- Email: [email protected]
Optimizing Use of the Internal Thoracic Arteries for Total Myocardial Revascularization
Ann Thorac Surg 2005;79:752–56
We appreciate the correspondents’ interest in our work and hope that this response satisfies their request for information and clarifies our position on the mechanism and treatment of CIMR. Joseph H. Gorman III, MD Robert C. Gorman, MD Hospital of the University of Pennsylvania 6 Silverstein 3400 Spruce St Philadelphia, PA 19104 e-mail: [email protected]
References 1. Salgo IS, Gorman JH III, Gorman RC, Jackson BM, Bowen FW, Plappert T, et al. The effect of annular shape on leaflet curvature in reducing mitral leaflet stress. Circulation 2003; 106:711–7. 2. Gorman JH III, Gorman RC, Jackson BM, Enomoto Y, St. John Sutton MG, Edmunds LR Jr. Annuloplasty ring selection for chronic ischemic mitral regurgitation: lessons from the ovine model. Ann Thorac Surg 2003;76:1556 – 63. 3. Gorman JH III, Jackson BM, Enomoto Y, Gorman RC. The effect of regional ischemia on mitral valve annular saddle shape and function. Ann Thorac Surg 2004;77:544 – 8.
CORRESPONDENCE
753
Jean Minjoz Hospital Department of Thoracic and Cardiovascular Surgery 3 Bd Fleming Besançon 25000, France e-mail: [email protected].
References 1. Vicol C, Nollert G, Mair H, Reichart B. Optimizing use of the octopus system for off-pump total arterial myocardial revascularization with the TY graft. Ann Thorac Surg 2004;77:731–3. 2. Prapas SN, Anagnostopoulos CE, Kotsis VN, et al. A new pattern for using both thoracic arteries to revascularize the entire heart: the pi-graft. Ann Thorac Surg 2002;73:1990 –2. 3. Stoica L, Chocron S, Falcoz PE, Kaili D, Etievent JP. The mammary loop— or how to do an adjustable “Y” graft with the left internal thoracic artery. Ann Thorac Surg 2004;78: 1103– 4. 4. Stoica L, Chocron S, Falcoz PE, Kaili D, Etievent JP. How to tailor a “” graft for complex myocardial revascularization—a variant of the mammary loop technique. Ann Thorac Surg 2004. In press.
Reply
Optimizing Use of the Internal Thoracic Arteries for Total Myocardial Revascularization To the Editor: Vicol and associates [1] presented a technique that allows all arterial coronary revascularization using a composite graft made with the left internal thoracic artery (LITA) and the radial artery (RA), called the TY graft. It permits three or four coronary anastomoses in the end-to-side fashion. The TY graft is similar to the graft described by Prapas and colleagues [2] that is made with two skeletonized internal thoracic arteries (ITAs). The disadvantage of the two techniques is that we must precisely measure and cut segments of LITA, RITA, or RA before the anastomoses are done on the left descending artery (LAD) or on the most distal artery on the lateral or posterior wall. An error of measurement may compromise these bypass grafts and the entire operation. We use the mammary loop technique which permits a Y graft using only a LITA or a graft using two ITAs [3, 4]. The distal end of the skeletonized LITA is anastomosed to the proximal LITA to form a loop. That will be cut open just before the coronary anstomosis at the desirable level to provide an adjustable Y graft. This kind of Y graft permits bypass grafts the LAD, diagonal artery, ramus intermedius, or a high lateral artery when the anatomy for a sequential bypass graft is inappropriate. The loop technique simplifies graft construction. First we made a Y graft with two skeletonized ITAs. The loop is made by anastomosing the distal end of the LITA to the RITA. After section of the loop, we obtain a graft. There are four variants of loop construction for a graft: LITA on RITA, LITA on LITA, RITA on LITA, and RITA on RITA; so we can adapt the graft for each case. We used these techniques in 20 patients who underwent on-pump or off-pump surgery. These mammary loop techniques allow construction of adjustable composite grafts with both ITAs. In our experience this method is sure, reproducible, and easier to perform than the “classic graft” or the TY graft. Lucian Stoica, MD, PhD Sidney Chocron, MD, PhD Joseph Philippe Etievent, MD © 2005 by The Society of Thoracic Surgeons Published by Elsevier Inc
