Patent Internal Thoracic Artery Research Articles

Redo mitral surgery after coronary artery bypass grafts under hyperkalemic hypothermia using thoracotomy and axillary artery cannulation in a patient with functioning bilateral internal thoracic arteries and atheromatous aorta

BackgroundRedo mitral valve surgery using resternotomy after coronary artery bypass grafting (CABG) is challenging as previous CABG with patent internal thoracic artery (ITA) poses a risk of injury due to dense adhesion. It is paramount to have alternative method to minimize this risk.Case presentation: We report a case of redo mitral and tricuspid valve repair via right thoracotomy under hypothermia and systemic potassium administration with axillary artery cannulation in a patient after CABG with patent bilateral ITA grafts crossing over the sternum. Herein, critical dissection around the aorta and functioning ITA grafts was avoided by performing the procedure under systemic hypothermia via thoracotomy. Furthermore, considering the presence of atheroma in the aorta, the axillary artery was used as a perfusion route to prevent stroke events. Postoperative course was uneventful and echocardiography demonstrated preserved cardiac function.ConclusionPerforming axillary artery cannulation and right thoracotomy under hypothermic cardiac arrest with systemic hyperkalemia without clamping the patent bilateral ITAs and aorta allowed us to perform redo mitral valve surgery after CABG without major postoperative cardiac or cerebral complications.

Towards Endoscopic No-Touch Saphenous Vein Graft Harvesting in Coronary Bypass Surgery.

The saphenous vein is the most used conduit for coronary artery bypass surgery. However, the patency rate of this graft is inferior to the internal thoracic artery patency rate, which is the gold standard. Using the conventional technique, the saphenous vein is harvested via a large open incision and excised in such a way that causes both vascular damage and wound healing complications. Consequently, vein graft patency and surgical site infection may be compromised. Graft patency is markedly improved when the saphenous vein is harvested atraumatically with minimal damage and with surrounding cushion of perivascular fat intact. However, despite the improved graft performance, wound healing complications and infection remain a problem. Although wound healing complication is reduced when using endoscopic vein harvesting, there may be a negative impact on graft performance. This is due to vascular damage associated with application of forces to the vein that are usually avoided in open vein harvesting, including traction, adventitial stripping, and venous compression. There is evidence to suggest that improved patency of endoscopically harvested saphenous veins is associated with the surgeon’s experience of the technique. Recently, endoscopic methods of harvesting have been described where the saphenous vein is removed intact and with minimal vascular damage caused. In addition, wound healing complications, infection, and scarring are reduced. While the effect of these techniques on vein graft patency have yet to be reported, the ability to obtain a superior graft with reduced wound complications will be of great benefit to patients undergoing coronary revascularization procedures.

Right Internal Thoracic Artery Patency Is Affected More by Target Choice Than Conduit Configuration

BackgroundAlthough coronary artery bypass grafting using bilateral internal thoracic arteries (ITA) maximizes long-term survival, knowledge of the effect of different right ITA (RITA) inflow configurations on graft patency is limited. We have compared RITA occlusion among these configurations and identified its risk factors while adjusting for outflow coronary target location. MethodsFrom January 1972 to January 2016, of 7092 patients undergoing bilateral ITA grafting at a single center, 1331 received one ITA to the left anterior descending coronary artery and had one or more evaluable postoperative coronary angiograms: 835 (63%) in situ, 496 free RITA grafts (311 [63%] originating from aorta; 98 [20%] left ITA [LITA], 76 [15%] saphenous vein graft, 11 [2%] radial graft). RITA occlusion reported on 1983 angiograms performed a median of 5.8 years later was estimated using nonlinear mixed-effects longitudinal modeling. ResultsRITA patency was 90% at 1 year, 87% at 5 years, and 86% at 10 and 15 years. At 15 years, in situ RITA patency was 91% and free RITA patency from aorta was 91%, LITA 89%, and saphenous vein graft 77%. After adjusting for coronary target location and degree of stenosis, occlusion was similar in free RITAs from aorta (P = .15), LITA (P = .4), saphenous vein grafts (P = .13), and in situ RITAs. However, RITAs grafted to the left anterior descending coronary artery had fewer occlusions (P < .001), with patency similar to LITAs. ConclusionsAmong patients with bilateral ITA grafting requiring interval coronary angiography, long-term RITA patency was high and independent of its inflow configuration. Therefore, priority should be a RITA configuration optimizing its reach to important coronary targets, including the left anterior descending coronary artery.

