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Ann Thorac Surg 2002;73:779-784
© 2002 The Society of Thoracic Surgeons

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Original article: cardiovascular

Aortic valve surgery after previous coronary artery bypass grafting with functioning internal mammary artery grafts

^a Division of Cardiac Surgery, Brigham & Women’s Hospital, Boston, Massachusetts, USA

* Address reprint requests to Dr Byrne, Division of Cardiac Surgery, Brigham & Women’s Hospital, 75 Francis St, Boston, MA 02115 USA
e-mail: jbyrne{at}partners.org

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. Aortic valve surgery after coronary artery bypass grafting (CABG) in the setting of patent pedicled internal mammary artery (IMA) grafts poses a high risk because of the underlying ischemic and valve disease. Unlike mitral valve surgery or CABG, in which aortic clamping (AoX) may be optional, aortic valve surgery uniformly requires AoX unless circulatory arrest is used. Management of the IMA graft in these circumstances has traditionally involved dissection and clamping to prevent regional myocardial warming and cardioplegia "washout" during AoX. An alternative strategy involves avoiding dissection of the IMA, leaving the IMA graft open and establishing moderate-to-deep hypothermia during AoX and cardioplegic arrest. To date, no study has been published documenting the safety and efficacy of the latter practice.

Methods. A total of 94 patients who had patent IMA graft and underwent aortic valve surgery under AoX and cardioplegia between April 1992 and March 2001 were analyzed. The IMA was avoided and left open during AoX, and the patients were cooled systemically (median 20°C). Patients ranged in age from 55 to 90 years (median 73.5 years). Ejection fraction was 15% to 83% (median 50%). Of the patients, 18 (19%) underwent minimally invasive upper hemi-resternotomy. Analysis for predictors of outcome was performed.

Results. The operative mortality, perioperative myocardial infarction (MI), and stroke rates were 6.4%, 7%, and 11%, respectively. No significant independent predictors of operative mortality or MI could be identified in the multivariate analysis, although a trend was shown for operative mortality with urgent procedures and patients requiring concomitant surgery of the ascending or arch aorta or aortic root. Advanced age and prolonged cardiopulmonary bypass predicted stroke in the multivariate analysis. There were five (5%) IMA injuries, all occurring during reentry or mediastinal dissection, but none in the subgroup of patients who underwent minimally invasive procedures. All patients survived.

Conclusions. Patients undergoing aortic valve surgery after CABG in the presence of patent IMA represent a potentially high-risk group. Because AoX is almost uniformly required, a decision regarding the management of the IMA pedicle is needed. We have found that leaving the IMA undissected and unclamped is a reasonable strategy, provided that systemic cooling for myocardial protection is established to prevent regional warming and to compensate for cardioplegia washout effect during AoX.

	Introduction

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Progression of aortic valve stenosis is not infrequently encountered in patients who, at the time of CABG, have only minimal aortic valve gradients [1]. If aortic valve stenosis progresses in its severity, then reoperation may be required. The presence of patent pedicled internal mammary artery (IMA) grafts poses a significant risk and requires specific considerations for myocardial protection and prevention of IMA graft injury. Unlike mitral valve surgery or CABG, in which aortic clamping (AoX) may be optional, aortic valve surgery uniformly requires AoX unless circulatory arrest is used. Various approaches to myocardial protection in the presence of patent IMA graft have been proposed [2]. The most common strategy involves resternotomy, dissection, and temporary occlusion of the IMA, with subsequent AoX and cardioplegic arrest. It has the advantage of reducing cardioplegia "washout" in the IMA territory. However, the IMA graft is at some risk for injury, which is not infrequently fatal [3, 4].

Another strategy, which we favor, is to establish moderate-to-deep hypothermia (20°C), apply the AoX, give cardioplegia (CP), but avoid dissection of the IMA pedicle while performing the operation as expeditiously as possible. This approach is uniquely characterized by the discrepancy in myocardial protection between the anterior myocardium supplied by the IMA, where the CP is gradually washed out, and the remainder of the myocardium, where CP may take longer to washout via collaterals. This technique has only anecdotally been mentioned by Lytle and colleagues [5], who asserted that before the advent of retrograde cardioplegia, myocardial protection could be achieved by establishing deep hypothermia and leaving the IMA unclamped. Their report not withstanding, no other reports, and no results of a consecutive series of patients in whom the IMA was left unclamped during cardioplegic arrest, have previously been published.

