Invited Commentary

Abstract

The old adage “there are a hundred ways to skin a cat” is aptly applicable to this article by Takahashi and colleagues [1Takahashi K. Takeuchi S. Ito K. Chiyoya M. Kondo N. Minakawa M. Reoperative coronary artery bypass surgery: avoiding repeat median sternotomy.Ann Thorac Surg. 2012; 94: 1914-1919Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar]. They have found many approaches, techniques, and conduits to perform revascularization in their patients coming for reoperation. The article highlights the resourcefulness of the authors. They deserve appreciation and applause. Takahashi et al. have demonstrated by comparison that by avoiding resternotomy, they have abolished altogether all mortality and complications in 79 patents. They have also demonstrated the safety and feasibility of using various arterial conduits, inflow sites, and routes to accomplish satisfactory revascularization. Most of their patients required one or two bypass grafts. Perhaps the authors plan to provide graft patency data in the future. Resternotomy is associated with a high risk of problems, such as catastrophic or fatal hemorrhage and injury to patent grafts, because as surgeons we do not generally take the necessary care to make reoperation safe. The large majority of surgeons ignore the risk of not covering the heart or routing coronary grafts across the midline. In my four decades of experience (12,000 operations), I have closed the pericardium (or mediastinal fat, pleura, or thymus) over the heart to avoid these very complications. This was done in all operations including coronary bypass operations. Routing the right internal thoracic artery through the transverse sinus and bringing posterior grafts through the transverse sinus have allowed such complete pericardial cover without compression or other adverse effects. In more than 500 resternotomies, there were none of these complications if at the primary surgery the pericardium was closed and the safety cover for the heart was restored. I believe this article highlights two learning opportunities. 1Take adequate steps at primary surgery (cover the heart and do not route grafts across the midline) to ensure safe resternotomy.2Use alternate routes, conduits, and inflow sites (proximal anastomoses) when redo surgery is inevitable in patients at risk of resternotomy. Reoperative Coronary Artery Bypass Surgery: Avoiding Repeat Median SternotomyThe Annals of Thoracic SurgeryVol. 94Issue 6PreviewMortality and morbidity in reoperative coronary artery surgery are considered to be higher than those for initial surgery. Contributing factors include cardiac injury and damage to patent grafts in repeat median sternotomy. To avoid these complications, reoperative cases were performed off pump to avoid repeat median sternotomy. Full-Text PDF