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Ann Thorac Surg 2005;79:589-595
© 2005 The Society of Thoracic Surgeons

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Original article: Cardiovascular

Modification of Surgical Planning Based on Cardiac Multidetector Computed Tomography in Reoperative Heart Surgery

^a Department of Radiology
^b Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel

Accepted for publication July 9, 2004.

^* Address reprint requests to Dr Mohr, Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center, 6 Weizman St, Tel Aviv 64239, Israel (E-mail: marion{at}tasmc.health.gov.il).

	Abstract

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
BACKGROUND: Repeat open heart surgery is associated with an increased risk of injury to old conduits and cardiac structures. To reduce this risk, we evaluated the contribution of multidetector computed tomography angiography in planning repeat cardiac operations.

METHODS: Fifteen patients who had previous coronary artery bypass grafting procedures underwent retrospective-gated computed tomographic angiography with a 16-slice multidetector computed tomography. Relation of the grafts to the expected median sternotomy line, graft patency and anatomic course, possible aortic cannulation and cross-clamp sites, distances between the right ventricle to the sternum, and calcification of the ascending aorta were assessed.

RESULTS: Multidetector computed tomography demonstrated 45 conduits (mean, 3 ± 1.1); 18 arterial grafts and 13 saphenous vein grafts that were patent, and 2 internal mammary artery grafts and 12 saphenous vein grafts that were occluded. Significant narrowing was shown in 3 of the patent internal mammary arteries and 4 of the patent saphenous vein grafts. Adherence of the right ventricle, left internal mammary artery, and saphenous vein graft to the sternum (0 to 3 mm in the midline) was demonstrated in 8, 2, and 1 patients, respectively. Two patients had a heavily calcified aorta. During surgery, all multidetector computed tomographic findings were confirmed. Three aspects of the operative plans of 4 patients were modified according to multidetector computed tomographic findings: median sternotomy approach (3 patients), cannulation site (2 patients), and myocardial preservation technique (3 patients). On the basis of multidetector computed tomographic evaluations, surgery was cancelled in 2 patients in whom repeat operation was judged to be associated with increased risk: 1 patient, scheduled for coronary artery bypass grafting, had an extremely calcified aorta, and the other, scheduled for aortic valve replacement, had grafts that were adherent to the sternum.

CONCLUSIONS: Multidetector computed tomography is a new noninvasive tool for three-dimensional preoperative assessment of complex cardiac and graft anatomy. Our initial experience suggests that it may provide information to warrant modifying surgical planning, thus contributing to the safety of reoperative heart surgery.

	Introduction

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Cardiac reoperations are more complicated than the initial procedure [1]. Conventional selective angiography is the standard diagnostic tool for anatomic evaluation of grafts and native coronary arteries of reoperative patients who have undergone prior coronary artery bypass grafting (CABG) [2]. Selective angiography, however, does not provide the surgeon with complete information on the proximity of the aorta, right ventricle, coronary arteries, and grafts to the sternum, nor on the extent of aortic involvement in the calcified atherosclerotic process. This supplemental information can reduce the risks of injury to preexisting coronary grafts and other cardiac structures during sternotomy, and prevent stroke related to atheromatous or calcified embolus dislodgement from the diseased aorta. Recent reports suggest that these values can be obtained preoperatively from electrocardiograph-gated multisection computerized tomography (CT) of the heart (MDCT) [2].

We evaluated the contribution of MDCT angiography in the planning of repeat cardiac operations.

	Patients and Methods

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Between July 2003 and February 2004, 24 post-CABG patients were referred for reoperations: 18 for repeat CABG and 6 for aortic valve replacement. Fifteen of them (14 men and 1 women, ages 49 to 85 years; mean, 67 years) were examined with a 16-slice CT scanner (Mx 8000 IDT; Philips Medical Systems, Cleveland, OH). The mean duration after the initial CABG was 5.6 years (range, 1 week to 18 years).

Computed Tomographic Data Acquisition, Image Reconstruction, and Processing
The 15 patients were examined by an MDCT that acquires 16 parallel rows of data at a gantry rotation time of 420 ms with a resulting average temporal resolution between 70 and 210 ms (depending on heart rate and pitch). The patients were examined while in a supine position after attachment of the electrocardiograph leads. All studies were performed during one breathhold. The scanning volume covered the region between the thoracic inlet and the apex of the heart, or between the thoracic inlet and the upper abdomen when a right gastroepiploic artery graft was present. A total of 130 to 150 mL of contrast material at a concentration of 370 mg of iodine per milliliter (Ultravist, Schering, Berlin, Germany) was injected at a rate of 4.0 mL/s. On the MDCT day, the patients received their routine medications (including blocking agents), without supplementary doses of ß-blockers.

