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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Salvatore Lentini Sossio Perrotta Roberto Gaeta Permission Requests Citing Articles Citing Articles via HighWire Google Scholar Articles by Lentini, S. Articles by Gaeta, R. PubMed Articles by Lentini, S. Articles by Gaeta, R. Related Collections Minimally invasive surgery Valve disease

Letters to the Editor

Surgical approach for isolated aortic valve replacement with patent coronary grafts

^a Cardiac Surgery Unit, University Hospital, University of Messina, Messina, Italy
^b Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Göteborg, Sweden

Received 14 February 2009; accepted 10 March 2009.

^_* Corresponding author. Address: UOC Cardiochirurgia, Policlinico G Martino, Università di Messina, Viale Gazzi, 98100 Messina, Italy. Tel.: +39 090 2217086; fax: +39 090 2217086. (Email: salvolentini{at}alice.it).

Key Words: Aortic valve replacement • Redo surgery • Risk score • Minimally invasive surgery

We read with interest the paper of Khaladj and co-workers [1]. The authors performed AVR through redo full sternotomy on 39 patients with still patent coronary grafts (30 LIMA grafts). On the basis of their results the authors showed that high risk patients can be operated with lower risk than anticipated by EuroSCORE risk stratification. They conclude that: ‘old fashioned surgical approach should still be considered the gold standard of treatment for high risk AVR’.

We would like to analyse two aspects:

(A) This report is a retrospective study analysing patients who underwent aortic valve replacement as a redo operation during a period of 12 years. From a total of 349 patients, a subgroup of 39 with patent grafts was retrospectively analysed. Now, the point is that in this series we analyse just the patients who received surgery. We do not know if other patients needing the same operation in the same period of time were turned down for surgery because they were considered at high risk. Risk can be either for redo operation, or for comorbidities. A prospective study comparing standard surgery and percutaneous alternatives for high risk redo patients in need of AVR, would have a stronger statistical weight.

(B) We understand that expert technical skills are important in the outcome of those particular patients, and we congratulate the authors. However, we would like to add something on the adopted technique. The authors used a full re-sternotomy. The authors who are aware of the risks of a re-sternotomy, focus on the importance of a preoperative CT scan for proper operative planning, in order to avoid injury to bypass grafts, native coronary vessels, or the right ventricle during re-sternotomy.

We believe that in experienced hands, those risks may be reduced; however, we could further reduce them. For example, the use of a minimal invasive technique in those kind of patients may be of help, in particular an upper J ministernotomy with transversal sternal incision on the third or fourth right intercostals space. During AVR, there is no need to expose the right ventricle, or the left side of the heart near the pulmonary trunk. Therefore with a J sternal incision, just the right side of the chest is split on one side only. This will allow central arterial cannulation and right atrial cannulation. The right ventricle is not exposed, therefore decreasing the risk of adhesions dissection. The patent LIMA will be left undisturbed on the left side of the chest. There is actually no need to isolate and clamp the LIMA during the aortic cross-clamp time. Different types of myocardial protection may be used with this technique, such as a continuous antegrade coronary blood perfusion or other types of cardioplegia on the surgeon preference. Our group has used this particular minimal invasive approach in 18 patients with patent LIMA with good results. This may be another option to further reduce surgical risk.

References

1. Khaladj N, Shrestha M, Peterss S, Kutschka I, Strueber M, Hoy L, Haverich A, Hagl C. Isolated surgical aortic valve replacement after previous coronary artery bypass grafting with patent grafts: is this old-fashioned technique obsolete?. Eur J Cardiothorac Surg 2009;35(2):260-264.[Abstract/Free Full Text]

This article has been cited by other articles:

				N. Khaladj, M. Shrestha, A. Haverich, and C. Hagl Reply to Lentini et al.: Redo-sternotomy and myocardial protection in patients with patent LIMA-grafts Eur. J. Cardiothorac. Surg., June 1, 2009; 35(6): 1114 - 1115. [Full Text] [PDF]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Salvatore Lentini Sossio Perrotta Roberto Gaeta Permission Requests Citing Articles Citing Articles via HighWire Google Scholar Articles by Lentini, S. Articles by Gaeta, R. PubMed Articles by Lentini, S. Articles by Gaeta, R. Related Collections Minimally invasive surgery Valve disease