Ann Thorac Surg 2005;80:1532-1533
© 2005 The Society of Thoracic Surgeons
How to do it
Inferior T Hemisternotomy After Previous Bypass Grafting With the In Situ RITA in Front of the Aorta
Fadi Farhat, MD
a
,
*
,
Stéphane Aubert, MD
a
,
Pascal Rosamel, MD
b
,
Olivier Jegaden, MD
a
a Department of Cardiovascular Surgery, Professor Jegaden, Hôpital Pradel, Université Claude Bernard, Bron, France
b Department of Anesthesia, Professor Lehot, Hôpital Pradel, Bron, France
Accepted for publication April 20, 2004.
* Address reprint requests to Dr Farhat, Department of Cardiovascular Surgery, Unit 31, Professor Jegaden. Hôpital Pradel, Université Claude Bernard, INSERM E0226, 28, Ave du Doyen Lepine, 69677 Bron Cedex, France (Email: fadi.farhat{at}chu-lyon.fr).
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Abstract
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Aortic valvular surgery is often challenging in patients with coronary artery bypass (CABG) using in situ right internal thoracic artery (RITA) crossing in front of the aorta to the left anterior descending artery (LAD). Full sternotomy and aortic dissection result sometimes in graft injury and subsequent myocardial ischemia. The benefit of an inferior T hemisternotomy through the second intercostal space is discussed. The grafts are neither dissected nor clamped, and the access to the aortic root is excellent. Graft lesions are avoided. The absence of graft clamping does not seem to impair the myocardial function.
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Introduction
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Redo surgery is often challenging in patients with patent coronary artery bypass grafts (CABG), especially in case of an in situ right internal thoracic artery (RITA) crossing in front of the ascending aorta to the left anterior descending (LAD). Thus, the access to the aortic root can be limited and sometime dissection results in graft injury and subsequent myocardial ischemia. Some surgeons avoid this problem by different techniques, such as Y-grafts or T-grafts between RITA and LITA, or by passing the RITA into the transverse sinus to revascularize the marginal branches. We describe the technique of inferior "T" sternotomy passing through the second intercostal space and discuss its advantages in avoiding injuries of the RITA grafts.
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Technique
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Four patients (3 male, 1 female, mean age 75 ± 5 years) underwent aortic valve surgery, in a mean time of 10.9 ± 1.7 years after previous CABG. All presented with good left ventricular functions. Three patients had a triple arterial revascularization (RITA-LAD, LITA-circumflex ± diagonal, right gastroepiploic artery-posterior descending) and one had two arterial grafts (RITA-LAD, RGA-PD); all were patent. The surgical indications were valvular stenosis in 3 patients and aortic root dilation in 1 patient.
External defibrillating pads were installed before the procedures, as well as transesophageal echography (TEE). Right femoral artery and vein were prepared first in all cases. An inferior T hemisternotomy passing through the second intercostal space was performed (Fig 1). The heart was dissected free from epicardial adhesions to access to the aortic root and to the anterior wall of the right ventricle. In all cases, this allowed aortic cross-clamping and epicardial implantation of temporary pacemaker wires at the end of the procedure (Fig 2). The grafts were neither controlled nor clamped. We did not have graft lesions during dissection, all the RITAs passing behind the manubrium. Femoral arterial and venous canulations were then performed. A DLP arterial canula (18–20 Fr) was inserted into the femoral artery using a Seldinger technique. A double-stage 25 Fr venous canula was positioned through the femoral vein into the right atrium under TEE control. It was then connected to a centrifugal pump to improve the venous return. Cardiopulmonary bypass (CPB) was started with mild hypothermia (35°C) and an aortic venting was positioned into the ascending aorta. The aorta was clamped as low as possible to avoid damage of the RITA. Antegrade cold crystalloid cardioplegia (Celsior) was delivered into the aortic root, and then the aorta was opened transversely. The myocardium presented with cardiac arrest followed after few minutes by fibrillation. No additional cardioplegia was delivered during the procedure. We didn't notice important backbleeding through the coronary ostias during valvular implantation. Three patients had aortic valve replacement (bioprosthesis) and 1 patient had a modified Bentall procedure. After declamping, an external electrical shock was delivered to achieve sinus rhythm, and de-airing was made through the aortic needle under TEE control, without further left venting. CPB was weaned as usual without inotropic support. Temporary pacemaker wires were attached to the right ventricle. Two pericardial drains were inserted and the sternum was closed using transverse and vertical steel wires.
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Fig 1. Incision lines and anatomic relation to underlying heart. The incision always gave a satisfactory access to the aortic root.
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Fig 2. Operative view of the aortic root and the anterior wall of the right ventricle. The operative field is free from arterial grafts.
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Cross clamping and CPB times were 69 ± 21 and 96 ± 32 minutes. Myocardial enzymes were normal in postoperative course. Mean postoperative bleeding was 206 ± 91 mL. Mean intubation, intensive care, and hospital stay times were 14 ± 8 hours, 3 ± 2 days, and 11 ± 2 days, respectively. Postoperative echographic control revealed excellent valvular and ventricular functions in all patients without residual pericardial effusion. All the patients were discharged to postoperative rehabilitation.
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Comment
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Aortic valve surgery in patients with previous coronary artery bypass is often challenging in case of patent in situ RIMA-to-LAD graft passing in front of the ascending aorta. Lesions of the RIMA are frequent when reopening the sternum with subsequent myocardial ischemia. Moreover, redo surgery is associated with an overt mortality [1]. Therefore, some authors have reported different tips for protecting the grafts [2, 3]. Others have described surgical approaches avoiding sternotomy to prevent graft injuries, often based upon selective intubation, femoro-femoral bypass, and right thoracotomy [4, 5]. In our previous experience of aortic valve surgery by upper ministernotomy, we have noticed that the first centimeters of the aortic root were below the manubrium [6]. We have also noticed in coronary redo surgery that the RITA often passes behind the manubrium when grafted in situ to the LAD. For these reasons, the choice of an inferior T sternotomy in aortic valve surgery was obvious because this approach could spare the RITA and avoid dissection lesions.
This is the first report of an inferior T sternotomy for aortic valve surgery in patients with previous coronary artery bypass. Biplane ITA angiograms were helpful to evaluate the course of the grafts in relation to the sternum. Thus, all the RITA grafts passed behind the manubrium and consequently were protected from injury during dissection. In literature, cardiac protection is often associated with deep hypothermia, graft clamping, or retrograde cardioplegia [5]. In our series, the absence of hypothermia and graft clamping were not associated with myocardial infarction or postoperative low cardiac output. Significant backbleeding from the coronary ostias was absent, which probably means that the native coronary network was obstructed after it was bypassed. Moreover, unclamped patent grafts provided an efficient myocardial perfusion. Yet, all the patients had good preoperative left ejection fraction, and underwent redo surgery in a mean of more than ten years after first intervention. Therefore, a word of caution must be brought for patients with impaired left ventricular function and those with a recent first intervention.
According to our initial experience, the inferior T sternotomy is an excellent alternative to avoid damage of the graft. It allows aortic valve surgery in good surgical exposure, and does not seem to increase postoperative morbidity, despite the fact that grafts are left unclamped with the heart in normothermia and fibrillation. Careful angiographic assessment of the coronary network is important before surgery with special attention to the course of the RITA behind the sternum. Further evaluations are necessary to identify the candidates for this technique in terms of ventricular function and distance after initial operation.
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References
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Abstract
Introduction
