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Minimally invasive lower hemisternotomy for valvular heart surgery after previous CABG with patent internal mammary graft.
Amit Pawale, MD, Anelechi C. Anyanwu, MD, David H. Adams, MD.
Mount Sinai Medical Center, New York, NY, USA.

Minimally invasive lower hemisternotomy for valvular heart surgery after previous CABG with patent internal mammary graft.
Objective
Patient needing mitral or aortic valve surgery after previous coronary artery bypass grafting with patent internal mammary artery (IMA) grafts are technically challenging subset of reoperations due to potential for IMA injury during re-entry. Reoperative sternotomy without dissecting or clamping the IMA, right thoracotomy approach have been used to avoid IMA injury. We present our technique of lower hemisternotomy approach for such patients.
Methods
A contrast CT scan is performed as preoperative work up. Patients with ascending aorta relatively lower in relation to the sternum and IMA graft close to the manubrium are selected for this approach. Cardiopulmonary bypass is established using right axillary artery graft, direct cannulation of right axillary vein and percutaneous cannulation of IVC through femoral vein. Lower hemisternotomy is performed with a stryker saw and lower sternal table is dissected off the heart. The sternal retractor is gradually opened in stages. After dissecting ascending aorta, moderate systemic hypothermia is used and aorta is cross clamped (Image 1 D). Antegrade and then retrograde blood cardiolplegia is used every 20 minutes. IMA is not looked for.
Case 1: 73 year old male with patent LIMA behind the manubrium (Image 1 A) and case 2: 63 year old male with patent RIMA to the LAD, crossing the midline (Image 1 B)- both underwent MV repair (Image 1 E, F) with trans-septal approach for severe MR along with TV repair.
Case 3: 77 year old male with patent LIMA to LAD graft close behind the manubrium (Image 1 C), underwent AVR for severe symptomatic aortic stenosis.
Results
All three patients had uneventful recovery and were discharged home within a week.
Conclusion
Minimally invasive lower hemisternotomy is a viable approach to avoid patent IMA graft injury. This technique has potential advantages over the right thoracotomy in terms of ability to cross clamp aorta safely, less potential for ventricular distension, better de-airing and avoiding thoracotomy when hostile pleural space. It is more likely to avoid IMA injury than full sternotomy.


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