Ann Thorac Surg 2009;87:714. doi:10.1016/j.athoracsur.2008.12.044
© 2009 The Society of Thoracic Surgeons
Original Articles: Adult Cardiac
Invited Commentary
Eugene A. Grossi, MD
Department of Surgery, New York University School of Medicine, 530 First Ave, Ste 9V, New York, NY 10016
(Email: grossi{at}cv.med.nyu.edu).
The authors describe an operative experience of 181 patients with prior sternotomy who underwent mitral valve operations through a right lateral 4- to 8-cm minithoracotomy [1]. The cardiopulmonary bypass support technique used femoral vessel access and retrograde arterial perfusion. In more than 75% of these patients, the mitral operation was done without cross-clamping and with the technique of ventricular fibrillation. The authors report relatively good results—a 30-day mortality of 6.6% and a stroke incidence of 3.8%. Although it is difficult to have a comparable control group, as described in their limitations section, the authors have achieved excellent results in this difficult cohort of patients.
Several good points mentioned by the authors should be reemphasized. The importance of a preoperative chest computed tomography scan to evaluate the anatomy and aid in approach planning should not be underestimated. The presence of right pleural disease (due to prior resection or pleurodesis) is a serious contraindication and should lead the surgeon to evaluate a left-sided approach. Finally, this large series reconfirms the efficacy and safety of "ignoring" a patent left interior mammary artery graft and mitigates its presence by the strategy of additional core cooling.
I am disappointed, however, that in this large series, central aortic or right axillary arterial cannulation was never used; each approach has the advantage of antegrade aortic perfusion. Although this is a relatively young cohort with presumably less atherosclerotic aortic burden and at low risk for complications from retrograde perfusion, data from our institution and the Cleveland Clinic demonstrate a lower incidence of neurologic complications when overall antegrade perfusion strategy is used. These alternative cannulation techniques are important to have in one's armamentarium; central arterial perfusion provides a good option when femoral or iliac occlusive disease is present. The authors stated that the femoral system was evaluated with preoperative computed tomography, but did not state what happened to these patients when such disease was encountered.
The authors are to be congratulated on this fines series. By applying the basic surgical principals of good vision and approach through a relatively virgin operative field, they have achieved excellent results for this cohort of high-risk reoperative patients.
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References
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- Seeburger J, Borger MA, Falk V, et al. Minimal invasive mitral valve surgery after previous sternotomy: experience in 181 patients Ann Thorac Surg 2009;87:709-714.[Abstract/Free Full Text]
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