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

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Correspondence

Reply

Department of Thoracic and Cardiovascular Surgery, Sapporo Medical University School of Medicine, South 1 West 16, Central Ward, Sapporo, Japan

(Email: kmori{at}sapmed.ac.jp).

To the Editor:

Thank you for the opportunity to comment on this letter from Dr Luciani and associates [1]. They have obtained excellent results using their sophisticated strategies. The hospital mortality rate was only 2% in 137 redo valvular patients, and deaths were not related to re-entries. We agree that prophylactic use of femro-femoral bypass is beneficial for high-risk patients. A brief circulatory arrest facilitates sternal dissection under any conditions. However, this technique should be limited to high-risk patients because it is time consuming. Prolonged operative time increases operative costs. Considering the recent trend of diminishing reimbursement, routine use of circulatory arrest is inappropriate. Its use should be considered after examining retrosternal adhesions by computed tomographic scans. Technical maneuvers for re-entry should be individualized because there are a variety of preoperative situations ranging from insidious adhesions to accessible ones.

The morphology of the thorax and valvular pathology, as the authors pointed out, are key factors for determining the risk of re-entry. However, life-threatening cardiac or vascular adhesions exist in patients who need a third or fourth sternotomy [2]. In our experience, the aorta or the right ventricle adheres to the sternum in more patients undergoing fourth sternotomy than in patients undergoing a second sternotomy. Our multivariate analysis confirmed a fourth sternotomy is a significant factor for risk of sternotomy-related injury [3]. However, we do not intend to perform computed tomographic scans only in patients requiring third or fourth sternotomies; any patient who has risk factors for re-entry needs preoperative computed tomographic scans.

Finally, we emphasize that surgical skills in addition to preoperative assessment are important for dealing with these demanding situations.

	References

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1. Luciani N, Nasso G, Piscitelli M, Possati G, Anselmi A. Computed tomography scan in redo valvular surgery (letter) Ann Thorac Surg 2005;80:2422-2423.[Free Full Text]
2. Piehler JM. Invited commentary Ann Thorac Surg 2003;75:1481.[Free Full Text]
3. 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]

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 Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Kiyofumi Morishita Tomio Abe Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Morishita, K. Articles by Abe, T. Search for Related Content PubMed Articles by Morishita, K. Articles by Abe, T. Related Collections Valve disease Related Article