The "no-dissection" technique is safe for reoperative aortic valve replacement with a patent left internal thoracic artery graft.
OBJECTIVE
Management of a patent left internal thoracic artery graft during reoperation is controversial. The "no-dissection" technique avoids dissection and clamping of the left internal thoracic artery graft, and myocardial protection is achieved using adjunctive systemic hypothermia and hyperkalemia. We compared the postoperative outcomes after isolated reoperative aortic valve replacement in patients with previous coronary artery bypass grafting with a patent left internal thoracic artery graft using a no-dissection technique with the outcomes of patients with previous coronary artery bypass grafting without a left internal thoracic artery graft.


METHODS
The outcomes were analyzed for patients who underwent isolated reoperative aortic valve replacement with previous coronary artery bypass grafting from January 1, 2002, to June, 30, 2011. Patency of the left internal thoracic artery was confirmed using either coronary angiography or computed tomography angiography. The patent left internal thoracic artery group did not undergo dissection or clamping of the left internal thoracic artery graft, and myocardial protection was obtained using systemic hypothermia and hyperkalemia. The no left internal thoracic artery group underwent isolated aortic valve replacement with previous coronary artery bypass grafting but had no left internal thoracic artery graft.


RESULTS
A total 174 patients were identified for the patent left internal thoracic artery group and 26 for the no left internal thoracic artery group. The perfusion and crossclamp times were similar. No differences were seen between the 2 groups in operative mortality (6.9% vs 7.7%, P = 1.00). The complication rates were similar, and the peak creatine kinase-MB values within 24 hours of surgery were not significantly different between the 2 groups (median, 27.4 vs 29 μ/mL; P = .72).


CONCLUSIONS
Reoperative aortic valve replacement in patients with previous coronary artery bypass grafting and a patent left internal thoracic artery graft can be performed safely without dissection or clamping of the left internal thoracic artery using systemic hyperkalemia and hypothermia. We believe this method prevents unnecessary injury during dissection of the left internal thoracic artery graft.
Department of Cardiac Surgery, Brigham and Women's Hospital, Boston, MA, USA.
Tsuyoshi
T
Kaneko
Foeke
F
Nauta
Wernard
W
Borstlap
Siobhan
S
McGurk
James D
JD
Rawn
Lawrence H
LH
Cohn
D000368:Aged; D000369:Aged, 80 and over; D001021:Aortic Valve / Q000601:surgery*; D015415:Biomarkers / Q000097:blood; D001900:Boston; D050792:Circulatory Arrest, Deep Hypothermia Induced; D003250:Constriction; D017023:Coronary Angiography; D003331:Coronary Vessels / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D052279:Creatine Kinase, MB Form / Q000097:blood; D004210:Dissection; D005260:Female; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D006801:Humans; D006947:Hyperkalemia; D007387:Internal Mammary-Coronary Artery Anastomosis / Q000009:adverse effects / Q000401:mortality; D008297:Male; D008323:Mammary Arteries / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D011183:Postoperative Complications / Q000097:blood / Q000209:etiology; D011189:Potassium Chloride / Q000008:administration & dosage; D012086:Reoperation; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D014654:Vascular Patency
D015415:Biomarkers; D011189:Potassium Chloride; D052279:Creatine Kinase, MB Form