Given the documented superiority of the IMA graft [6] and the potential high mortality associated with its injury [3, 4], we have attempted to maintain IMA graft integrity and also to provide adequate myocardial protection. With the recent development of minimally invasive valve reoperations [7–9], in which isolation and clamping of the IMA pedicle is difficult or impossible, this strategy may have particular relevance. Therefore, we reviewed our entire experience since 1992 in patients who underwent minimally invasive or conventional aortic valve surgery after CABG with patent unclamped IMA, and we report on safety and efficacy of this approach. We did not examine the question of whether an aortic valve replacement should have been performed at the time of the primary CABG operation. The echocardiographic data at the time of the first operation were limited either because of remote operations or because preoperative evaluation or CABG operation had been performed elsewhere.

	Material and methods

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Patients
Between April 1992 and March 2001, a total of 94 consecutive patients with patent pedicled left internal mammary artery (LIMA) or right internal mammary artery graft underwent aortic valve replacement (AVR) in moderate-to-deep hypothermia (20°C), AoX, and cardioplegic arrest leaving the IMA unclamped. Of the patients, 92 had a patent pedicled LIMA pedicle and 2 a patent pedicled right internal mammary artery. The interval between the CABG procedure and AVR ranged between 0.06 and 25.9 years (median 7.0 years). Age ranged between 55 and 90 years (median 73.5 years). Of the patients, 23 (24%) were female. A total of 75 patients were in normal sinus rhythm preoperatively. Clinical presentation was stenosis in 78 of 94 of cases (83%), regurgitation in 11 of 94 (12%), and mixed in 5 of 94 (5%). In all, 60 patients (64%) were in New York Heart Association functional class III or IV and ejection fraction ranged between 15% and 83% (median 50%). A total of 22 procedures (23%) were nonelective, and for 9 patients (10%) this was the third or fourth cardiac procedure.

Procedures
In 75 patients, (80%) the approach was made through a full sternotomy incision. However, 18 patients (19%) underwent minimally invasive upper hemi-resternotomy [7, 8], and 1 (1%) had a right anterior thoracotomy. Femoral arterial cannulation was used in 58 patients (62%), whereas the femoral vessels were routinely exposed before resternotomy in patients in whom intrathoracic cannulation was used. Cardiopulmonary bypass (CPB) was instituted in the majority of patients before re-sternotomy so as to protect the patent IMA graft. Patients were then weaned from bypass for mediastinal dissection. Vacuum assistance of venous drainage was routinely applied in the most recent cases.

On CPB, patients were cooled to a median temperature of 20°C (range 14° to 30°C). Cardioplegia was administered both antegrade and retrograde in 60 patients (64%), retrograde only in 2 (2%), antegrade only in 31 (33%), and no CP but deep hypothermia and AoX (18°C) in 1 (1%). If collateral back-flow out of the left main ostia (from the patent IMA) obscured the operative field during AVR, pump flows were temporarily turned down to approximately 500 to 1500 mL/min, as needed for visualization. No attempts were made to dissect and clamp the IMA in any patient. Procedures on the valves, aorta, or coronary arteries were performed based on patient indications using standard techniques. After removal of the AoX, deairing was accomplished using transesophageal echocardiography guidance, and the aortic root vent was maintained open until the patient was separated from CPB.

Statistical analysis
Descriptive statistics of preoperative and intraoperative characteristics as well as intraoperative complications and mortality are reported for the entire cohort (n = 94), whereas postoperative complications are reported for survivors only (n = 88). Univariate and multivariate analysis using Fisher’s exact test and logistic regression was performed to determine predictors of outcome at a 0.05 level of significance.

	Results

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The aortic valve prosthesis was St. Jude Medical (St. Jude Medical Inc, Minneapolis, MN) in 39 of 94 patients (41%), Carpentier-Edwards pericardial (Baxter Healthcare Corporation, CardioVascular Group, Irvine, CA) in 32 of 94 (34%), Hancock porcine (Medtronic, Inc, Minneapolis, MN) in 21 of 94 (22%), and homograft in 2 of 94 (2%). Concomitant coronary artery bypass grafting (CABG) was performed in 25 (27%) patients. Of 25 bypasses, 18 were single (72%), 5 (20%) were double, and 2 (8%) were triple, whereas 6 of 25 (24%) included the distal LAD. Other concomitant procedures included mitral valve replacement or repair in 9 patients (10%), replacement of the aortic root, ascending aorta or arch in 13 (14%), ventricular septal defect closure in 1 (1%), and carotid endarterectomy in 2 (2%)

Ischemia time and cardiopulmonary bypass time ranged between 40 and 236 minutes (median 81 minutes), and between 74 and 359 minutes (median 167.5 minutes), respectively. Eight patients (9%) required hypothermic circulatory arrest (median 24 minutes, range 12 to 67 minutes).

