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Ann Thorac Surg 2000;70:1366-1370
© 2000 The Society of Thoracic Surgeons

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Original articles: cardiovascular

Current indications for left thoracotomy in coronary revascularization and valvular procedures

^a Division of Cardiothoracic Surgery, The Ohio State University, Columbus, Ohio, USA

Address reprint requests to Dr Brown, Division of Cardiothoracic Surgery, The Ohio State University, N825 Doan Hall, 410 W. 10th Ave, Columbus, OH 43210-1228
e-mail: brown-4{at}medctr.osu.edu

	Abstract

Top Abstract Introduction Patients and methods Comment Acknowledgments References

 
Background. Left thoracotomy is infrequently used for cardiac procedures, but its application in reoperative and minimally invasive coronary revascularization and in valvular procedures has been reported recently.

Methods. Three case reports and a review of the current literature illustrate the unique benefits of this approach for myocardial revascularization and valve replacement.

Results. Reoperative coronary revascularization of the left anterior descending and circumflex coronary arteries was performed off-pump via a left posterolateral thoracotomy. For the second case, this approach was used for coronary artery bypass grafting of the right coronary and left anterior descending arteries with femoral-femoral cardiopulmonary bypass in a patient with congestive heart failure and coronary artery disease who also required closure of a patent ductus arteriosus. In the third case, mitral valve replacement using femoral venous and aortic cannulation for cardiopulmonary bypass was performed via a left thoracotomy to avoid a retrosternal gastric conduit in a patient with severe mitral stenosis and congestive heart failure. All patients returned to normal activity and are asymptomatic.

Conclusions. These case reports and a comprehensive review of the literature demonstrate the utility of left thoracotomy as an alternative approach to standard median sternotomy in selected cases of revascularization and valvular procedures.

	Introduction

Top Abstract Introduction Patients and methods Comment Acknowledgments References

 
Median sternotomy is the standard surgical approach for the majority of cardiac operations. Right thoracotomy has been used as an adjunct for reoperative atrioventricular valve procedures and more recently in minimally invasive procedures [1]. Left thoracotomy is only infrequently used for cardiac procedures, but its application in reoperative and minimally invasive coronary revascularization, aortic arch and descending aortic aneurysm repair, and aortic valve replacement has recently been reported. As coronary artery reoperations increase, minimally invasive surgical techniques advance, and patients survive various thoracic oncologic procedures, the left thoracotomy approach provides a safe alternative to the hazards of reoperative sternotomy.

We report three cases and review the current literature illustrating various techniques and unique benefits of the left thoracotomy approach in a wide variety of cardiac, vascular, and valvular procedures.

	Patients and methods

Top Abstract Introduction Patients and methods Comment Acknowledgments References

 
A MEDLINE search was conducted from 1966 to the present using thoracotomy, coronary artery bypass grafting, myocardial revascularization, aorta, mitral valve repair/replacement, and aortic valve repair/replacement as key words. Cross-referencing was done using the bibliographies of the articles obtained. Cases utilizing a right thoracotomy approach were excluded.

Case 1
A 57-year-old man who had previously undergone an elective four-vessel coronary artery bypass grafting (CABG) presented 10 years later with unstable angina and a non-Q wave myocardial infarction. Cardiac catheterization revealed a totally occluded proximal left anterior descending (LAD) coronary artery, circumflex coronary artery, and proximal right coronary artery (RCA) with three of four grafts patent. The saphenous vein graft to the LAD was 90% stenosed, the vein graft to the first obtuse marginal was 90% stenosed, the RCA graft was totally occluded, and the left internal mammary artery (LIMA) to the first diagonal branch was patent. The ejection fraction was 28%. The patient was scheduled for reoperative coronary artery bypass grafting to the LAD and circumflex coronary arteries via a left posterolateral thoracotomy.

