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Ann Thorac Surg 1997;64:578-579
© 1997 The Society of Thoracic Surgeons

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Update

Right Thoracotomy, Femorofemoral Bypass, and Deep Hypothermia for Re-replacement of the Mitral Valve

Updated in 1997

Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts

The use of a small right anterior thoracotomy, femorofemoral bypass, and deep hypothermia with or without cardioplegia has increased since the report from our service in 1989 [1]. As originally reported, this modification resulted from the original report by Neptune and Bailey [2]. As increasing numbers of patients return for mitral valve reoperations due to bioprosthetic valve dysfunction; for complications of prosthetic valve replacement, endocarditis of other types of valves, or perivalvular leak; or, more frequently, after previous coronary revascularization, the use of this procedure has expanded. Experience with this procedure now totals 115 patients at the Brigham including the originally reported group. In the past 20 years, this represents about one fourth of all reoperative mitral valves (115/451). The most common current indications are (1) previous coronary bypass operations, especially with patent internal mammary artery-to-left anterior descending artery bypass, (2) prior mediastinitis, (3) prior aortic valve replacement, and (4) multiple early or late reoperations [3]. The ease of this procedure on the patient because of reduced surgical trauma, reduced blood use, and prophylaxis against cardiac structural injury during sternal reentry makes this a desirable approach for almost all complicated mitral reoperations, obviating repeat sternotomy.

Deep hypothermia (20°C) and low-flow femorofemoral bypass perfusion, without the necessity of aortic cross-clamping, provides adequate myocardial protection. If the patient has mild to moderate aortic regurgitation, aortic cross-clamping can be done and blood cardioplegia administered antegrade through the ascending aorta and retrograde via the right atrium and coronary sinus. Transesophageal echocardiography should be used in all cases for monitoring removal of air from intracardiac structures; this technique allows for reliable air removal given inaccessibility of parts of the heart.

We know from many reported series that reoperative coronary bypass surgical manipulation of atherosclerotic bypass grafts, even when they appear to be excellent from an angiographic point of view, can be detrimental to patient outcome due to atherosclerotic emboli with subsequent small or large acute myocardial infarction [3]. The right thoracotomy approach affords complete avoidance of these grafts if a mitral valve operation is needed after coronary artery bypass grafting. Another difficult patient subset are those patients requiring mitral valve replacement after previous implantation of an aortic valve device, making the mitral valve operation via sternotomy dangerous and very difficult in most situations. This approach allows better exposure of the aortic-mitral trigone and thus greatly enhances fixation of the valve.

Continued evaluation of various approaches for reoperative valve procedures is important, particularly for complicated reoperations, to enhance patient survival and improve long-term outcome. We and others continue to seek optimal solutions for these complex clinical problems that at the same time use strategies that will reduce cost and patient morbidity.

Footnotes

Address reprint requests to Dr Cohn, Division of Cardiac Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115.

References

1. Cohn LH, Peigh PS, Sell J, DiSesa VJ. Right thoracotomy, femorofemoral bypass, and deep hypothermia for re-replacement of the mitral valve. Ann Thorac Surg 1989;48:69–71.[Abstract/Free Full Text]
2. Neptune WB, Bailey CB. Mitral commissurotomy through the right thoracic approach. J Thorac Surg 1954;27:15–22.
3. Savage EB, Cohn LH. "No touch" dissection, antegrade-retrograde blood cardioplegia, and single aortic cross-clamp significantly reduce operative mortality of reoperative CABG. Circulation 1994;90(Suppl 2):140–3.

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This Article Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Lawrence H. Cohn Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Cohn, L. H. Search for Related Content PubMed PubMed Citation Articles by Cohn, L. H.