Risks and Outcomes of Reoperative Cardiac Surgery in Patients With Patent Bilateral Internal Thoracic Artery Grafts

BackgroundReoperative cardiac surgery in patients with patent bilateral internal thoracic artery (ITA) grafts is technically challenging. MethodsFrom 2008 to 2017, of 7640 patients undergoing reoperative cardiac surgery, 116 (1.5%) had patent bilateral ITA grafts, including 28 with a right ITA crossing the midline. Mean age was 70 ± 9.6 years, and 111 patients (96%) were men. Reoperations included isolated coronary artery bypass grafting (n = 11), isolated valve (n = 55), valve + coronary artery bypass grafting (n = 26), and other procedures (n = 24). Clinical details, intraoperative management, and perioperative outcomes were analyzed. ResultsAortic cannulation was central in 64 patients (56%) and through the femoral or axillary artery in 50 (44%). Four patients (3.4%) had planned transection and reattachment of ITAs crossing the midline, and 4 (3.4%) had ITA injuries, all right ITAs, 3 crossing the midline; 3 were repaired with an interposition vein graft, and 1 was managed by translocating the right ITA as a Y-graft off another graft. Patent ITAs were managed by atraumatic occlusion during aortic clamping in 90 patients (78%) and by systemic cooling without ITA occlusion in 19. There were 6 operative deaths, all due to low cardiac output syndrome (5.2%); 4 strokes (3.4%); and 5 cases of new postoperative dialysis (4.3%). ConclusionsRisk of injury to bilateral ITA grafts during reoperation is high, and right ITAs crossing the midline present a particular risk of injury and should inform planning for primary coronary artery bypass grafting. Risk of low cardiac output syndrome underscores the challenge of ensuring adequate myocardial protection.

Selection of optimal endarterectomy technique in the left anterior descending artery for diffuse coronary atherosclerosis

Aim. To determine the optimal method for performing coronary artery endarterectomy (СE) based on immediate and long-term outcomes of coronary artery bypass grafting (CABG) in combination with open or closed CE in the left anterior descending artery (LAD).Material and methods. This retrospective study included 103 patients who underwent CABG in combination with closed CE and 204 after open CE in the LAD during the period from 2003 to 2016. In both groups, the patient age was comparable (65 years [56; 69] vs 67 years [58; 72] (p=0,263)). There were more men (88,3% vs 81,4% (p=0,421). The mean follow-up period was 94 months [38; 180]. Long-term outcomes were assessed in 86,4% (n=89) and 83,8% (n=171) of patients from the closed and open CE groups, respectively (p=0,141). Angiographic data were studied in 75,3% and 67,3% of patients, respectively (p=0,441).Results. In the closed and open CE groups, in-hospital mortality was 4,8% and 1,5% (p=0,0012), incidence of perioperative myocardial infarction — 11,6% vs 2,5%, (p&lt;0,001), survival rate after 7,8 years — 81,3±5,1% and 84,4±3,2% (p=0,342), respectively. The patency of arterial shunts was significantly higher in the open CE group — 93,1% vs 80,6% (p=0,004). At the same time, the patency of venous shunts in the long-term period between the groups was comparable — 70,1% vs 73,7% (p=0,314).Conclusion. Open CE in combination with CABG provides better immediate outcomes compared to closed CE. Long-term survival and freedom from angina between the groups were comparable. In the long-term period, the patency of internal thoracic artery after open CE is better than after the closed technique. Open CE is a safe and effective method to achieve complete myocardial revascularization in patients with severe diffuse LAD atherosclerosis.

Surgical myocardial revascularization outcomes in Kawasaki disease: systematic review and meta-analysis.

