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Ann Thorac Surg 2007;84:359-360
© 2007 The Society of Thoracic Surgeons
Department of Cardiothoracic Surgery, James Cook University Hospital, Cardiothoracic Department, Marton Road, Middlesbrough, TS4 3BW United Kingdom
(Email: atlot{at}doctors.net.uk).
We would like to thank Dr Elami [1] for his comments on our report about using a Doppler flow probe to locate, temporarily occlude, and confirm subsequent flow in patent bilateral internal mammary artery grafts at reoperation [2].
We are happy to acknowledge that in our literature review we did not come across his article, published more than 12 years ago, which briefly mentioned, along with many other recommendations, the possibility of using a Doppler probe in reoperative median sternotomy [3]. We are sure that the reviewers of our article would also happily acknowledge this omission.
His article suggests that "A Doppler flow-probe may be helpful in detecting the [internal mammary artery] IMA graft if it cannot be visualized or palpated ... ," and further on "... dissection of this area assisted by palpation, visualization, and auscultation by Doppler facilitates a safe dissection" [3]. The technique is not described any further. The article describes a series of 48 successful re-sternotomies in which internal mammary artery damage was avoided, but does not mention if a Doppler probe was routinely used or in how many patients it helped in the dissection [3].
The intent of our contribution was to report and demonstrate how an extended use of contemporary Doppler equipment helped us in dealing with a particular patient, in both locating and controlling patent bilateral internal mammary grafts.
In our report [2] we cited two articles [4–5] that contained reference to Elami and colleagues’ article [3]. These articles quoted Elami and colleagues’ [3] work to reinforce the concept that "Nevertheless injury to a patent [Left Internal Thoracic Artery-Left Anterior Descending] LITA-LAD graft at reoperation can have catastrophic consequences" [4], and to further stress that "At the time of reoperation, careful review of the posteroanterior (PA) and lateral chest roentgenogram to locate the IMA grafts by their associated clips, as well as other prophylactic measures, such as institution of CPB, during resternotomy, have been suggested" [5].
We are interested in Elami’s view [1] that new technologies will enable the avoidance of re-sternotomy altogether and presumably render both of our articles to the category of "historical interest only." Although these techniques are clearly evolving at a considerable rate, we believe that re-sternotomies will be with us for some time further, and would thus suggest that all surgeons embarking on redo surgery read Dr Elami and colleagues’ article [3], which provides a clear description of how a careful and thoughtful operative plan, alongside the use of technology (such as a Doppler flow probe), can help reduce mortality and morbidity in this high-risk group of patients.
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