Scanning Variables
The tube voltage was 140 kV at 400 mA. The detector collimation was 16 x 0.75 mm in 13 patients and 16 x 1.5 mm in 2 patients who could not hold their breath long enough for covering the large scanning volume. The pitch was set at 0.22 to 0.3, depending on the heart rate and breathhold capabilities of the individual patient, and the volume to be covered. The length of scanned volume was 24 to 28 cm, and the total scan time varied from 24 to 37 seconds. The range of the patients' heart rate was 57 to 93 beats/min (mean, 70 beats/min).

Image processing and data analysis were performed on a separate workstation (MxView; Philips Medical Systems) using dedicated cardiac software. Volume-rendering three-dimensional images were obtained for global presentation of the heart, the coronary arteries, and the grafts. Initially, a set of images demonstrating the grafts' relative location to the sternum was created. The sternum was then virtually removed from the three-dimensional images to expose the vessels located just behind it (Fig 1, top left).

View larger version (141K): [in this window] [in a new window]   Fig 1. Preoperative assessment of a 58-year-old man who had undergone previous coronary artery bypass grafting and who underwent the following grafts: left internal mammary artery to left anterior descending coronary artery, saphenous vein grafts to the marginal and posterior descending branch of the right coronary artery. (Top left) Coronal three-dimensional volume-rendered reconstruction of the heart and great vessels after sternal removal. The left internal mammary artery (white arrow) and saphenous vein graft to right coronary artery (black arrow) are located at the midline (white arrowhead = left anterior descending coronary artery; black arrowhead = right coronary artery). (Top right) Sagittal maximal intensity projection reconstruction demonstrating the proximity of left internal mammary artery (white arrow), near the third sternal wire and saphenous vein graft (black arrow), near the fifth sternal wire, to the sternum (arrowheads point to the sternal wires). (Bottom left) Curved multiplanar reconstruction demonstrating significant stenosis of the left internal mammary artery 0.5 cm proximal to the anastomosis (white arrow). (LAD = left anterior descending coronary artery, black arrow; black arrowhead = anastomosis site.) (Bottom right) Coronal volume rendered image of the sternum demonstrating the extent of the sternal incision: the upper border of the incision is marked by the fifth stainless steel wire.

Curved multiplanar reconstruction images were created in several planes for each coronary artery and for each graft for the assessment of occlusion or stenosis (Fig 1, bottom left).

Each examination, including patient preparation and scanning, required 10 minutes. Image reconstruction and processing generally required 45 to 90 minutes.

The study was approved by the institutional review board, and all the subjects gave informed consent to participate.

	Results

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Of 24 suitable candidates for repeat operations, 15 underwent preoperative assessment with electrocardiographic-gated coronary CT angiography. Nine patients were not assessed by CT owing to the urgency of the operative procedure, renal failure, or temporary unavailability of the CT service.

The 15 study patients had a total number of 45 CABG conduits (mean, 3 ± 1.1), all of which were demonstrated by MDCT. Twenty grafts were arterial (14 left internal mammary arteries [IMAs], 4 right IMAs, 1 radial artery, and 1 gastroepiploic artery) and 25 were saphenous vein grafts (SVGs). Two of the arterial grafts (1 left IMA and 1 right IMA) and 12 of the SVGs were occluded. Significant narrowing of grafts was demonstrated in 3 of the left IMAs (Fig 1, bottom left) and in 4 of the SVGs. Imaging artifacts caused by surgical clips prohibited the demonstration of 1 SVG anastomosis and 3 of the distal IMA anastomoses (metal clips were used routinely during harvesting of these IMAs as skeletonized vessels). All other distal anastomoses of patent grafts could be visualized.

Sixteen-slice CT enabled exact localization of conduits and their proximity to the sternum and chest wall. During surgery, all MDCT findings were confirmed.

Adherence of the right ventricle, left IMA, and SVG to the sternum (0 to 3 mm in the midline, future resternotomy line) was demonstrated in 8, 2, and 1 patients, respectively. A heavily calcified aorta was demonstrated in 2 patients.

Computed tomographic angiography affected the management of 6 of 15 patients who were studied: in 4 patients the operative plan was modified, and in 2 patients surgery was deferred. Three aspects of the operative plans were modified according to MDCT findings: median sternotomy approach (n = 3), cannulation site (n = 2), and myocardial preservation technique (n = 3).