BackgroundKawasaki disease (KD) is a systemic inflammatory condition occurring predominantly in children. Coronary artery bypass grafting (CABG) is performed in the presence of inflammation and aneurysms of the coronary arteries. The objectives of our study were to assess which CABG strategy provides better graft patency and early and long-term outcomes.MethodsA systematic review using Medline, Cochrane, and Scopus databases was performed in February 2020, incorporating a network meta-analysis, performed by random-effect model within a Bayesian framework, and pooled prevalence of adverse outcomes. Hazard ratios (HR) and corresponding 95% credible intervals (CI) were calculated by Markov chain Monte Carlo methods.ResultsAmong 581 published reports, 32 studies were selected, including 1,191 patients undergoing CABG for KD. Graft patency of internal thoracic arteries (ITAs), saphenous veins (SV), and other arteries (gastroepiploic artery and radial artery) was compared. ITAs demonstrated the best patency rates at long-term follow-up (HR 0.33, 95% CI: 0.17–0.66). Pooled prevalence of early mortality after CABG was 0.28% (95% CI: 0.00–0.73%, I 2 = 0%, tau2 = 0), with 63/1,108 and 56/1,108 patients, undergoing interventional procedures and surgical re-interventions during follow-up, respectively. Pooled prevalence was 3.97% (95% CI: 1.91–6.02%, I 2 = 60%, tau2 = 0.0008) for interventional procedures and 3.47% (95% CI: 2.26–4.68%, I 2 = 5%, tau2 <0.0001) for surgical re-interventions. Patients treated with arterial, venous, and mixed (arterial plus second venous graft) CABG were compared to assess long-term mortality. Mixed CABG (HR 0.03, 95% CI: 0.00–0.30) and arterial CABG (HR 0.13, 95% CI: 0.00–1.78) showed reduced long-term mortality compared with venous CABG.ConclusionsCABG in KD is a safe procedure. The use of arterial conduits provides better patency rates and lower mortality at long-term follow-up.

Coronary Artery Bypass Graft Patency and Survival in Patients on Dialysis

BackgroundLittle is known about graft patency after coronary artery bypass grafting (CABG) performed in patients on dialysis. Our aim was to assess patency of internal thoracic artery (ITA) grafts and saphenous vein grafts (SVGs) in these patients. MethodsFrom 1/1997 to 1/2018, 500 patients on dialysis underwent primary CABG with or without concomitant procedures at Cleveland Clinic, 40 of whom had 48 postoperative angiograms for recurrent ischemic symptoms. Complete follow-up was obtained on all but 1 patient lost to follow-up 1 y after CABG. Thirty-six ITA grafts and 65 SVGs were evaluable for stenosis and occlusion. ResultsTwo of 40 patients (5%) had emergency CABG; 3 (7.5%) with calcified aortas had a change in operative strategy to avoid ascending aortic manipulation, 2 (5%) had poor conduit quality, and 12 (30%) had severe diffuse atherosclerotic disease with calcification of the coronary targets causing technical difficulties. Thirty-three patients (82%) were bypassed with an in situ ITA and 3 (7.5%) had a free ITA graft. Three of 36 ITA grafts were occluded at 0.78, 1.8, and 9.4 y (too few to model). SVG patency was 52% and 37% at 1 and 2 y, respectively. ConclusionsAmong patients on dialysis who underwent CABG, coronary angiography for ischemic symptoms in a select subset revealed that SVG patency was lower than expected from published reports in the general CABG population and may contribute to the poor prognosis of this cohort. Further work is needed to guide graft selection and improve graft patency in dialysis patients.

Ministernotomy aortic valve surgery in patients with prior patent mammary artery grafts after coronary artery bypass grafting.

Patients with patent internal thoracic artery (ITA) grafts after prior coronary artery bypass grafting surgery who require aortic valve replacement (AVR) pose unique technical challenges for safe and optimal myocardial protection. The purpose of this study is to review our short- and long-term outcomes with redo minimally invasive AVR in patients with patent in situ ITA grafts. From 2008 to 2016, 48 patients with at least 1 patent in situ mammary artery graft underwent minimally invasive AVR. Preoperative computed tomography was performed in all patients to evaluate the relationship of patent grafts to the sternum. Retrograde coronary sinus and pulmonary vent catheters were placed via the right internal jugular vein. The in situ ITA grafts were not clamped during AVR. Transverse aortotomy, taking care to avoid the grafts arising from the aorta, was performed to expose the aortic valve. The median age of the patients was 78 years [Quartile 1 (Q1)-Quartile 3 (Q3): 71-81]. Thirty-nine (81%) patients were men, and 46 (96%) patients had aortic stenosis. The median cardiopulmonary bypass and cross-clamp times were 124 (Q1-Q3: 108-164) and 92 (Q1-Q3: 83-116) min, respectively. Moderate hypothermia at 28-30°C was used in all patients. Most patients received cold blood cardioplegia with antegrade induction and continuous retrograde delivery. Four patients received only retrograde delivery due to some degree of aortic insufficiency. Thirty-day mortality was 4% (2 of 48 patients). There was no conversion to full sternotomy, and no reoperations were performed for postoperative bleeding or sternal wound infection. Excluding the 2 patients who died in the hospital, the median postoperative length of stay was 7 days (Q1-Q3: 5-8). Overall survival at 1, 5 and 10 years was 94%, 87% and 44%, respectively. Percutaneous retrograde cardioplegia combined with antegrade cardioplegia and moderate hypothermia, without interruption of ITA flow, is a safe and reliable strategy in patients with patent ITA grafts undergoing aortic valve replacement. This strategy combined with a minimally invasive approach may reduce surgical trauma, and is a safe and effective technique in these challenging patients.

