the advantage of Mini-OPCABG following modified Bentall Procedure. It allows ready access to the target requiring minimal dissection around the heart.

The patient recovered uneventfully without any complications and was discharged home on the 4th post operative day. Our strategy was a well planned Mini-OPCAB pathway for early recovery. This involved.

1.

Pre-emptive analgesia with local intercostal block at incision site.

2.

ET tube with single lumen blocker.

3.

Short acting anaesthetic protocol.

4.

Paravertebral block after completion of the procedure.

5.

On table extubation.

6.

Early mobilisation and physiotherapy.

7.

Early discharge.

The patient benefits from expedited recovery, minimal blood loss, early mobilisation and early discharge at four days with return to routine activities within 3 weeks of surgery.