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Ann Thorac Surg 2004;77:718-720
© 2004 The Society of Thoracic Surgeons

Case report

Aortic valve replacement in a patient with a patent internal thoracic artery graft

Takashi Ueda, MD*a, Tetsuji Kawata, MDa, Hidehito Sakaguchi, MDa, Nobuoki Tabayashi, MDa, Takehisa Abe, MDa, Tomoaki Hirose, MDa, Shigeki Taniguchi, MDa

a Department of Surgery III, Nara Medical University, Nara, Japan

Accepted for publication April 9, 2003.

* Address reprint requests to Dr Ueda, Department of Surgery III, Nara Medical University, 840 Shijo-cho, Kashihara, Nara 634-8522, Japan
e-mail: u-taka{at}naramed-u.ac.jp


   Abstract
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 Abstract
Introduction
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Myocardial protection in patients requiring a second open-heart surgical procedure after coronary artery bypass grafting, especially when there is a patent left internal thoracic artery graft to the left anterior descending coronary artery, remains controversial. We present the case of a patient in whom aortic valve replacement was undertaken 18 months after coronary artery revascularization. Unusual features included beating-heart aortic valve replacement with continuous retrograde coronary sinus perfusion and avoidance of dissection of the patent grafts, including the left internal thoracic artery and a saphenous vein graft.


   Introduction
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 Abstract
 Introduction
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We report the case of a patient who underwent aortic valve replacement (AVR) in the presence of a patent left internal thoracic artery (LITA) graft 18 months after previous coronary artery bypass grafting. Conventional AVR requires cardiac arrest with cardioplegia, which mandates dissection and proximal control of the patent ITA. Injuries to the patent ITA graft associated with dissection can result in devastating complications. Therefore, we undertook AVR on a beating heart using continuous retrograde coronary sinus (CS) perfusion to avoid these anticipated difficulties.

A 72-year-old man underwent coronary artery bypass grafting (LITA–left anterior descending coronary artery and saphenous vein–obtuse marginal branch) combined with repair of an abdominal aortic aneurysm. He also had severe aortic regurgitation that was not apparent at that time and chronic aortic dissection (DeBakey IIIb) that had been observed during follow-up. The patient was scheduled for AVR 18 months after coronary artery revascularization.

The technique of beating-heart valve operation with retrograde CS perfusion of oxygenated blood was performed as previously described [1–3] (Fig 1). Total cardiopulmonary bypass at normothermia was established by cannulating the ascending aorta and both venae cavae through a full repeat sternotomy. Decompression of the left ventricle was performed using left ventricular venting through the right superior pulmonary vein. Dissection of the left side of the heart was not done, and thus neither dissection nor clamping of the patent LITA graft was attempted. The adhesions around the heart were severe, especially between the ascending aorta and the pulmonary artery, which necessitated the application of an aortic clamp distal to the anastomotic site of the saphenous vein graft.



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  		Fig 1. On-pump beating-heart aortic valve replacement using retrograde coronary sinus (CS) perfusion. (RSPV = right superior pulmonary vein.)

 
Retrograde CS perfusion was begun simultaneously with aortic clamping. Although we initially started the retrograde CS perfusion at a rate of 300 mL/min, an idioventricular rhythm developed in the heart. We increased the CS flow to a maximum rate of 650 mL/min, with recovery of sinus rhythm. After that, the mean flow of the retrograde CS perfusion was regulated at 600 mL/min, providing a CS mean pressure of less than 120 mm Hg to maintain sinus rhythm. Aortic valve replacement with a bioprosthetic valve was performed with good exposure. Intraoperative transesophageal echocardiography revealed no abnormal findings in the ventricles, and the patient was easily weaned from cardiopulmonary bypass.

Postoperative recovery was uneventful. The patient underwent replacement of the descending thoracic aorta 22 days after AVR.


   Comment
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 Comment
References
 
Aortic valve replacement in patients with a patent ITA graft remains a challenging procedure because of the possibility of injury to the graft and inadequate myocardial protection. Byrne and co-workers [4] reported aortic valve replacement with cardioplegic arrest but without dissection and clamping of an ITA graft. In their method, moderate to deep hypothermia was required to compensate for inadequate myocardial protection resulting from regional myocardial warming and washout of cardioplegic solution in the territory supplied by the ITA. However, reperfusion injury secondary to cardioplegic arrest under hypothermia can have a detrimental effect on a hypertrophic or impaired left ventricle. Savitt and associates [5] reported a simple technique of AVR on the beating heart using antegrade continuous coronary perfusion without cardioplegia. Although reperfusion injury was eliminated in their procedure, there remained the possibility of damaged coronary ostia and impairment of view by the presence of multiple cannulas for the perfusion of the native coronary arteries and saphenous vein grafts.

Beating-heart valve operations using retrograde oxygenated CS perfusion have advantages in terms of avoiding potential damage to a patent LITA graft and obtaining adequate myocardial protection. Proximal control of an ITA graft or of saphenous vein grafts is not required. In patients with proximal anastomoses of saphenous vein grafts to the ascending aorta at the time of the previous coronary artery bypass grafting, it often can be difficult to dissect the ascending aorta to clamp proximal to the anastomotic sites. Previous clinical studies of on-pump beating-heart operations [1–3] recommended that CS flow be more than 300 mL/min and CS pressure be less than 60 mm Hg. We controlled the CS flow at a rate of 600 mL/min and the CS mean pressure at lower than 120 mm Hg, as Eke and associates [6] had shown this to be the safe limit of CS perfusion pressure in an experimental study. Moreover, we increased the CS flow to 650 mL/min temporarily to recover normal sinus rhythm from idioventricular rhythm. No detrimental effects were observed in the patient's clinical course. We think that CS flow should be maintained as high as possible and that the CS pressure should be lower than 120 mm Hg.

In conclusion, we believe that on-pump beating-heart AVR with retrograde CS perfusion is one option for patients with a patent ITA graft because it allows good myocardial protection and avoidance of injury to a patent graft.


   References
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 Abstract
 Introduction
 Comment
 References
 

  1. Gersak B. Mitral valve repair or replacement on the beating heart. Heart Surg Forum 2000;3:232-237.[Medline]
  2. Gersak B., Sutlic Z. Aortic and mitral valve surgery on the beating heart is lowering cardiopulmonary bypass and aortic cross clamp time. Heart Surg Forum 2002;5:182-186.[Medline]
  3. Matsumoto Y., Watanabe G., Endo M., Sasaki H., Kasashima F., Kosugi I. Efficacy and safety of on-pump beating heart surgery for valvular disease. Ann Thorac Surg 2002;74:678-683.[Abstract/Free Full Text]
  4. 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]
  5. Savitt M.A., Singh T., Agrawal S., Choudhary A., Chaugle H., Ahmed A. A simple technique for aortic valve replacement in patients with a patent left internal mammary artery bypass graft. Ann Thorac Surg 2002;74:1269-1270.[Abstract/Free Full Text]
  6. Eke C.C., Gundry S.R., Fukushima N., Bailey L.L. Is there a safe limit to coronary sinus pressure during retrograde cardioplegia?. Am Surg 1997;63:417-420.[Medline]



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