A 73-year-old man, who underwent total esophagectomy and gastric tube reconstruction via the retrosternal route for esophageal cancer 10 years eariler, was referred to our hospital with chest pain. He was suspected of acute coronary syndrome, and coronary artery angiography was performed, showing in-stent restenosis of the proximal site of the right coronary artery, diagnosed as the culprit lesion, and drug-coated ballooning was performed. His symptoms improved, however, the poor expansion of the stent and in-stent stenosis remained, and he was referred to our department for coronary artery bypass surgery. Because the gastric tube was reconstructed just below the sternum and performing sternotomy seemed to be difficult, a left mini-thoracotomy approach using great saphenous vein was planned. Under general anesthesia, an approximately 10-cm skin incision was made on the left fifth rib from the anterior axillary to the midclavicular line, and the chest wall was opened at the fifth and third intercostal spaces from the same skin incision, to secure views of the AV node branch and ascending aorta. First, the great saphenous vein was anastomosed to the ascending aorta from the third intercostal space, using 3.8 mm puncher and Heartstring III (Getinge, Lindholmspiren, Sweden). After that, the graft was guided extrapericardially via the left intrathoracic cavity, and was anastomosed to the AV nodal branch from the fifth intercostal space. The graft blood flow was 48 ml/min. The postoperative course was uneventful and contrast-enhanced CT confirmed the patency of the graft.

We report on a case of left ventricular outflow tract myectomy with Y-incision annular enlargement and aortic valve replacement for aortic valve regurgitation associated with subvalvular aortic stenosis. Subvalvular aortic stenosis is recognized as congenital heart disease, with a few reports in adult cases. Left ventricular outflow obstruction in cases of subvalvular aortic stenosis can be relieved by either the Konno procedure or a modified Konno procedure. Additionally, there has been an increasing number of reports of valve annular enlargement using the Y-incision technique recently. Unlike the Manouguian and Konno procedure, the Y-incision technique allows for valve annular enlargement without cutting the left atrium, mitral valve, or right ventricular outflow tract. While the Konno procedure would typically be considered for this case, the Y-incision technique was selected for valve annular enlargement. This approach provided a clear view from the aortic valve annulus, enabling the excision of fibrous thickening and abnormal myocardium excision. This case resulted in a favorable postoperative course.