International Society For Minimally Invasive Cardiothoracic Surgery

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Ministernotomy Aortic Valve Surgery In Patients With Prior Patent Mammary Artery Grafts After Coronary Artery Bypass Grafting
Vasily Kaleda1, Oleg Orlov2, Vishal Shah2, Cinthia Orlov2, Konstadinos Plestis2.
1Central Clinical Hospital, Moscow, Russian Federation, 2Lankenau Medical Center, Philadelphia, PA, USA.

BACKGROUND: Patients with patent mammary grafts after prior coronary artery bypass grafting (CABG) who require aortic valve replacement (AVR) pose unique technical challenges for safe and optimal myocardial protection. The purpose of this study is to review our experience with mini AVR (MIAVR) in patients with patent mammary artery grafts. METHODS: From 2008 to 2016, 49 patients with at least one patent in situ mammary artery graft underwent upper sternotomy MIAVR. Preoperative computed tomography was performed in all patients to evaluate the relationship of the patent grafts to the sternum. Retrograde coronary sinus and pulmonary vent catheters were placed via the right internal jugular vein. All grafts remained undissected and unclamped. A transverse aortotomy below the grafts was used to expose the aortic valve. RESULTS: Median age was 78 years (range 57-90). Forty (81.6%) patients were male and 47 (95.9%) patients had aortic stenosis. Forty-five (91.8%) patients had one patent in-situ mammary artery graft and in 4 (8.2%) patients both in-situ mammary artery grafts were patent. One patient had a right mammary artery graft crossing the midline. Median cardiopulmonary bypass and cross-clamp times were 127 (range 72-331) and 92 (range 66-195) minutes respectively. Mild hypothermia (32-34C) was used in 39 (79.6%) patients and moderate (28-30C) in 10 (20.4%) patients. Five (10.2%) patients received sole retrograde cold cardioplegia. In 38 (77.6%) patients, electromechanical arrest was achieved by single dose cardioplegia in the aortic root or single dose retrograde cardioplegia. To maintain cardiac arrest, cardioplegia was given either continuously 35 (37.1%) or intermittently 14 (28.6%). Thirty-day mortality was 4% (2/49). There was no conversion to full sternotomy. There were no reoperations for postoperative bleeding or sternal wound infection. Median postoperative length of stay was 7 days. Survival at five years was 87.7%. CONCLUSIONS: Percutaneous retrograde cardioplegia combined with antegrade cardioplegia and mild hypothermia provide safe and reliable myocardial protection in patients with patent mammary artery grafts undergoing reoperative valve surgery. This strategy combined with a minimally invasive approach may reduce surgical trauma and ensures excellent results in this complicated group of patients.
LEGEND: MIAVR with prior patent mammary artery grafts after CABG


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