Evaluation of the internal thoracic artery blood flow before and after Nuss operation: is it reversible?

Objective: Obstruction of the internal thoracic arteries (ITAs) by the Nuss bars in minimally invasive repair of pectus excavatum (MIRPE) has been documented in the literature. In this study, we aim to investigate the patency of ITAs before and after repair of the pectus excavatum with the Nuss procedure, by using color Doppler ultrasonography (US). Materials and Methods: Nineteen patients who underwent Nuss procedure were included in this study prospectively. Color Doppler US examinations were performed for comparing ITA patency after insertion of the Nuss bars and after their removal. Patients were evaluated according to gender, age, symmetry of deformity, Haller index, and the number of Nuss bars inserted. Results: Nineteen patients operated with MIRPE (17 male and 2 females with a mean age 21.78±6.35) were enrolled in the study. Eight patients (42.1%) with normal ITA blood flow preoperatively had normal blood flow after removal of the bar. In preoperative examination, 6 patients had bilateral (n=2) or unilateral (n=4) obstruction of the ITA and 5 patients had bilateral (n=2) or unilateral (n=3) abnormally disturbed flow. After the bar removal only 2 (10%) of the affected patients (57.9 %) still had obstruction whereas patent blood flow of the ITAs has been noted in 9 patients. Conclusion: We have shown that after the Nuss bar removal, only 10% of the ITAs are compromised

Internal Thoracic Artery Patency Before and After Insertion of Specially Designed Pectus Bar

Internal Thoracic Artery Patency Before and After Insertion of Specially Designed Pectus Bar

Management of a Left Internal Thoracic Artery Graft Injury during Left Thoracotomy for Thoracic Surgery

There have been some recent reports on the surgical treatment of lung cancer in patients following previous coronary artery bypass graft surgery. Use of internal thoracic artery graft is a gold standard in cardiac surgery with superior long-term patency. Left internal thoracic artery graft is usually patent during left lung resection in patients who present to the surgeon with an operable lung cancer. We have presented our institutional experience with left-sided thoracic surgery in patients who have had previous coronary artery surgery with a patent internal thoracic artery graft.

Internal thoracic artery patency before and after specially designed Pectus bar

Internal thoracic artery patency before and after specially designed Pectus bar

Should Coronary Artery Bypass Grafting Be Performed in Patients With Moderate Stenosis of the Left Anterior Descending Coronary Artery?

In this issue of Circulation , Harskamp and colleagues1 use 12- to 18-month angiographic follow-up data from the Project of Ex-vivo Vein Graft Engineering via Transfection IV (PREVENT IV) trial to determine the frequency of internal thoracic artery (ITA) graft failure, its risk factors, and its association with postoperative clinical events. They identified left anterior descending coronary artery (LAD) stenosis <75%, additional bypass graft to a diagonal, and absence of diabetes mellitus as risk factors for ITA graft failure, and reported that graft failure was associated with a high risk of postoperative repeat revascularization. Because of the association of ITA failure with moderate LAD stenosis and risk of early postoperative revascularization, the authors question the benefit of coronary artery bypass grafting (CABG) in patients with moderate, or non–ischemia-producing, lesions of the LAD. Article see p 131 This article adds to the extensive literature on the association of native coronary artery competitive flow and ITA patency.2–7 Its considerable strength is systematic angiographic follow-up. What is new is their thesis that these findings raise concern that CABG may not be beneficial in patients with moderate stenosis of the LAD. To evaluate whether these concerns are justified, it is necessary to review what is known about the effect of competitive flow on ITA patency, whether saphenous veins are more effective grafts than ITAs to coronary arteries with only moderate stenosis, and whether grafting a coronary artery with moderate stenosis is beneficial or harmful. Competitive flow is the most important factor influencing ITA graft patency (and the patency of all arterial bypass grafts, as well).2 Competitive flow is defined as native coronary artery blood flow in a coronary artery to which a bypass graft has been anastomosed—flow that progressively lessens as proximal coronary artery stenosis increases. Studies evaluating the …

