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Ann Thorac Surg 2002;74:1269-1270
© 2002 The Society of Thoracic Surgeons

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How to do it

A simple technique for aortic valve replacement in patients with a patent left internal mammary artery bypass graft

^a Providence St. Vincent Heart Institute and Medical Center, Albert Starr Academic Center, Portland, Oregon, USA

Accepted for publication May 1, 2002.

* Address reprint requests to Dr Savitt, 9155 SW Barnes Rd, Suite 240, Portland, OR 97225 USA
e-mail: msavitt{at}starrwood.com

	Abstract

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Aortic valve replacement in patients with a patent left internal mammary artery graft is often a challenge because of the difficulties with dissection of the left internal mammary artery and optimum myocardial protection. We describe a simple technique of aortic valve replacement with a beating heart and continuous coronary perfusion for this difficult group of patients.

	Introduction

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Routine usage of the left internal mammary artery (LIMA) to left anterior descending coronary artery anastomosis with its improved long-term patency and survival has resulted in an increased referral of patients presenting with significant aortic valve disease in combination with patent previous coronary artery bypass grafts. Aortic valve replacement can be a technically challenging procedure in this subset of patients. These patients present two distinct technical issues. First, dissection of the LIMA to gain control can be tedious, time consuming, and often dangerous. Second, adequate myocardial protection is often difficult because delivery of cardioplegia is often not optimal. Antegrade cardioplegia often results in poor protection, particularly in the left internal mammary artery territory due to native coronary artery disease, and retrograde cardioplegia is not reliable for protection of the right ventricle [1]. Optimal protection is generally achieved by a combination of both techniques, but this too can result in variable protection depending on the inherent native coronary anatomy and the status of the previous bypass grafts. We describe a simple alternative technique for performing aortic valve replacement in this difficult group of patients.

	Technique

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Surgical access is gained through a median sternotomy and minimal dissection is performed to cannulate the aorta and the right atrium. No attempt is made to dissect the left side of the heart, thus avoiding any potential damage to the LIMA. Patients receive heparin (300 U/kg), and cardiopulmonary bypass is established using a standard technique by cannulating the aorta and right atrium. Systemic hypothermia is maintained at 32°C. An aortic cross clamp is applied, and transverse aortotomy is performed. The coronary ostia are cannulated using Jehler coronary perfusion cannula (Pilling Surgical, Fort Washington, PA). This cannula has a soft foam head at the ostial end that allows for improved fixation and reduction of ostial trauma. The coronaries are continuously perfused with oxygenated blood at 32°C at the rate of 200 to 300 mL/min (Fig 1). The advantage of cannulating the coronary ostia is that the native coronaries are continuously perfused while the operative field is kept dry by preventing ostial back flow from the patent LIMA-left anterior descending coronary artery. If the patient has patent venous grafts, they are either perfused intermittently through the aortotomy with a handheld cannula, or if they are located high on the ascending aorta, they are positioned above the aortic cross clamp to allow continuous perfusion (Fig 1).

View larger version (42K): [in this window] [in a new window]   Fig 1. Diagram demonstrating continuous coronary perfusion set up. Illustration shows a patent left internal mammary artery graft and two previous patent saphenous vein grafts. Note that the patent graft to the circumflex system is positioned distal to the aortic cross clamp. The graft to the right coronary system is positioned proximal to the cross clamp and is intermittently perfused with a handheld cannula.

	Comment

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The most devastating complication of aortic valve replacement in patients with patent LIMA is inadvertent injury to the LIMA during dissection to gain proximal control. A secondary issue is the adequacy of myocardial protection in these graft-dependent hypertrophied hearts. To avoid these problems we have adopted a technique of aortic valve replacement in the beating heart with aortic cross-clamping and continuous coronary perfusion. This technique provides a safe and effective method of myocardial protection and minimizes potential injury to the patent LIMA graft.

To date we have not experienced any difficulty with continuous coronary perfusion. The Jehler soft coronary perfusion cannulas are easy to maneuver, take approximately 5 minutes to insert, and their excellent fixation prevents blood from flooding the operative field. These cannula generally stay in the coronary ostia quite nicely; however, we did have difficulty (only once), in which we secured the cannula with a short stay stitch from the aortic sinus, and when that failed we used a handheld cannula and intermittently perfused the coronary ostia. If a patent vein graft is diseased, then we replace the graft and perfuse down the new vein graft. We perform all of our coronary operations with intermittent cross clamp on the fibrillating heart without cardioplegia. We replace the diseased grafts first, and then perfuse down the new vein graft, and perform the proximal anastomisis after the aortotomy is closed. We have not seen any evidence of coronary ostial stenosis related to this technique, even though we are well aware of the small risk of this complication over the long term, but we do believe that this risk is no different then that seen with handheld aortic perfusion cannula.

Beating heart operation in conjunction with cardiopulmonary bypass has been used effectively for right-sided open-heart procedures, myocardial revascularization, reoperative mitral valve replacement, and closure of postinfarction ventricular septal defect [2, 3]. Our opinion is that the perfused beating heart reduces myocardial ischemia in this group of elderly patients who generally have hypertrophied myocardiums that tolerate prolonged ischemia poorly. We have used this technique in 16 patients to date without any complications. The cross-clamp times have been between 60 to 100 minutes with a total bypass time of 90 to 130 minutes. The heart is continuously perfused with blood at 32°C and is allowed to beat in sinus rhythm with a normal electrocardiogram. The heart always appears well perfused and healthy. Twelve of the 16 patients maintained a sinus rhythm with an isoelectric electrocardiogram at a coronary flow of 200 mL/min. In the additional 4 patients, the heart either fibrillated requiring defibrillation (n = 3) or developed segment elevation changes (n = 2) on the electrocardiogram, necessitating an increase in our coronary perfusion to either 250 mL/min (n = 3) or 300 mL/min (n = 1). This action resulted in normalization of the electrocardiogram and return to sinus rhythm in all 4 patients.

In conclusion, aortic valve replacement in the beating heart with aortic cross clamping and continuous coronary perfusion is a safe, simple, and effective method of providing excellent myocardial protection while minimizing potential injury to the patent LIMA graft.

	References

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1. Partington M.T., Ascar C., Buckberg G.D., Julia P.L., Kofsky E.R., Bugyi H.I. Studies of retrograde cardioplegia. J Thorac Cardiovasc Surg 1989;97:605-612.[Abstract]
2. Takahashi T., Kodoba K., Taniguchi K., et al. Repair of postinfarction ventricular septal defect on a beating heart. Ann Thorac Surg 1996;61:1816-1817.[Abstract/Free Full Text]
3. Perrault L.P., Menasche P., Peynet J., et al. On-pump, beating-heart coronary artery operations in high-risk patients: an acceptable trade-off?. Ann Thorac Surg 1997;64:1368-1373.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) 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): Michael A. Savitt Ambuj Choudhary Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Savitt, M. A. Articles by Ahmed, A. Search for Related Content PubMed PubMed Citation Articles by Savitt, M. A. Articles by Ahmed, A. Related Collections Valve disease