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Ann Thorac Surg 2005;80:2422-2423
© 2005 The Society of Thoracic Surgeons

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Correspondence

Computed Tomography Scan in Redo Valvular Surgery

^a Department of Cardiovascular Medicine, Catholic University, Largo Francesco Vito 1, Rome, Italy
^b Department of Cardiovascular Sciences, Campus Bio-Medico University of Rome, Via Longoni 83, Rome, Italy

(Email: nicola.luciani{at}tiscalinet.it; amedeo.anselmi{at}aliceposta.it).

To the Editor:

We read with great interest the article by Morishita and associates [1] concerning the role of computed tomography (CT) in redo valvular surgery.

We agree with Morishita and associates [1] that preoperative CT can play an important role in the assessment of the risk of re-entry injuries in redo patients and in the planning of the optimal surgical strategy. Their group is to be congratulated for their further contribution to the interesting and challenging field of cardiac reoperations.

However, their experience merits few comments.

First, we believe that the number of previous sternotomies does not increase the risk of re-entry injuries to the heart or to the great vessels, or to both. Conversely, the morphology of the thorax (as assessed by latero-lateral chest roentgenogram) and the kind of valvular pathology (ie, namely severe tricuspid lesion and aortic stenosis even without aortic aneurysm) have a major impact in determining this risk. In our opinion the CT scan without contrast agent is always advisable in redo patients, but it becomes mandatory in the presence of the mentioned conditions regardless of the number of previous sternotomies.

Second, in high risk patients with close adhesions between the ascending aorta and the right ventricle and the posterior surface of the sternum, femoro-femoral cannulation is performed in our center. Next we start extracorporeal circulation (ECC) as with our Japanese colleagues also, but we cool the patient up to 28°C (rectal temperature). The cooling is achieved very slowly, while the cardiac activity and the occurrence of left ventricular distension are routinely monitored by two-dimensional transesophageal echocardiography. A brief circulatory arrest is then performed while cutting the sternum with an oscillating saw. If no lesion occurs, ECC is restarted and the patient's rewarming begins when the most insidious adhesions are removed. Although time consuming, this method is probably safer than the protocol adopted by Morishita and associates [1]. A lesion of the ascending aorta may be very difficult to manage by normothermic ECC without the risk of severe, prolonged cerebral hypoperfusion with a risk of fatal neurologic sequelae.

When and how to use ECC for re-sternotomy is an area of debate, and in patients with severe tricuspid valve disease affected by hepatomegaly and ascites, we are very liberal in the adoption of full flow ECC through femoral vessels before re-sternotomy. This reduces the risk of catastrophic lesions and decompresses the heart within the pericardial adhesions; therefore the patient can be weaned safely and expeditiously without hemodynamic and arrhythmic disturbances. Moreover, as a consequence of decreased central venous pressure, hepatomegaly is dramatically reduced, and a large volume of fluid can be removed from the hemo-concentrator connected to the heart-lung machine.

We obtain good systemic perfusion and excellent myocardial protection before passing to aortic cross clamping after complete removal of pericardial adhesions. In our last 137 redo valvular cases, we operated on our patients by adopting these strategies and using the harmonic scalpel as suggested by Lamm and colleagues [2]; we had 3 hospital deaths, no re-entry injuries, and 3 revisions for bleeding with an average total blood loss of 280 ± 110 mL.

	References

Top References

 

1. Morishita K, Kawaharada N, Fukada J, et al. Three or more median sternotomies for patients with valve diseaserole of computed tomography. Ann Thorac Surg 2003;75:1476-1481.[Abstract/Free Full Text]
2. Lamm P, Juchem G, Schutz A, Rreichart B. Is the harmonic scalpel feasible in cardiac reoperations? Ann Thorac Surg 2001;72:2185.[Free Full Text]

This article has been cited by other articles:

				N. Luciani, G. Nasso, A. Anselmi, F. Glieca, M. Gaudino, F. Girola, M. Piscitelli, M. Perisano, L. Martinelli, and G. Possati Repeat Valvular Operations: Bench Optimization of Conventional Surgery Ann. Thorac. Surg., April 1, 2006; 81(4): 1279 - 1283. [Abstract] [Full Text] [PDF]

				K. Morishita, N. Kawaharada, J. Fukada, K. Kuwaki, and T. Abe Reply Ann. Thorac. Surg., December 1, 2005; 80(6): 2423 - 2423. [Full Text] [PDF]

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): Nicola Luciani Giuseppe Nasso Gianfederico Possati Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Luciani, N. Articles by Anselmi, A. Search for Related Content PubMed PubMed Citation Articles by Luciani, N. Articles by Anselmi, A. Related Collections Valve disease Related Article