The median sternotomy technique was altered because of MDCT findings in 3 patients. In 1 patient a partial lower sternotomy enabled exposure of the operative field and performance of the operation without the risk of injury to the conduits that were adherent to the sternum at its upper portion (Fig 1). In a second patient, the median sternotomy technique was modified, and the steel wires were kept in place during sawing of the sternum to protect the right ventricle, which was severely adherent to the sternum, (acute marginal branch at a distance of 3 mm from the posterior plate at the midline; Fig 2). The left IMA was also adherent to the sternum in a third patient but the adherence point was localized, with the help of MDCT, as being 8 mm lateral to the midline (Fig 3, top), thus permitting a safe median sternotomy. The sternal retractor was placed only after complete separation of the mammary artery from the area attaching the sternum.

View larger version (135K): [in this window] [in a new window]   Fig 2. Preoperative assessment of a 68-year-old man with a history of prior coronary artery bypass grafting. Axial maximal intensity projection image demonstrating the proximity of the right ventricle and the acute marginal branch to the sternum (arrow).

View larger version (82K): [in this window] [in a new window]   Fig 3. Preoperative assessment for aortic valve replacement in a 65-year-old man with a history of prior coronary artery bypass grafting. (Top) Axial maximal intensity projection image showing that the closest part to the sternum of the left internal mammary artery (arrow) was at the manubrium level, 8 mm lateral to the midline (asterisk). (Bottom) Axial maximal intensity projection image. The left internal mammary artery (white arrow) and saphenous vein graft (black arrow) were adherent to each other at the level of the aortic arch.

Myocardial protection was modified in 3 patients. The off-pump technique was used in 2 of them owing to inaccessibility of the ascending aorta in 1 (Fig 1, bottom right) and heavy calcifications involving the ascending aorta in the other (Fig 4). In the third patient, MDCT showed that the IMA was very thin (Fig 5) and that it was supplying a very small area of myocardium. On the basis of this observation and previous reports [3, 4], it was decided that its occlusion was not critical for adequate myocardial preservation; instead, body temperature was lowered to 28°C, and cold retrograde cardioplegia was used successfully.

View larger version (146K): [in this window] [in a new window]   Fig 4. Preoperative assessment of a 69-year-old woman with a history of prior coronary artery bypass grafting. Sagittal oblique maximal intensity projection image demonstrating the heavily calcified aorta (arrow).

View larger version (117K): [in this window] [in a new window]   Fig 5. Preoperative assessment of a 68-year-old man with a history of prior coronary artery bypass grafting (same patient as in Fig 2): Volume-rendered reconstruction showing the extremely narrow left internal mammary artery (white arrows), the patent saphenous vein graft to the proximal left anterior descending coronary artery (black arrow), and the proximal segment of the occluded vein graft to the left anterior descending coronary artery (black arrowheads). The distal left anterior descending coronary artery is diffusely and heavily calcified, but the artery is patent with internal flow (white arrowhead).

View larger version (111K): [in this window] [in a new window]   Fig 6. Preoperative assessment for aortic valve replacement in a 73-year-old man with stable angina and a history of two prior coronary artery bypass graftings. Axial image showing the right internal mammary artery crossing the midline (arrowheads). The minimal distance between the right internal mammary artery and sternum is 0.6 mm.

	Comment

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

Median sternotomy is a blind procedure that can cause catastrophic bleeding in repeat operations because of injury to cardiac structures and extracardiac conduits adherent to the posterior plate of the sternum. In a survey of 2,046 catastrophic bleeding events in reoperations reported by 1,116 surgeons, the most common cardiac structures injured were the right ventricle (39%), SVG (20%), aorta (15%), IMA (12%), and innominate vein (6%). The relative distribution of anatomic structures injured reflected their most common location in relation to the midline [13]. In a retrospective review of 610 reoperations performed at the University of New Mexico, the only independent variable that increased the risk of catastrophic bleeding as a result of injury was the presence of a patent conduit (SVG or IMA) [13].

A large proportion of reoperative patients with a patent left IMA are "graft dependent." The reported incidence of injury to a patent left IMA in the Cleveland Clinic experience is 5.3%, with a perioperative infarction rate of 50% [14]. In that report, chest radiography and cardiac catheterization were used to identify left IMA grafts that were close or adherent to the sternum. Unfortunately, those imaging techniques provide insufficient information for avoiding left IMA injury associated with sternal division. Better spatial (three-dimensional) localization of the left IMA and its relation to a future median sternotomy line can be obtained with axial sections and volume-rendered images using the MDCT.