Surgical technique
After general endotracheal intubation with a double-lumen endotracheal tube, the patient was positioned in a modified right lateral decubitus position with the pelvis rotated to the left. The saphenous vein was harvested from the left thigh while the left common iliac artery and vein were exposed through an incision parallel and superior to the inguinal ligament for possible cannulation. A left posterolateral thoracotomy was performed through the fourth intercostal space. The left subclavian artery was isolated and the proximal anastomosis with reversed saphenous vein was made after heparinization (10,000 units). The pericardium was opened parallel and posterior to the phrenic nerve. Tracing the old vein grafts identified the target coronary arteries. Distal anastomoses were created sequentially to the obtuse marginal and LAD coronary arteries in a standard running fashion, after stabilization was achieved on the beating heart (Optiflex; US Surgical Corp, Norwalk, CT). Inflow occlusion was not necessary, as the surgical field was easily cleared of blood with a carbon dioxide blower. An epidural catheter was placed before transporting to the intensive care unit for postoperative pain management.

The patient was discharged 4 days postoperatively after an uneventful hospital course. He has remained without angina for more than 10 months with resumption of normal activities.

Case 2
A 71-year-old woman complained of shortness of breath and chest pain. Clinical examination demonstrated both the thrill and murmur of a patent ductus arteriosus (PDA). At cardiac catheterization, a 90% mid RCA lesion and a 90% tubular lesion in the LAD coronary artery were identified. The ejection fraction was 62%. The pulmonary artery pressure was 34/22. An oxygen saturation step up from 61.3% to 79.9% between the right ventricle and pulmonary artery was noted. The patient was scheduled for coronary artery bypass grafting to the RCA and LAD with ligation of the PDA through a left thoracotomy.

Surgical technique
After double-lumen endotracheal intubation, the patient was placed in a modified right lateral decubitus position. The saphenous vein was harvested from the left thigh and the left femoral artery and vein were exposed. A left posterolateral thoracotomy was performed through the bed of the resected fifth rib. The ductus was exposed and ligated. The LIMA was mobilized and prepared for grafting. The pericardium was opened longitudinally, anterior to the phrenic nerve. After heparinization, the femoral artery and vein were cannulated. A long venous cannula from the femoral vein to the right atrium was used.

Cardiopulmonary bypass was instituted and the patient was cooled to 30°C. The ascending aorta was mobilized and cross-clamped after a combined cardioplegia and venting cannula was inserted. The heart was arrested with antegrade cold blood cardioplegia solution. Once decompressed, the heart was rotated counterclockwise, easily exposing the distal right coronary artery. The RCA was opened proximal to the bifurcation and the vein was anastomosed in a standard running fashion. In a similar fashion, the LIMA was anastomosed to the LAD. A partial occlusion clamp was applied and the proximal anastomosis was performed at the cardioplegic cannula site in a standard running fashion. The bypass time was 100 minutes with a cross-clamp time of 36 minutes.

She did well postoperatively and was discharged to a rehabilitation facility on the fifth postoperative day. She was readmitted on postoperative day 7 for atrial fibrillation and again on postoperative day 15 with a left pleural effusion (chylothorax), which responded to dietary management. At 36 months, she remains asymptomatic.

Case 3
A 70-year-old man presented with complaints of chest pain and signs of congestive heart failure with pulmonary edema. His cardiac examination was remarkable for a blowing systolic ejection murmur and atrial fibrillation. In 1989, he had esophageal cancer for which he had undergone an esophagogastrectomy with substernal gastric conduit reconstruction. At cardiac catheterization, he was noted to have 75% stenosis of both the LAD and circumflex coronary arteries and a severely calcified mitral valve with a valve area of 0.8 cm² and a 12-mm gradient. Chest computed tomography demonstrated a large substernal gastric pouch overlying the precordium and extending into the right chest. Transluminal coronary angioplasty was performed 1 week before the planned mitral valve replacement.

Surgical technique
After double-lumen endotracheal intubation, the patient was positioned in the right lateral decubitus position. A left posterolateral thoracotomy through the fourth intercostal space was performed. After heparinization, the proximal descending aorta was cannulated. The left common femoral vein was exposed and cannulated with a 19 French Bio-Medicus cannula directed into the right atrium. Cardiopulmonary bypass was instituted, then the patient was allowed to drift in temperature to 32°C. The pericardium was opened parallel and anterior to the phrenic nerve. Additional venous drainage was accomplished with a vent in the main pulmonary artery. A cardioplegia catheter and vent was placed in the aortic root. The ascending aorta was cross-clamped and antegrade cold blood cardioplegia was delivered, arresting the heart. The left atrium was opened behind the left atrial appendage anterior and cephalad to the left pulmonary veins. The valve was excised, the annulus debrided, and a 33-mm St. Jude Silzone mechanical prosthesis was placed using interrupted pledgeted sutures in a supra-annular fashion. The bypass time was 116 minutes with a cross-clamp time of 64 minutes.

