Introduction
With the aging of the population and improvement in survival rates, the incidence of re-operative cardiac surgery is increasing. Re-operative aortic valve replacement (AVR) with a patent internal thoracic artery (ITA) previously anastomosed to the left anterior descending (LAD) is challenging. Adequate myocardial protection is required while cross-clamping the aorta to dissect and clamp the ITA and prevent cardioplegia washout. However, several fatal complications, such as ITA graft injury, catastrophic bleeding, and myocardial damage, can occur. Conventional re-operative cardiac surgery with patent ITA anastomosed to the coronary artery involves re-sternotomy, adequate tissue detachment, and ITA clamping during aortic cross-clamping. Herein, we report a case of re-operative AVR in a patient with a patent left ITA (LITA) flow to LAD after coronary artery bypass grafting (CABG).