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Ann Thorac Surg 2003;75:637
© 2003 The Society of Thoracic Surgeons

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Correspondence

Reoperative aortic valve replacement with patent internal thoracic artery and venous grafts

Department of Cardiothoracic Surgery, Stanford University School of Medicine, Falk CVRB, Stanford, CA 94305-5407, USA

To the Editor:

We read with great interest the recent article by Dr Bryne and coworkers regarding their approach to the increasing problem of late aortic valve replacement in the setting of functioning internal mammary grafts [1]. As the Boston group had previously reported [2], their approach focuses on minimal dissection by utilizing an upper hemisternotomy and combining hypothermic perfusion of the mammary graft (20°C) with percutaneous retrograde coronary sinus cannulation.

We used a similar approach to patients with this clinical scenario; however, our operative strategy differed from theirs in that it obviates the need for hypothermia and percutaneous retrograde coronary sinus cannulation. The latter aspect of the procedure can be time-consuming, even for an experienced anesthesiologist.

After exposing the upper mediastinum and after intrathoracic arterial and venous cannulation, we let the patient drift only to 31°C to 33°C; ventricular fibrillation is either spontaneous or induced, the aorta is cross-clamped, and a vertical aortotomy is performed. The venous graft ostia are then individually cannulated with 6 F pediatric retrograde cardioplegia cannulas. These catheters (Medtronic DLP, Grand Rapids, MI) are secured to the edge of the aortotomy with a 5–0 polypropylene suture and continuously perfused with cold blood (10°C to 15°C). Mean pressures of 30 to 40 mm Hg have been monitored distal to the low-pressure manually inflatable balloons.

We concur with Dr Byrne’s observation of decreased operative time, blood loss, and transfusion requirement. This technique may prove useful for elderly patients, as well as for those who preoperatively refuse any potential administration of blood products.

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 grafts. Ann Thorac Surg 2002;73:779-784.[Abstract/Free Full Text]
2. Byrne J.G., Aranki S.F., Couper G.S., Adams D.H., Allred E.N., Cohn L.H. Reoperative aortic valve replacement: partial upper hemisternotomy versus conventional full sternotomy. J Thorac Cardiovasc Surg 1999;118:991-997.[Abstract/Free Full Text]

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 Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Luca A. Vricella Bruce A. Reitz Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Vricella, L. A. Articles by Reitz, B. A. Search for Related Content PubMed PubMed Citation Articles by Vricella, L. A. Articles by Reitz, B. A. Related Collections Valve disease