The patient was discharged 5 days later after an uneventful postoperative course. The patient has remained asymptomatic for 15 months.

	Comment

Top Abstract Introduction Patients and methods Comment Acknowledgments References

 
The left thoracotomy surgical approach for cardiac procedures dates from 1910, when Alexis Carrel conceived the idea of using this approach in his thoracic aorta to coronary artery bypass. Because of the exposure, ease of cannulation, and manipulation of the heart and great vessels, the median sternotomy incision, however, became the standard approach for the majority of operations in cardiac surgery. With the recent surge in minimally invasive techniques, there is a renewed interest in thoracotomy exposure. This is especially true with the left anterior thoracotomy for minimally invasive direct coronary artery bypass (MIDCAB), right anterolateral thoracotomy for tricuspid and mitral valvular procedures, and for the repair of atrial septal defects and partial or hemi-sternotomy for aortic and mitral valve exposure. The advantages of the thoracotomy approach are most evident when considering the hazards of reoperative sternotomy.

As with our first case, the left posterolateral thoracotomy for myocardial revascularization has primarily been used as an alternative approach for reoperative revascularization of the anterior descending and posterior coronary circulation [2–12]. Decisions regarding this approach are based primarily on localization of previously patent aortocoronary or internal mammary grafts beneath the sternum and a history of sternal or mediastinal complications at the time of initial revascularization. Since 1978, several papers have reported using this technique for reoperative surgery in a total of approximately 195 patients; Grosner and associates [4] described the largest series, consisting of 20 patients. Although the majority of cases were for grafting of the circumflex distribution, more recent literature demonstrated the advantage of this approach for the LAD and its tributaries [2, 5, 7–9, 12]. Despite the usual increase in morbidity and mortality associated with reoperative coronary revascularization, the cumulative incidence of early graft closure and death in these series were 5.2% and 2.1%, respectively. With our second case, we also demonstrate that the main trunk of the RCA system can be bypassed via a left thoracotomy in nonreoperative case with concomitant left thoracic pathology.

The surgical approach to each patient should be individualized to the needs of that patient. Patients should be positioned in the right lateral decubitus position with the hips slightly rotated to the left, allowing for access to the right saphenous vein and left femoral vessels, avoiding the need to reposition the patient after saphenectomy. Techniques for localizing the target vessels include preoperative echocardiography and computer tomography or magnetic resonance imaging [13, 14], as well as following prior aortocoronary grafts. Inflow for grafts can include the left subclavian artery, descending thoracic aorta, and, as illustrated in the second case, ascending aorta. The choice of conduits are surgeon dependent and can include the LIMA, the radial artery free graft, reversed saphenous vein, and pedicle grafts from the right gastroepiploic, inferior epigastric, or subscapular arteries.

The need for cardiopulmonary bypass depends upon the condition of the patient and the location of the target vessel. Variability exists regarding sites of cannulation. If a large femoral venous cannula cannot be obtained or difficulty exists in reaching the right atrium from the groin, additional venous drainage can be obtained by cannulating the pulmonary artery or right ventricular outflow tract. Similarly, instead of femoral arterial cannulation, arterial cannulation can be performed in the ascending aorta or proximal descending thoracic aorta. As surgeons become more comfortable with beating heart anastomoses and stabilizing devices improve, coronary artery bypass grafting from the left chest without cardiopulmonary bypass on the beating heart may be more commonplace. Methods to avoid aortic cross-clamping include cardiopulmonary bypass with temporary circulatory arrest [9, 10, 15] or with fibrillatory arrest [3, 6, 8, 16].