The TY graft described by us [1] and the graft described by Prapas and colleagues [2] are intended to revascularize three to five coronary arteries. The loop technique as featured by Stoica and colleagues is limited to only three vessels, according to Dr Stoica’s letter. Doctor Stoica states that a disadvantage of the TY and graft techniques is the necessity to exactly measure the length of the short free graft segments and that an error in this measurement may compromise graft patency. However, his loop technique is actually a step in the construction of a TY or graft and can be also affected by a wrong appreciation of segment length. Usually we oversize lengths of short, free graft segments at the time of TY graft construction and determine the definitive length before performing each anastomosis to target coronary arteries. In this way, we avoid the risk of length mismatch or kinking. We used the TY graft construction in 46 patients without technical dificulties and with good results. We did not compare it with the loop technique for constructing TY or grafts; therefore, we cannot state if it is more reproducible and easy to perform, as Dr Stoica states. Nevertheless, the loop technique seems to be an ingenious method to construct a TY or graft. Calin Vicol, MD Ludwig Maximilians University Grosshadern Medical Center Marchioninistrasse 15 Munich 81377, Germany e-mail: [email protected].
References 1. Vicol C, Nollert G, Mair H, Reichart B. Optimizing use of the octopus system for off-pump total arterial myocardial revascularization with the TY graft. Ann Thorac Surg 2004;77:731–3. 2. Prapas SN, Anagnostopoulos CE, Kotsis VN, et al. A new pattern for using both thoracic arteries to revascularize the entire heart: the pi-graft. Ann Thorac Surg 2002;73:1990 –2. 0003-4975/05/$30.00
MISCELLANOUS
To the Editor:
We appreciate the correspondents’ interest in our work and hope that this response satisfies their request for information and clarifies our position on the mechanism and treatment of CIMR. Joseph H. Gorman III, MD Robert C. Gorman, MD Hospital of the University of Pennsylvania 6 Silverstein 3400 Spruce St Philadelphia, PA 19104 e-mail: [email protected]
References 1. Salgo IS, Gorman JH III, Gorman RC, Jackson BM, Bowen FW, Plappert T, et al. The effect of annular shape on leaflet curvature in reducing mitral leaflet stress. Circulation 2003; 106:711–7. 2. Gorman JH III, Gorman RC, Jackson BM, Enomoto Y, St. John Sutton MG, Edmunds LR Jr. Annuloplasty ring selection for chronic ischemic mitral regurgitation: lessons from the ovine model. Ann Thorac Surg 2003;76:1556 – 63. 3. Gorman JH III, Jackson BM, Enomoto Y, Gorman RC. The effect of regional ischemia on mitral valve annular saddle shape and function. Ann Thorac Surg 2004;77:544 – 8.
CORRESPONDENCE
753
Jean Minjoz Hospital Department of Thoracic and Cardiovascular Surgery 3 Bd Fleming Besançon 25000, France e-mail: [email protected].
References 1. Vicol C, Nollert G, Mair H, Reichart B. Optimizing use of the octopus system for off-pump total arterial myocardial revascularization with the TY graft. Ann Thorac Surg 2004;77:731–3. 2. Prapas SN, Anagnostopoulos CE, Kotsis VN, et al. A new pattern for using both thoracic arteries to revascularize the entire heart: the pi-graft. Ann Thorac Surg 2002;73:1990 –2. 3. Stoica L, Chocron S, Falcoz PE, Kaili D, Etievent JP. The mammary loop— or how to do an adjustable “Y” graft with the left internal thoracic artery. Ann Thorac Surg 2004;78: 1103– 4. 4. Stoica L, Chocron S, Falcoz PE, Kaili D, Etievent JP. How to tailor a “” graft for complex myocardial revascularization—a variant of the mammary loop technique. Ann Thorac Surg 2004. In press.
Reply
Optimizing Use of the Internal Thoracic Arteries for Total Myocardial Revascularization To the Editor: Vicol and associates [1] presented a technique that allows all arterial coronary revascularization using a composite graft made with the left internal thoracic artery (LITA) and the radial artery (RA), called the TY graft. It permits three or four coronary anastomoses in the end-to-side fashion. The TY graft is similar to the graft described by Prapas and colleagues [2] that is made with two skeletonized internal thoracic arteries (ITAs). The disadvantage of the two techniques is that we must precisely measure and cut segments of LITA, RITA, or RA before the anastomoses are done on the left descending artery (LAD) or on the most distal artery on the lateral or posterior wall. An error of measurement may compromise these bypass grafts and the entire operation. We use the mammary loop technique which permits a Y graft using only a LITA or a graft using two ITAs [3, 4]. The distal end of the skeletonized LITA is anastomosed to the proximal LITA to form a loop. That will be cut open just before the coronary anstomosis at the desirable level to provide an adjustable Y graft. This kind of Y graft permits bypass grafts the LAD, diagonal artery, ramus intermedius, or a high lateral artery when the anatomy for a sequential bypass graft is inappropriate. The loop technique simplifies graft construction. First we made a Y graft with two skeletonized ITAs. The loop is made by anastomosing the distal end of the LITA to the RITA. After section of the loop, we obtain a graft. There are four variants of loop construction for a graft: LITA on RITA, LITA on LITA, RITA on LITA, and RITA on RITA; so we can adapt the graft for each case. We used these techniques in 20 patients who underwent on-pump or off-pump surgery. These mammary loop techniques allow construction of adjustable composite grafts with both ITAs. In our experience this method is sure, reproducible, and easier to perform than the “classic graft” or the TY graft. Lucian Stoica, MD, PhD Sidney Chocron, MD, PhD Joseph Philippe Etievent, MD © 2005 by The Society of Thoracic Surgeons Published by Elsevier Inc
The TY graft described by us [1] and the graft described by Prapas and colleagues [2] are intended to revascularize three to five coronary arteries. The loop technique as featured by Stoica and colleagues is limited to only three vessels, according to Dr Stoica’s letter. Doctor Stoica states that a disadvantage of the TY and graft techniques is the necessity to exactly measure the length of the short free graft segments and that an error in this measurement may compromise graft patency. However, his loop technique is actually a step in the construction of a TY or graft and can be also affected by a wrong appreciation of segment length. Usually we oversize lengths of short, free graft segments at the time of TY graft construction and determine the definitive length before performing each anastomosis to target coronary arteries. In this way, we avoid the risk of length mismatch or kinking. We used the TY graft construction in 46 patients without technical dificulties and with good results. We did not compare it with the loop technique for constructing TY or grafts; therefore, we cannot state if it is more reproducible and easy to perform, as Dr Stoica states. Nevertheless, the loop technique seems to be an ingenious method to construct a TY or graft. Calin Vicol, MD Ludwig Maximilians University Grosshadern Medical Center Marchioninistrasse 15 Munich 81377, Germany e-mail: [email protected].
References 1. Vicol C, Nollert G, Mair H, Reichart B. Optimizing use of the octopus system for off-pump total arterial myocardial revascularization with the TY graft. Ann Thorac Surg 2004;77:731–3. 2. Prapas SN, Anagnostopoulos CE, Kotsis VN, et al. A new pattern for using both thoracic arteries to revascularize the entire heart: the pi-graft. Ann Thorac Surg 2002;73:1990 –2. 0003-4975/05/$30.00
MISCELLANOUS
To the Editor: