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Ann Thorac Surg 2001;71:762
© 2001 The Society of Thoracic Surgeons

Correspondence

Repeat coronary artery bypass via left thoracotomy

Thoralf M. Sundt, III, MDa, Arun K. Singhal, MDa

a Division of Cardiothoracic Surgery, Washington University School of Medicine, Suite 3108 Queeny Tower, Barnes-Jewish Hospital Plaza, St. Louis, MO 63110, USA

e-mail: sundtt{at}msnotes.wustl.edu

To the Editor

Ricci and colleagues recently described a technique to prevent kinking of coronary bypass grafts placed from the descending thoracic aorta to the obtuse margin of the heart through a left thoracotomy [1]. Their technique involves creating a tunnel between the inferior and superior veins to permit a more direct route of travel for the graft.

We too have had a long-standing interest in reoperative coronary bypass through the left chest, particularly in the presence of a patent internal mammary artery graft. Before the popularization of "off-pump" surgery we, like others, employed this approach with femoral cannulation for cardiopulmonary bypass with or without fibrillatory arrest. As stabilizing devices have become available we too perform these procedures "off pump" and have been pleased with the results.

We have dealt with the problem of kinking of the graft in a different and, we believe, simpler manner than Dr Ricci and associates. It is our routine to perform the anastomosis to the aorta first and, after dividing the inferior pulmonary ligament, to bring the graft underneath the hilum in the manner labeled by Dr Ricci as "the original technique." We choose to approach the distal target in the reverse orientation from that of Dr Ricci, placing the heel of the graft distally on the target and the toe of the graft more proximally. This too prevents kinking of the graft, turning the course of the graft into a gentle U rather than S curve. Dissection between the pulmonary veins is unnecessary and manipulation of the lung is minimized.

References

  1. Ricci M., Karamanoukian H.L., D’Ancona G., Salerno T.A., Bergsland J. Reoperative "off-pump" circumflex revascularization via left thoracotomy: how to prevent graft kinking. Ann Thorac Surg 2000;70:309-310.[Abstract/Free Full Text]




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