In reviewing the literature, several unique situations have occurred wherein the left thoracotomy approach to myocardial revascularization is beneficial. Hirose and associates [17], Safi and associates [15], and La Francesca and associates [16] successfully revascularized patients who had had esophagogastrectomies through a left posterolateral thoracotomy approach to avoid substernal conduits. Mihaljevic and associates [18], using the left thoracotomy as the standard approach to descending thoracic aortic aneurysm, combined aortic aneurysmorrhaphy with coronary artery bypass grafting in 2 patients with significant coronary artery disease and symptomatic aneurysms. In the first patient, a LIMA to LAD anastomosis was performed on the beating heart; in the second patient, a reversed saphenous vein to posterior descending coronary artery anastomosis was performed on a beating heart with implantation of the aortocoronary graft to the Dacron graft. Similarly Takamoto and associates [19] replaced the distal aortic arch and performed a LIMA to LAD anastomosis. The thoracotomy approach offers anatomic exposure advantages in performing planned lung resections in combination with myocardial revascularization. As illustrated by our second case, other concomitant left chest pathology, such as a patent ductus arteriosus, can be addressed at the time of planned coronary artery bypass grafting.

The left thoracotomy offers other advantages with regards to wound healing. Sternal healing is compromised by radiation exposure. In patients who receive mediastinal or anterior chest radiation therapy, such as for lymphoma, esophageal cancer, lung cancer, or breast cancer, a thoracotomy approach may be beneficial in avoiding the potential complications of sternal dehiscence [20]. Similarly, in patients with low-lying tracheostomies, the contamination and potential sternal wound infection can be avoided if the CABG is performed through a thoracotomy [21].

In addition to myocardial revascularization, the left thoracotomy approach can be applied to both mitral and aortic valve replacement and repair. This approach was frequently used in the past for closed mitral commissurotomies; however, it was "abandoned" in open procedures because of initial difficulties with cardiopulmonary bypass and poor visibility of the mitral apparatus. We presented 1 patient with a substernal gastric conduit in which a left thoracotomy gave excellent exposure to the diseased mitral valve. Other authors have used this approach for mitral valve replacement with concomitant patent ductus arteriosus [22] and combined with transmyocardial laser revascularization of the posterolateral heart [23]. Takahara and associates [24] and Hirose and associates [25] reported aortic valve replacement using the left thoracotomy approach in patients who had substernal colonic interpositions after esophagogastrectomy. The key anatomic element to aortic valve exposure from this approach is that the valve is in the rightward orientation and that the pulmonary artery limits access to the aorta. To improve exposure, the main pulmonary artery must be transected or decompressed. Techniques of cardiopulmonary bypass and venting for valvular replacement are the same as those described for myocardial revascularization.

Two important points must be made regarding anesthesia for the left thoracotomy approach. First, double-lumen endotracheal intubation allows the left lung to collapse and improves exposure. Second, placement of an epidural anesthesia catheter at the completion of the procedure improves postoperative pain management, allowing patients to ambulate earlier and improve pulmonary toilet, thereby decreasing the risk of postoperative pulmonary complications.

Although the advantages to this technique are clear (Table 1), several limitations exist. Exposure is limited, especially access to the right atrium, right ventricle, and ascending aorta. Applications for this procedure are limited to predominantly coronary and valvular reoperations. Compared with median sternotomy, there is an increased tendency for patients to experience postthoracotomy pain syndromes.

	Acknowledgments

Top Abstract Introduction Patients and methods Comment Acknowledgments References

	References

Top Abstract Introduction Patients and methods Comment Acknowledgments References

 

1. Kumar A.S., Prasad S., Rai S., Saxena D.K. Right thoracotomy revisited. Tex Heart Inst J 1993;20:40-42.[Medline]
2. Walker W.S., Sang C.T.M. Avoidance of patent anterior grafts at revisional coronary artery surgery. Thorax 1986;41:692-695.[Abstract/Free Full Text]
3. Burlingame M.W., Bonchek L.I., Vazales B.E. Left thoracotomy for reoperative coronary bypass. J Thorac Cardiovasc Surg 1988;95:508-510.[Abstract]
4. Grosner G., Lajos T.Z., Schimert G., Bergsland J. Left thoracotomy reoperation for coronary artery disease. J Cardiac Surg 1990;5:304-308.[Medline]
5. Faning W.J., Kakos G.S., Williams T.E. Reoperative coronary artery bypass grafting without cardiopulmonary bypass. Ann Thorac Surg 1993;55:486-489.[Abstract]
6. Mills N.L., Dupin C.L., Everson C.T., Leger C.L. The subscapular artery. J Cardiac Surg 1993;8:66-71.[Medline]
7. Uppal R., Mills N.L., Wechester A.S., Smith P.K. 1993 Update. Ann Thorac Surg 1993;55:1275-1276.[Abstract]
8. Watanabe G., Haverich A., Spicer R. Third-time coronary artery revascularization. Thorac Cardiovasc Surgeon 1993;41:163-166.[Medline]
9. Suma H., Kigawa I., Horii T., Tanaka J., Fukuda S., Wanibuchi Y. Coronary artery reoperation through the left thoracotomy with hypothermic circulatory arrest. Ann Thorac Surg 1995;60:1063-1066.[Abstract/Free Full Text]
10. Calafiore A.M., Suma H. Radial artery from left subclavian artery in redo coronary artery bypass grafting. Ann Thorac Surg 1996;62:901-902.[Abstract/Free Full Text]
11. Bolton J.W.R. Left thoracotomy for reoperative revascularization of the posterior coronary circulation. J Cardiovasc Surg 1997;38:407-410.[Medline]
12. Coulson A.S., Bakhshay S.A., Sloan T.J. Minimally invasive reoperation through lateral thoracotomy for circumflex coronary artery bypass. Tex Heart Inst J 1998;25:170-174.[Medline]
13. Soltanian H., Sanders J.H., Robb J.C., Marrin C.A.S. Hybrid myocardial revascularization after previous left pneumonectomy. Ann Thorac Surg 1998;65:259-260.[Abstract/Free Full Text]
14. Watanabe G., Misaki T., Kotoh K., Kawakami K., Yamashita A., Ueyama K. Multiple minimally invasive direct coronary artery bypass grafting for the complete revascularization of the left ventricle. Ann Thorac Surg 1999;68:131-136.[Abstract/Free Full Text]
15. Safi H.J., Barnett M.G., Turner W. Coronary artery bypass after substernal colon interposition for carcinoma of the esophagus. Cardiovasc Surg 1994;2:415-417.[Medline]
16. La Francesca S., Rurdo G., Greco E., Speziale G., Marino B. Left thoracotomy for coronary revascularization after esophagoplasty with substernal colon interposition. Tex Heart Inst J 1995;22:200-201.[Medline]
17. Hirose H., Amano A., Yoshida S., Takahashi A. Coronary artery bypass graft after esophagogastrectomy. Eur J Cardio Thorac Surg 1999;15:729-731.[Abstract/Free Full Text]
18. Mihaljevic T., Tonz M., von Segesser L.K., Turina M.I. Combined coronary artery bypass grafting and repair of aneurysm of descending aorta. Ann Thorac Surg 1999;67:1497-1499.[Abstract/Free Full Text]
19. Takamoto S., Matsuda T., Harada M., Shimamura Y. Distal aortic arch aneurysmectomy and coronary revascularization through a left thoracotomy. Ann Thorac Surg 1993;55:151-152.[Abstract]
20. Evez E., Eldar S., Sharoni E., Abramov D., Sulkes A., Vidne B.A. Coronary artery operation in patients after breast cancer therapy. Ann Thorac Surg 1998;66:1312-1317.[Abstract/Free Full Text]
21. Nataf P., Regan M., Cantani E., Bonnet N., Gandjbakheh I. Video-assisted coronary artery bypass in patients with pre-existing tracheostomy. Ann Thorac Surg 1999;67:1153-1154.[Abstract/Free Full Text]
22. Monro JL, Sbokos CG, Conway N. Simultaneous mitral valve replacement and ligation of persistent ductus arteriosus. J Thorac Cardiovascular Surg 69;1:102–3.
23. Hughes G.C., Donovan C.L., Lowe J.E., Landolfo K.P. Combined TMR and mitral valve replacement via left thoracotomy. Ann Thorac Surg 1998;65:1141-1143.[Free Full Text]
24. Takahara Y., Sudo Y., Nakazima N. Aortic valve replacement via left thoracotomy after an esophageal operation. Ann Thorac Surg 1997;63:225-227.[Abstract/Free Full Text]
25. Hirose H., Umeda S., Mori Y., Murakawa S., Azuma K., Hashimot T. Another approach for aortic valve replacement through left thoracotomy. Ann Thorac Surg 1994;58:554-556.

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