Hospital mortality
Hospital mortality was 6% (n = 6); in the majority of cases (n = 4), mortality was from cardiac causes (Table 1). Univariate analysis revealed urgent procedures, concomitant procedures of the ascending or arch aorta or aortic root, and longer bypass times to be associated with hospital mortality (Table 2). Postoperative bleeding and low cardiac output were also more common in these patients. No independent predictors reached statistical significance in the multivariate analysis, although urgent procedures and concomitant procedures on the ascending or arch aorta or aortic root showed a trend (Table 2).

Cardiac/IMA injury
Intraoperative complications included injury of the IMA in 5 patients (5%) and injury of other cardiac structures in 4 (4%). All IMA injuries were related to sternal reopening or dissection of the mediastinal structures away from the posterior aspect of the sternum. All injured IMAs were repaired, either immediately or after institution of CPB. Three patients received prophylactic vein grafts to the LAD. None of these patients developed perioperative myocardial infarction, and all survived. No IMA injuries occurred in the minimally invasive upper resternotomy subgroup.

Myocardial infarction and low cardiac output
Six of 88 survivors (6.8%) sustained perioperative myocardial infarction, defined as new Q-wave in the electrocardiogram, creatine kinase-MB (CK-MB) equal to or greater than 50 IU/L, and CK-MB/CK ratio greater than 5% or new wall motion abnormality on echocardiography. In 2 patients the MI occurred in the IMA territory; 1 of these patients underwent surgery under only mild hypothermia (30°C).

Postoperative low cardiac output (defined as postoperative requirements of high doses of inotropic agents or the use of a mechanical assist device irrespective of preoperative status) was highly associated with operative mortality (100% versus 14%, p < 0.0005). All 12 survivors with low cardiac output (14%) required placement of an intraaortic balloon pump (IABP). Only 4 of 12 revealed perioperative myocardial infarction. Nine (10%) required delayed sternal closure to improve early postoperative hemodynamics or to accommodate diffuse postoperative bleeding.

Neurologic complications
Ten patients (11%) sustained postoperative stroke; 1 was hemorrhagic, 4 were embolic, 4 hypoxic, and 1 mainly embolic and hypoxic. Four patients (2 with embolic and 2 with hypoxic stroke) showed steady improvement of symptoms on discharge; 1 patient (with embolic stroke) remained asymptomatic under anticonvulsant medication; and the other 5 patients had significant residual deficits. Univariate analysis revealed cardiopulmonary bypass for more than 220 minutes to be associated with stroke (24% versus 60%, p = 0.025), whereas concomitant mitral valve surgery (7% versus 30%, p = 0.052) and age 75 years or more (39% versus 70%, p = 0.065) showed a trend. In the multivariate analysis, advanced age (ie, age 75 years or more) and CPB for more than 220 minutes were identified as independent predictors of stroke (age 75 years, OR = 5.8 [95% CI: 1.2 to 28.2], CPB > 220 minutes, OR = 7.5 [95% CI: 1.6 to 33.5]). Femoral arterial cannulation did not appear to be associated with higher incidence of stroke.

Other complications
Six patients (7%) required prolonged ventilator support (> 2 days) or reintubation for protracted respiratory insufficiency. Deep sternal wound infection occurred in 4 patients (5%).

	Comment

Top Abstract Introduction Material and methods Results Comment References

 
With improved long-term results of CABG and the widespread use of a LIMA-LAD graft as a standard part of most CABG operations [6], as well as the increasing use of bilateral internal mammary artery (BIMA) grafts [10], a growing number of older patients are likely to require reoperative cardiac surgery in the setting of a patent IMA graft. This is particularly relevant in patients who have undergone CABG in the setting of mild aortic valve stenosis, which progresses in severity and requires AVR in the setting of patent IMA graft. Unlike mitral valve surgery or CABG, in which AoX may be optional, aortic valve surgery uniformly requires AoX unless circulatory arrest is used. The traditional approach in these situations has been reoperative median sternotomy with isolation and clamping of the IMA pedicle. Gillinov and colleagues [3] reported a 5.3% prevalence of injury to the IMA graft, which has been associated with a mortality rate up to 50% [4, 5, 11]. Several techniques at primary operation have been reported to reduce the risk of IMA injury at reoperation. Allowing the left lung to interpose between chest wall and LIMA [12] or the use of polytetrafluoroethylene membrane to cover the LIMA [13] are prophylactic measures at primary operation. 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 [14, 15].

This report documents the results of a consecutive group of patients in whom a patent IMA graft was left open during AoX, allowing the IMA graft to perfuse the anterior myocardium during aortic valve surgery. Our strategy of leaving the IMA open (regardless of whether the AVR was performed through a small or large incision) enabled us examine a relatively homogeneous cohort to document the overall safety and efficacy of this approach. In patients in whom the IMA pedicle is easily identified, as in some patients undergoing concomitant CABG, clamping and control may be the safest approach. However, in patients in whom access to the IMA pedicle is difficult or impossible, as in minimally invasive reoperative valve surgery [7, 8], these findings may be particularly pertinent.

