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Ann Thorac Surg 1997;64:288-289
© 1997 The Society of Thoracic Surgeons
Department of Cardiovascular Thoracic Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Rd, Lucknow 226 014, India, e-mail:aganjoo{at}sgbgi.ren.nic.in.
To the Editor:
Perhaps one of the most common difficulties in the conduct of a coronary artery bypass grafting operation is obtaining good exposure of the circumflex artery and its marginal branches. In a recent journal article from Germany, Splittgerber and associates [1] have described a method of improved exposure to these vessels by flipping the heart over into the opened right pleural cavity. The heart stays in this position, supported by sponges inserted under the right half of the sternum.
I wish to point out here that the concept of the heart folding over on itself to the right and staying there with the help of strategically placed moist sponges has probably been in practice for more than 25 years, and was recently published by my colleague and me [2]. This method differs somewhat from that of Splittgerber and associates and gives better exposure and more working space for constructing grafts in the circumflex territory. The midline skin incision over the sternum is brought down and at about the level of the xiphisternum is taken slightly to the left for about 3 to 4 cm. The left anterior rectus sheath is then incised longitudinally and the underlying belly of the left rectus muscle freed off the linea alba, which is left intact. The rectus muscle and its anterior sheath are now freed from their sternocostal attachments 2 cm from the left sternal border. Releasing the lower left sternum in this manner results in the left hemisternum moving higher and outward when the sternal retractor blades are opened as usual. The heart is then flipped over into the opened right chest just like Splittgerber and associates describe. However, we believe that instead of a two-stage cannula, which they use for venous return, two separate venous cannulas should be used; venous return then is usually not a problem with even exteme atrial distortion. Because the left half of the sternum is higher relative to the right, there is much more room available to work on the circumflex artery and its branches than there would be in a standard midsternotomy incision. After completion of the grafting, we try to loosely reapproximate the pericardium over the heart. This would probably explain why we have not found the adhesions of the lung to the right atrium, a concern expressed by Splittgerber and associates, to be a particular problem in reoperations in our patients.
An added advantage of performing this modified midsternotomy is the ease with which the left internal mammary artery can be harvested without the need for any different sternal retractor or attachments.
References
Department of Thoracic Cardiovascular Surgery, Essen University Medical School, Hufelandstr 55, Opz 1, D-45122 Essen, Germany, e-mail:fred.splittgerber{at}uni-essen.de
To the Editor:
I appreciate the opportunity to comment on Dr Ganjoo's letter.
Doctor Ganjoo points out correctly that the heartflip technique has been known for a long time. Doctor Talbert taught me this technique, he again had been taught by Dr Kroncke, and I am passing this knowledge on to my residents. The reviewers who read the article before it was accepted for publication seemed familiar with the technique; it was one of them who suggested the term "heartflip technique."
Doctor Ganjoo's point of using two caval cannulas is well taken, although a dual-stage cannula works quite to my satisfaction. Pericardial closure is certainly a helpful step in avoiding cardiac torsion and the formation of adhesions between the visceral pleura and the epicardium.
I disagree with Dr Ganjoo about the need for more exposure. Doctor Ganjoo releases the rectus muscle from its sternocostal attachments. In my experience the heartflip technique by itself is fully sufficient to obtain good access to the circumflex coronary artery; I do not see a need for additional dissection. This view is supported by Tripp and Selle [1], who use the heartflip technique to graft the proximal circumflex coronary artery.
Reference
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