Does Bilateral ITA Grafting Increase Perioperative Complications? Outcome of 6,476 Patients with Bilateral versus 5,020 Patients with Single ITA Bypass.

Despite the superior patency of internal thoracic artery (ITA) grafting compared with saphenous veins, frequency of bilateral ITA (BITA) grafting in Europe is still approximately 10%. The aim of the present study was to compare the early outcome of patients receiving either BITA or single ITA (SITA) grafting. A total of 11,496 patients with isolated coronary artery bypass grafting (CABG), operated between January 1996 and December 2012, were analyzed retrospectively; 0.6476 patients (mean age 65.2 years, 81.3% males) received BITA and 5,020 patients (mean age 66.6 years, 76.7% males) SITA grafting. Mean body mass index (BMI) was 27.2 versus 27.4, p = 0.017. Incidence of diabetes was 28.9 versus 28.4%, p = 0.08. Ejection fraction (EF) > 50 was 71.3% (BITA) versus 66.3% (SITA), p < 0.001. Elective operations were performed in 88.4% (BITA) versus 83.3% (SITA), and urgent/emergent surgery was necessary in 11.6% (BITA) versus 16.7% (SITA), p < 0.001. Number of grafts was 3.76 (BITA) versus 3.06, p < 0.001. Duration of surgery (194.4 vs. 180.4 minutes) as well as X-clamp time (60.4 vs. 51.7 minutes) was prolonged for BITA, p < 0.001. Perioperative infarction rate revealed 3.2% (BITA) versus 3.6%, p = 0.54. Frequency of rethoracotomy due to bleeding was higher in the BITA group (3.8 vs. 2.1%), p < 0.001. Sternal instabilities occurred in 2.3% (BITA) versus 2.2%, p = 0.749. Duration of mechanical ventilation < 12 hours was 74.6 versus 77.1%, p = 0.09 and duration of in-hospital stay was 10.5 versus 10.4 days, p = 0.68. Thirty-day mortality was 2.4% (BITA) versus 3.0%, p = 0.09. Multivariate analysis identified prolonged duration of surgery, BMI > 30, emergent operations, advanced age, and BITA grafting as predictor for sternal instabilities. EF < 30%, advanced age plus emergency were associated with increased 30-day mortality. CABG using BITA can be performed routinely with good clinical results and low mortality. Compared with SITA grafting, bleeding complications were enhanced.

CABG without Pump and Clamp! Is It Better or Worse?

CABG without Pump and Clamp! Is It Better or Worse? Benefits of off-pump coronary artery bypass grafting in reducing complications of coronary artery bypass grafting are well established in literature. Moreover avoiding aortic manipulation and using bilateral internal thoracic artery during off-pump coronary artery bypass grafting has the advantage of improving long-term outcome and reducing stroke incidence. In spite of compelling evidence, OPCAB is poorly adopted by the skeptics. Contemporary evidences of grafts patency, completeness of revascularization and survival after on and off-pump coronary artery bypass grafting are discussed in this review. Similar internal thoracic artery patency rate in Danish off-pump versus on-pump randomized study suggest both techniques are comparable. Various factors affecting graft patency after coronary artery bypass grafting were discussed. Anaortic off-pump coronary artery bypass grafting has the added advantage of reducing the incidence of stroke and can be the best surgical alternative to percutaneous coronary intervention.

Reskeletonization of Patent Graft Using Ultrasonic Scalpel in Redo Surgery

A patent graft is one of the major concerns in redo cardiacsurgery. A full skeletonization technique using an ultrasonic scalpel is a breakthrough method to harvest the internal thoracic artery, being first reported in 2000. Here, we describe a reskeletonization technique to safely dissect a patent internal thoracic artery graft using an ultrasonic scalpel in redo cardiac surgery after coronary artery bypass graft surgery. This technique can be used not only to expose the patent graft to simply mobilize or clamp it, but also to recycle a patent graft to revascularize other coronary arteries.

Repeated valve replacement surgery: technical tips and pitfalls

For successful repeated valve replacement surgery, it is essential issue that the preoperative evaluation includes an assessment of the previous operation record, computed tomography (CT: including 3D-CT), ultrasound cardiography, coronary artery angiography, and so on. Although it is especially needed for repeated valve replacement surgery, setting up of the external defibrillation pads is the most important preparation just prior to the surgery. In regard to the approach, re-sternotomy is frequently employed as a standard fashion because it allows us to re-entry any part of the heart. As alternative approaches, partial sternotomy, right thoracotomy for minimally invasive cardiac surgery approach have also been highlighted recently. Myocardial protection is another important consideration in repeated valve replacement surgery, especially in post-coronary artery bypass grafting cases with a patent internal thoracic artery. In repeated valve replacement surgery, special and unique techniques are required both for taking the affected prosthetic valve out and for implanting a new valve, which is dependent on the types of the previous prosthetic valve and the condition of the affected prosthetic valve. Therefore, for performing repeated valve replacement surgeries, surgeons should be highly skilled in these special techniques.

The "free" right internal thoracic artery: a versatile and durable conduit.

Despite its potential advantages, the right internal thoracic artery (RITA) is used as a conduit in only 4% of coronary revascularizations. To broaden its application, we frequently use the RITA as a free graft. In this study, we review our experience with the RITA as an in situ and free graft. We reviewed the perioperative outcomes and angiographic patency rates of 479 consecutive patients who underwent RITA grafting between January 1987 and December 2011. The RITA was harvested free (FRITA) in 380 patients (79%) and in situ in 99 (21%). The predominant target for the in situ RITA was the right coronary system (79%). The predominant targets for the FRITA were divided between the right (54%) and left coronary systems (46%). There was no perioperative mortality. Mean follow-up was 10 years. Perioperative complications included myocardial infarction (0.4%), sternal nonunions (0.4%), and reoperation for hemorrhage (0.6%). Coronary angiograms were performed in symptomatic patients (17%) after a median of seven years. FRITA patency rates at five, 10, and 15 years were 100%, 95%, and 95%, respectively, comparable to the left internal thoracic artery patency rates and superior to those of saphenous vein graft. Survival rates of FRITA patients at 10, 15, and 20 years were 92%, 89%, and 76%, respectively. The FRITA graft reaches all distal coronary vessels and is associated with excellent patency and survival rates. Its application in coronary revascularization vastly expands the benefits of internal thoracic artery grafting.

Chronic competitive flow from a patent arterial or venous graft to the circumflex system does not impair the long-term patency of internal thoracic artery to left anterior descending grafts in patients with isolated predivisional left main disease: Long-term angiographic results of 2 different revascularization strategies

To compare 2 different surgical approaches to treatment of patients with isolated predivisional stenosis of the left main coronary artery (IOSLM) and to evaluate the effect of chronic competitive flow from a patent arterial or venous graft to the circumflex system on the long-term patency of internal thoracic artery (ITA) to left anterior descending grafts. Thirty-two patients with IOSLM were treated at our institutions during a 9-year period: 14 patients received double ITA grafts, whereas 18 underwent ITA graft plus saphenous vein (SV) bypass. All patients were reviewed clinically and angiographically at long-term follow-up. No patient died during hospitalization. At a mean follow-up of 96±9 months 7 patients had died (6 from noncardiac causes) and 5 had experienced angina/ischemia recurrence, without differences between the 2 revascularization strategies. At control reangiography all ITA and SV grafts were found to be fully patent, without evidence of caliber reduction or string sign in the ITA. In patients with IOSLM, long-term ITA to left anterior descending artery patency is not jeopardized by chronic flow competition from a concomitant arterial or venous graft to the circumflex system. Notably, the addition of a second ITA graft or of a SV to the first ITA does not lead to differences in long-term angiographic patency. Our results minimize the role of flow competition in this setting and should be kept in mind when choosing the appropriate graft configuration.

Invited Commentary

Experienced surgeons, when estimating the risk of surgical procedures, approximately double the predicted mortality when the procedure involves a reoperation. In fact, between 2003 and 2010, the New York State Cardiac Surgery Database predicted that patients undergoing valve and coronary procedures experienced an incremental odds ratio of between 1.5 and 2.1 if they had previously undergone open heart procedures [1Cardiovascular Disease Data and Statistics. New York State Department of Health. Available at: http://www.health.ny.gov/statistics/diseases/cardiovascular/. Accessed June 4, 2013.Google Scholar].In reviewing their results with 130 patients undergoing repeat surgical procedures through sternotomy, Ghoreishi and coauthors [2Ghoreishi M. Dawood M. Hobbs G. et al.Repeat sternotomy: no longer a risk factor in mitral valve surgical procedures.Ann Thorac Surg. 2013; 96: 1358-1366Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar] have shown that selected reoperative mitral valve procedures can be performed at a risk level equivalent to that of first-time operations. This somewhat counterintuitive result is attributable to careful planning and technique. Their work helps to establish best practices, including appropriate selection of patients for sternal versus thoracotomy reentry, preoperative risk stratification with computed tomographic scanning, preemptive exposure and in some cases cannulation of the femoral vessels, avoidance of lateral traction on mediastinal tissues during separation of the sternum, avoidance of dissection of patent internal thoracic artery grafts, and (presumably) careful attention to myocardial protection, particularly in patients with previous coronary grafts.The lateral thoracotomy approach to the reoperative mitral valve procedure has been widely advocated and remains a useful tool in the surgeons' repertoire, especially for patients with hostile mediastina, radiation, previous muscle flaps, aortic pathologic conditions, prior aortic and aortic valve surgical procedures, and other situations in which sternal division is hazardous. Nonetheless, these authors have taught us that sternal reentry need not substantially increase surgical risk, much less double it. Experienced surgeons, when estimating the risk of surgical procedures, approximately double the predicted mortality when the procedure involves a reoperation. In fact, between 2003 and 2010, the New York State Cardiac Surgery Database predicted that patients undergoing valve and coronary procedures experienced an incremental odds ratio of between 1.5 and 2.1 if they had previously undergone open heart procedures [1Cardiovascular Disease Data and Statistics. New York State Department of Health. Available at: http://www.health.ny.gov/statistics/diseases/cardiovascular/. Accessed June 4, 2013.Google Scholar]. In reviewing their results with 130 patients undergoing repeat surgical procedures through sternotomy, Ghoreishi and coauthors [2Ghoreishi M. Dawood M. Hobbs G. et al.Repeat sternotomy: no longer a risk factor in mitral valve surgical procedures.Ann Thorac Surg. 2013; 96: 1358-1366Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar] have shown that selected reoperative mitral valve procedures can be performed at a risk level equivalent to that of first-time operations. This somewhat counterintuitive result is attributable to careful planning and technique. Their work helps to establish best practices, including appropriate selection of patients for sternal versus thoracotomy reentry, preoperative risk stratification with computed tomographic scanning, preemptive exposure and in some cases cannulation of the femoral vessels, avoidance of lateral traction on mediastinal tissues during separation of the sternum, avoidance of dissection of patent internal thoracic artery grafts, and (presumably) careful attention to myocardial protection, particularly in patients with previous coronary grafts. The lateral thoracotomy approach to the reoperative mitral valve procedure has been widely advocated and remains a useful tool in the surgeons' repertoire, especially for patients with hostile mediastina, radiation, previous muscle flaps, aortic pathologic conditions, prior aortic and aortic valve surgical procedures, and other situations in which sternal division is hazardous. Nonetheless, these authors have taught us that sternal reentry need not substantially increase surgical risk, much less double it. Repeat Sternotomy: No Longer a Risk Factor in Mitral Valve Surgical ProceduresThe Annals of Thoracic SurgeryVol. 96Issue 4PreviewThe incidence of reoperative mitral valve (MV) surgical procedures is increasing, representing more than 10% of all MV operations in the United States. Previous clinical series have reported mortality rates of 5% to 18% and reentry injury rates of 5% to 10% for reoperative MV operations. Full-Text PDF