The surgical approach may be modified to accommodate patients with a patent IMA crossing the midline and one which is adherent to the sternum. The procedural modifications reported in our current study include partial sternotomy, axillary cannulation, off-pump revascularization, or deferring surgery. Other management modifications have been reported, among them left thoracotomy, minimally invasive coronary bypass grafting, subxiphoid procedures, and left or right minithoracotomy that leave the old graft untouched [13, 15, 16], or even avoiding surgery and opting for angina control with drug treatment [16].

The improved long-term survival of patients undergoing revascularization with the left IMA resulted in the increasing use of the right IMA. An in situ right IMA must cross the midline in its course to reach branches of the left coronary system (left anterior descending coronary artery, or the marginal branches of the circumflex artery). This pathway of the right IMA substernally across the midline increases the risk of injury to this conduit during resternotomy. Information regarding the proximity of the crossing right IMA to the posterior sternal plate is essential for the surgeon, and it can be obtained from a preoperative MDCT (Fig 6).

Imaging of patent SVGs and their relation to midline is also very crucial. Saphenous vein grafts to the right system may be injured during median sternotomy if they are routed anterior to the right ventricle during the first operation, as well as in cases with a dilated ascending aorta, with dilatation of the old SVG proximal anastomosis site, or with an enlarged right ventricle [2]. Manipulation of a patent but diseased graft can also cause myocardial damage owing to a shower of emboli into the distal circulation [2]. Accurate preoperative localization of the diseased vein grafts can help prevent myocardial damage.

An important contribution of MDCT in preoperative evaluation of the reoperative patient is the evaluation of involvement of the ascending aorta in atherosclerotic disease. Embolic dislodgement of atherosclerotic or calcified plaques during surgical manipulation of the ascending aorta has been recognized as a major cause of stroke [17]. In patients with atherosclerotic disease of the aorta, the risk of a cerebral event was 8.6% versus 1.8% in the absence of aortic disease [18].

Several modifications of the surgical approach in patients with a calcified aorta have been described, including off-pump CABG [19, 20], "no-touch" off-pump total arterial revascularization [21], axillary artery cannulation [22], and mechanical or suture-based clampless proximal connectors [23]. In the current report, management was modified in 6 of the 15 reoperative study patients as a result of the MDCT findings.

We therefore recommend MDCT for all patients with patent grafts or with increased risk of catastrophic bleeding (eg, second or third reoperation, enlarged right atrium or right ventricle, and dilatation or aneurysm of the ascending aorta) [13]. We also recommend MDCT for all patients who have an increased risk of calcific-atherosclerotic involvement of the ascending aorta, such as individuals with carotid disease, peripheral vascular disease, history of cerebrovascular event, diabetics, and those older than 75 years of age [17–23].

Despite the clear benefits that can be obtained from routine use of MDCT before repeat operation, only 15 of the 24 reoperative patients operated on during the study period were evaluated preoperatively with this imaging technique. The main reasons for not conducting MDCT were preoperative renal failure and surgical urgency. Most of the patients referred for surgery presented a short time after cardiac catheterization, and concern about nephrotoxicity associated with contrast media reexposure precluded the performance of MDCT. As stated above, the most common cardiac structure that can be penetrated during resternotomy is the right ventricle. Because the distance between the right ventricle and the sternum can also be evaluated without contrast material, we adopted the practice of performing cardiac-gated MDCT without contrast material in our most recent reoperative patients with renal dysfunction. This more limited examination is also valuable in detecting calcific involvement of the ascending aorta, and may provide some information on graft localization [2].

In conclusion, our findings show that MDCT is a new diagnostic tool that contributes valuable information to the preoperative evaluation of a patient who is a candidate for reoperation. With the information acquired from the analysis of the new-generation 16-slice MDCT, the surgeon can avoid both injury to patent conduits and cardiac chambers and manipulation of calcified aorta, thus reducing the operative risk associated with repeat operations.

	Acknowledgments

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
The authors thank Esther Eshkol for editorial assistance.

	References

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 

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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): Ram Sharony Amir Kramer Nahum Nesher Dan Loberman Yanai Ben-Gal Gideon Uretzky Rephael Mohr Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Aviram, G. Articles by Mohr, R. Search for Related Content PubMed PubMed Citation Articles by Aviram, G. Articles by Mohr, R. Related Collections Coronary disease