Interact CardioVasc Thorac Surg 2009;9:97. doi:10.1510/icvts.2008.201038B
© 2009 European Association of Cardio-Thoracic Surgery
eComment: Aortic valve replacement in patients with patent coronary grafts: how to do it?
Luca Botta and
Luigi Martinelli
Niguarda Cà Granda Hospital, Piazza dell'ospedale maggiore 3, 20162 Milan, Italy
Mini re-sternotomy for aortic valve replacement in patients with patent coronary bypass grafts
Surgical management of aortic valve disease in patients who already underwent bypass grafting is a matter of debate. In the paper of Dell'Amore and colleagues [1], 10 patients with patent grafts underwent aortic valve replacement through a j-shaped ministernotomy in the 3rd or 4th intercostal space over a period of almost two years. The authors are to be congratulated for these excellent outcomes. We agree with them about the surgical approach in ministernotomy since we believe that the minimally invasive approach shows its own best just in these intricate situations as it happens with the heart-port technique for mitral re-operations or mitral surgery in patent grafts. We would like to comment about the methods adopted by the authors in this cohort of patients.
- The surgical technique consisted in a limited dissection of the proximal vein-graft anastomosis without clamping the LITA. A single dose of antegrade blood cardioplegia was administered but when the heart resumed a sinus rhythm after a few minutes, it was elected to use no more cardioplegia allowing the heart to beat empty throughout the procedure. Did you experience other techniques of myocardial protection in the same setting? Of course, myocardial protection is a major issue for these patients, even more challenging in case of hypertrophied hearts due to aortic stenosis. We agree with Battellini et al. [2] that different strategies should be optimized to the individual patient findings.
- Another important issue is the location of the proximal anastomoses. In your experience, was cross-clamping feasible below the proximal anastomosis leaving venous grafts perfused? In this case, the technique suggested by Sutherland and colleagues [3] seems to be a good choice.
- In two patients a RIMA graft was present. Is there additional complexity in these cases?
- Can you please give some details about the anesthesiologic management of these patients? Have you adopted any ‘fast track’ protocol?
- In the discussion paragraph, you admit that the surgical approach should still be considered the gold standard treatment even in high-risk patients although catheter-based approach could be promising for them in the future. Which is your opinion about the trans-apical approach in these cases?
Thank you very much for this fine contribution.
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References
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- Dell'Amore A, Del Giglio M, Calvi S, Pagliaro M, Fedeli C, Magnano D, Tripodi A, Lamarra M. Mini re-sternotomy for aortic valve replacement in patients with patent coronary by-pass grafts. Interact CardioVasc Thorac Surg 2009;9:94–97.[Abstract/Free Full Text]
- Battellini R, Rastan AJ, Fabricius A, Moscoso-Luduena M, Lachmann N, Mohr FW. Beating heart aortic valve replacement after previous coronary artery bypass surgery with a patent internal mammary artery graft. Ann Thorac Surg 2007;83:1206–1209.[Abstract/Free Full Text]
- Sutherland FW, West M, Pathi V. Aortic valve replacement with continuously perfused beating heart in patients with patent bypass conduits. Eur J Cardiothorac Surg 2004;26:834–836.[Abstract/Free Full Text]
Related Article
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Mini re-sternotomy for aortic valve replacement in patients with patent coronary bypass grafts
- Andrea Dell'Amore, Mauro Del Giglio, Simone Calvi, Marco Pagliaro, Corrado Fedeli, Diego Magnano, Alberto Tripodi, and Mauro Lamarra
Interactive CardioVascular and Thoracic Surgery 2009 9: 94-97.
[Abstract]
[Full Text]
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