ATS
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Luciani, N.
Right arrow Articles by Possati, G.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Luciani, N.
Right arrow Articles by Possati, G.
Related Collections
Right arrow Valve disease

Ann Thorac Surg 2002;74:1747
© 2002 The Society of Thoracic Surgeons

Correspondence

Aortic valve surgery after previous coronary artery bypass grafting with patent internal mammary artery grafts: Personal Contributions

Nicola Luciani, MDa, Giuseppe Nasso, MDa, Gianfederico Possati, MDa

a Department of Cardiology and Cardiovascular Surgery, Catholic University of Sacred Heart, Largo Francesco Vito n.1 Rome, Italy,

e-mail: nicola.luciani{at}tiscalinet.it

To the Editor:

We read with interest the article by Byrne and associates [1] regarding aortic valve surgery after previous CABG with functioning internal mammary artery grafts. This article and the commentary prompted us to write this letter. Above all, we congratulate the authors for their impressive results in a large series of high-risk patients. We basically agree with their strategy, but in our limited experience (7 patients), we have simplified our management as described below.

First, if an isolated aortic valve replacement (AVR) is planned and preoperative angiograms show that the left internal mammary artery (LIMA) does not cross the midline, it is not necessary to heparinize the patient and to initiate cardiopulmonary bypass before resternotomy, as suggested by Gillinov and Lytle [2]. The groin surgical field is prepared without any incision, and femoral cannulation is carried out only if the patients become hemodynamically or electrically unstable or if the ascending aorta cannot be canulated.

After full median resternotomy, we do not isolate or clamp the LIMA pedicle. The AVR takes place in the upper and middle zones of the mediastinum. We gradually open the sternum to 10 to 12 cm, and dissect right and diaphragmatic surfaces of the heart and leave the entire left side intact. This allows us to insert venous cannula, coronary sinus catheter, and vent through the right superior pulmonary vein. We limit hypothermia to 24°C. At this temperature, pump flow can be reduced and short, repeated periods of circulatory arrest are safe and helpful to reduce collateral back flow from the coronary ostia.

For myocardial protection, we use continuous or intermittent (at least every 10 minutes) retrograde isothermic (the same temperature of perfusate) blood cardioplegia according to the mini-cardioplegia technique [2], without clamping the LIMA pedicle. The heart remains arrested, hypothermic, and almost continuously perfused. We avoid temperature gradients between the territory perfused by the LIMA and that of the cardioplegia solution, which occurs when crystalloid solution at 4°C is used, as reported by the authors. No operative death occurred, although 2 patients needed a short postoperative period of inotropic drug support. ([3])

References

  1. Byrne J.G., Karavas A.N., Filsoufi F., et al. Aortic valve surgery after previous coronary artery bypass grafting with functioning internal mammary artery grafts. Ann Thorac Surg 2002;73:779-784.[Abstract/Free Full Text]
  2. Gillinov A.M., Lytle B.W. Invited commentary. Ann Thorac Surg 2002;73:784.[Free Full Text]
  3. Luciani N., Martinelli M., Gaudino M., Alessandrini F., Glieca F., Possati G. Tepid systemic perfusion and intermittent isothermic blood cardioplegia in coronary surgery. J Cardiovasc Surg 1998;39:599-607.[Medline]




This Article
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Luciani, N.
Right arrow Articles by Possati, G.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Luciani, N.
Right arrow Articles by Possati, G.
Related Collections
Right arrow Valve disease

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS