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Ann Thorac Surg 2002;73:784
© 2002 The Society of Thoracic Surgeons

Invited commentary

^a Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Cleveland, OH 44195, USA

e-mail: gillinom{at}ccf.org

Reoperative cardiac surgery in the presence of a patent left internal thoracic artery (LITA) to left anterior descending (LAD) coronary artery bypass graft is increasingly common. The surgical challenges in this setting are to avoid damaging the LITA, secure myocardial protection, and accomplish the surgical mission.

Doctor Byrne and colleagues describe a strategy for management of a patent LITA-LAD graft in reoperations for aortic valve replacement. Their policy was to establish cardiopulmonary bypass via peripheral cannulation prior to the sternotomy. Once the sternotomy was accomplished, they did not attempt to control the LITA graft, but rather lowered the systemic temperature, cross-clamped the aorta, delivered antegrade and/or retrograde cardioplegia, and replaced the aortic valve.

There is logic behind this strategy, but there are also disadvantages. Reoperative sternotomy and dissection while on cardiopulmonary bypass can increase the risk of bleeding and mediastinal edema, and if the right ITA is to be used as a bypass graft, that dissection is more bloody and more difficult. Furthermore, systemic hypothermia, may not provide the same degree of myocardial protection as does antegrade and retrograde cardioplegia with control of the LITA pedicle. It is noteworthy that 20% of their patients experienced low cardiac output syndrome, 10% required delayed sternal closure, and 6% died. Also, damage to the LITA was not eliminated; this complication occurred in 5% of patients.

In reoperative cardiac surgery it is helpful to fit a spectrum of possible strategies to a spectrum of patients. The strategies detailed by Byrne and colleagues are very appropriate for some patients, and particularly those with cardiac or aortic structures that are adherent to the sternum, ITA grafts that cross the midline, or situations where patent ITA grafts are extremely hard to identify and isolate during the mediastinal dissection. However, the disadvantages of prolonged heparinization and prolonged cardiopulmonary bypass outweigh their advantages for most patients with patent ITA grafts. In the routine situation it is safe to reopen the sternum with an oscillating saw, dissect the mediastinal structures, and prepare the right ITA (if desired) for grafting without heparinization or cardiopulmonary bypass. Usually the left ITA can be isolated and myocardial protection accomplished with atraumatic ITA occlusion along with antegrade and retrograde cardioplegia delivery. A review of our experience with reoperative coronary and reoperative aortic valve surgery has identified the presence of a patent ITA graft as a factor decreasing, rather than increasing, reoperative risk, and the risk of ITA damage has been 3% to 4% overall. The approach described by Byrne and coworkers is a good one and it is appropriate for patients at high risk during the repeat median sternotomy, but in our opinion it is not necessary or desirable as a routine.

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Bruce W. Lytle Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Gillinov, A. M. Articles by Lytle, B. W. Search for Related Content PubMed Articles by Gillinov, A. M. Articles by Lytle, B. W. Related Collections Related Article