Patch aortotomy for aortic valve replacement after previous coronary artery bypass grafting

Reverse U aortotomy (Kırali incision) for aortic valve replacement

The presence of patent vein grafts on the proximal aorta may cause technical difficulties during reoperations for aortic valve replacement after previous coronary artery bypass surgery. A 65-year-old man underwent reoperation for aortic valve replacement two years after his first open heart surgery (valve-sparing aortic root replacement and aorta-right coronary artery saphenous vein graft). The aortotomy incision was started approximately 2 cm above the proximal anastomosis and continued down at both sides until the prosthetic graft. The reverse U aortotomy prevents unnecessary and risky manipulations of proximal anastomoses, provides perfect exposure, and can be used securely during reoperative aortic valve surgery.

Reverse "U" aortotomy for aortic valve replacement after previous coronary artery bypass grafting

The presence of patent vein grafts on the proximal aorta may give technical difficulties during exposure to aortic valve replacement after previous coronary artery bypass operations. A tongue or reverse "U" shape aortotomy allows excellent exposure of the aortic valve and antegrade cardioplegic administration without mobilizing vein grafts. This approach may facilitate uni- or bidirectional aortic root enlargement in patients with small aortic root.

Supraclavicular control of patent internal thoracic artery graft flow during aortic valve replacement

BACKGROUND

The mortality and morbidity of aortic valve replacement (AVR) after prior coronary artery bypass surgery (CABG) with patent left internal thoracic artery (LITA) is significant. The risk of LITA injury and inadequate myocardial preservation during the cross-clamp period may cause myocardial pump failure.

METHODS

A total of 43 patients with a patent LITA graft underwent AVR. The patients were divided into the two groups. Group 1 included 19 patients who underwent AVR with deep hypothermia (20 degrees C) without LITA clamping. Group 2 included 24 patients in whom LITA flow was controlled through supraclavicular occlusion and AVR performed with moderate hypothermia (28 degrees C).

RESULTS

Average cardiopulmonary bypass time (CPB) time was 118.79 +/- 20.36 minutes in group 1 and 102.67 +/- 9.66 minutes in group 2 (p = 0.006). Average cross-clamp time was 53.79 +/- 7.26 minutes in group 1 and 49.63 +/- 6.7 minutes in group 2 (p = 0.022). Inotropic support was required in 12 patients in group 1 and 4 patients in group 2 (p = 0.002). Average intensive care unit stay was 4.68 +/- 2.24 days in group 1 and 2.29 +/- 0.46 days in group 2 (p < 0.001). Average hospital stay was 11.84 +/- 2.91 days in group 1 and 8.04 +/- 2.38 days in group 2 (p < 0.001). Mortality due to myocardial failure developed in 4 patients in group 1 but in none of the patients in group 2 (p = 0.02).

CONCLUSIONS

Proximal control of LITA flow by extrathoracic supraclavicular occlusion reduces the incidence of myocardial failure due to nonhomogenous cardioplegia delivery to the anterior wall of the heart, resulting in improved myocardial protection and the elimination of the need for deep hypothermia.

Management of patients with mild aortic stenosis undergoing coronary artery bypass grafting

BACKGROUND

The management of mild aortic stenosis during coronary artery bypass grafting remains controversial.

METHODS

We reviewed the medical records of consecutive patients between January 1, 1977, and December 31, 1994, to identify 51 patients with mild aortic stenosis who underwent isolated coronary artery bypass grafting (group A), and 19 patients with mild aortic stenosis who underwent combined coronary artery bypass grafting and aortic valve replacement (group B). Patients with more than moderate aortic regurgitation were excluded. Preoperative angiograms were reviewed to assess the severity of calcification and restricted mobility of the aortic cusps.

RESULTS

In group A there were 11 deaths and 8 subsequent aortic valve replacements; in group B there were 5 deaths and 3 prosthetic valve-related complications. There was no difference in event-free survival between the two groups after adjusting for the difference in age. Among group A patients, the initial transvalvular gradient (p = 0.0005) and aortic valvular calcification (p = 0.06) identified patients who demonstrated progression to severe aortic stenosis during follow-up.

CONCLUSIONS

Our data suggest that routine aortic valve replacement during coronary artery bypass grafting in patients with mild aortic stenosis is not indicated, but concomitant aortic valve replacement may be appropriate in patients with higher transvalvular gradients and calcified valves.

Safety of remote aortic valve replacement after prior coronary artery bypass grafting

BACKGROUND

A previous coronary artery bypass grafting (CABG) procedure may complicate subsequent aortic valve replacement (AVR). However, the operative risks and long-term outcome of patients who undergo these two procedures remain poorly defined.

METHODS

The medical records of all patients undergoing AVR between February 1986 and September 1995 were reviewed retrospectively. The patients selected for analysis had previously undergone CABG.

RESULTS

We performed AVR in 23 consecutive patients who had previously undergone CABG (mean number of grafts, 2.8). The AVR was performed an average of 7.6 years after CABG (range, 2 to 17 years). There were 20 men and 3 women, with a mean age of 69 years (range, 56 to 85 years). Twenty patients were operated upon for aortic stenosis (mean gradient 54 mm Hg, mean valve area 0.7 cm2), and 3 patients underwent operation for aortic regurgitation. The average aortic valve gradient at the initial revascularization operation was 8 mm Hg (range, 0 to 29 mm Hg). There was no correlation between the aortic valve gradient at the initial revascularization and the interval between CABG and AVR. At the second operation, AVR was performed alone in 11 patients, combined with repeat CABG in 11 patients (mean number of grafts, 1.4), and with mitral valve replacement in 1 patient. A mechanical prosthesis was selected in 14 patients, and a bioprosthesis was used in 9 patients. There were no perioperative deaths. There were five late deaths at an average follow-up of 44 months. The 5-year actuarial survival was 71%.

CONCLUSIONS

Previous CABG poses added technical challenges at the time of reoperation for AVR. The operation can be performed safely, with the expectation of satisfactory long-term survival.