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Ann Thorac Surg 1997;64:992
© 1997 The Society of Thoracic Surgeons
DR HASSAN NAJAFI (Chicago, IL): We have come to expect nothing but excellent reports from Dr Kouchoukos and his colleagues over the years, and their fine presentation today is no exception. I wish to make a technical point.
In recent years, I have operated on 3 patients who had had a previous cardiac operation. The first patient had undergone a Björk-Shiley aortic valve replacement 10 years earlier. This patient required excision of that valve, mitral valve replacement, and insertion of a conduit. The second patient, who had had a segment of the ascending aorta replaced for acute dissection, was seen with mitral regurgitation, aortic root aneurysm, and aneurysm of the arch. This patient underwent mitral valve replacement, replacement of the arch, and insertion of a conduit. The third, a 79-year-old patient, had had replacement of the aortic valve and aortoplasty for an ascending aortic aneurysm. This patient required excision of the Carpentier-Edwards aortic valve, replacement of the mitral valve, replacement of the ascending aorta, and right coronary artery bypass graft.
My point is that in each of these patients, it was readily possible to replace the mitral valve with a 33-mm St. Jude valve through the aortic root. In reviewing the literature, I noted that only 13 patients have been reported to have had the mitral valve replaced through the aortic root. Two were from my institution. The advantages of this technique are obvious. None of us like to do extensive takedown of adhesions. Mobilizing the left ventricle, especially in the presence of coronary grafts, can be hazardous. And if one could avoid another cardiotomy, such as atriotomy or biatriotomy, that would make the operation simpler and more expeditious.
I suggest that in these patients, particularly those having redo operations, we look at the possibility of replacing the mitral valve through the aortic root before resorting to an atriotomy. This is a very good approach in select patients.
DR LARS G. SVENSSON (Burlington, MA): I compliment you on your excellent results, particularly the mortality rate, which is very good compared with that in older series. It is a marked achievement that you were able to keep it so low.
You mentioned you used the femoral artery. Have you always done that? We have found that the right subclavian artery is very useful, particularly in patients with chronic dissection of the aorta, and that it reduces some of the problems of potential malperfusion.
My colleagues and I have been using a minimal-access type of incision, a J incision, through the upper sternum and into the third or fourth intercostal space on the right side. This gives excellent access without the problems of bleeding complications and mobilizing the whole heart. This may be worth studying further. My other question concerns patients on whom you reoperate for composite valve grafts that have false aneurysms, usually related to the left main coronary artery ostium. I realize you do not wrap the aorta, but have you been taking the composite valve graft out entirely in patients with old valves and replacing the entire root, or have you just been repairing the site of the false aneurysm?
DR DOUGENIS:Thank you very much for the comments and the questions. None of our patients had had a mitral valve replacement through the aortic root. In regard to femoral artery cannulation, all but 6 patients in this series were cannulated through the femoral artery. The subclavian artery was used in 1 patient, and we agree that it is a useful technique.
A full median sternotomy incision was used in all patients.
Finally, regarding the very important point Dr Svensson raised concerning pseudoaneurysms at the root, the whole graft was replaced, and every effort was made to make the procedure as radical as possible. It is in this situation that interposition of the 8-mm graft was used most commonly if it was not easy to reanastomose the coronary arteries.
Related Article
Ann. Thorac. Surg. 1997 64: 986-992.
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