In general, three strategies may be followed in patients with patent IMA graft. The more popular technique of clamping both the aorta and the IMA graft has the advantage of shorter CPB times, with the use of moderate rather than deep hypothermia and the maintenance of a uniformly cooler myocardium than CPB temperature. However, clamping the IMA has the disadvantage of requiring a redo full sternotomy with the inherent risks of injury of the IMA or other cardiac structures. The open IMA technique, which we favor, has the advantage of permitting minimally invasive incisions for isolated AVR and avoiding dissection of the IMA pedicle, which would otherwise be time consuming and potentially dangerous. A unique feature in this strategy is the temperature discrepancy of the myocardial areas; the myocardium is protected by cardioplegia (4°C) cooler than CPB temperature (20°C), but the IMA territory may approach CPB temperature due to CP washout. Cardiopulmonary washout reduces the effect of myocardial protection; therefore, moderate to deep hypothermia is mandatory. Electrical activity is rarely resumed at 20°C, and in these cases the administration of additional CP achieves cardiac quiescence. If blood returning from the left main coronary ostia (through the open IMA) obscures the operative field during AVR, flows on CPB may easily be turned down temporarily for placement of sutures. The third strategy involves deep hypothermia and circulatory arrest without AoX or IMA clamp. This technique, which is occasionally required in patients with "porcelain" aorta [16], is rather time consuming in an already long reoperative procedure. Obviously, this technique should be limited to specific indications in which AoX is deemed to be particularly hazardous.

Despite our intent to avoid the IMA, the risk of injury remains. We encountered 5 IMA injuries, all of them occurring during full resternotomy or during dissection of the mediastinal structures from the posterior aspect of the sternum. Odell and associates [17] report an incidence of graft injury of 9%, which is similar to our incidence of 5%. No IMA or other cardiac injuries occurred in the subgroup undergoing minimally invasive surgery, supporting our previous suggestion that minimally invasive approaches may help to reduce the likelihood of IMA injury [8]. Accordingly, reoperative surgery may be where the true benefit of minimally invasive surgery resides.

We report an operative mortality of 6.4%, which is favorable compared with previous studies including patients with or without patent IMA grafts, which report mortality between 7.7% and 18.8% [1, 17–20]. Only one study reported a lower operative mortality (0%) in 23 patients who underwent operation over a 10-year period [21]. Although we examined only patients with patent IMA, we found a great reduction in operative mortality over time at our institution from 18.2%, reported by Collins and Aranki [1] in 1994, to 6.4% in this study. Several predictors of operative mortality in reoperative surgery have been proposed in previous reports, such as advanced age, low ejection fraction, and advanced New York Heart Association functional class [19, 22, 23], but we could not confirm these relationships. Urgency and concomitant major aortic procedures were associated with increased mortality in the univariate model, but they did not reach statistical significance in the multivariate analysis.

In our study, the incidence of perioperative MI and postoperative low cardiac output were 7% and 14%, respectively. High morbidity has been previously reported in similar groups of patients. Odell and associates [17] reported IABP requirements in 19%. Fighali and colleagues [20] described an 18% requirement of IABP and a 13% incidence of perioperative MI. Sundt and coworkers [19] reported a 19% incidence of IABP placement, but a 1.9% incidence of perioperative MI, using only electrocardiographic signs, however, for diagnosis. In our group, in only 2 patients with MI was there evidence that the IMA territory was involved; in 1 patient, we attribute this to inadequate myocardial protection because only mild hypothermia (30°C) was used.

The incidence of perioperative stroke in our study was 11%, which is rather high but is the same as that reported by Fighali and colleagues [20]. Age in our study ranged between 55 and 90 years, and 43% patients were more than 75 years old. Because advanced age has been firmly established as associated with stroke [24, 25] and because it constitutes an independent predictor of stroke [26], it was predictable that we would observe a relatively high incidence of stroke in this population, who, by definition also have atherosclerotic coronary disease. Our multivariate analysis confirmed that advanced age and prolonged CPB time were independent predictors for stroke.

In conclusion, patients undergoing AVR after CABG in the presence of patent IMA represent a potentially high-risk group. Because AoX is almost uniformly required, a decision regarding the management of the IMA pedicle is needed. We have found that leaving the IMA undissected and unclamped is a reasonable strategy, provided that systemic cooling for myocardial protection is established to prevent regional warming and to compensate for cardioplegia washout effect during AoX.

	References

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