Ann Thorac Surg 1997;64:1196
© 1997 The Society of Thoracic Surgeons
Invited Commentary
Invited Commentary
Hendrick B. Barner, MD
Department of Cardiothoracic Surgery, Washington University School of Medicine, One Barnes Hospital PlazaSuite 3108, St. Louis, MO 63110
See also page 1194.
Tovar and his associates have presented their experience with closure of a right ventriculotomy made accidentally in dissecting an intramural left anterior descending coronary artery (LAD) or incidentally in exposing an intracavitary LAD. Arguably their technique may be less likely to compromise septal branches than placing conventional horizontal mattress sutures extending from the epicardium of the right and left ventricles beneath the LAD, but any of the described techniques carry this risk. It is frequently necessary to dissect the intramural and rarely the intracavity LAD because the distal epicardial LAD is not of ideal size, and despite experience and caution (or an intracavitary position of the LAD) the right ventricle is occasionally entered. In more recent years awareness of this possibility has resulted in early recognition of this violation of the right ventricular cavity when the opening is small. This allows repair with a running or mattressed 6-0 polypropylene suture placed through the right ventricular endocardium without buttressing and without reaching into the septum. A second layer of sutures may be placed superficial to the first. The anastomosis to the LAD can be placed just distal to the site of the right ventricular entry or (if the LAD is not of adequate size) the LAD can be approached from the proximal side usually by following a diagonal artery. This approach has always prevented right ventricular bleeding without placement of additional sutures and avoids potential compromise of branches of the LAD. It also avoids potential compromise of the LAD, which can occur if the intracavitary LAD is not fully mobilized and brought entirely anterior to the repair to avoid a transition from an intracavitary to extracavitary position. Such a transition can be a source of bleeding from the right ventricular cavity or the LAD may be compressed by sutures or tissue if the repair is too snug in an effort to avoid bleeding. Occassionally this approach will not fit the situation and the method described by Tovar and associates is an excellent one to have ready.
Related Article
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Ventriculotomy Repair During Revascularization of Intracavitary Anterior Descending Coronary Arteries
- Eduardo A. Tovar, Alan Borsari, Daniel W. Landa, Paul B. Weinstein, and Alan B. Gazzaniga
Ann. Thorac. Surg. 1997 64: 1194-1196.
[Abstract]
[Full Text]
