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Right thoracotomy, femorofemoral bypass, and deep hypothermia for re-replacement of the mitral valve
As Originally Published in 1989:
Right Thoracotomy, Femorofemoral Bypass, and Deep Hypothermia for Re-replacement of the Mitral Valve L a w r e n c e H. C o h n , MD, P a m e l a S. Peigh, MD, Jeffrey Sell, MD, a n d Verdi J. DiSesa, MD Department of SurgeD'. Divisionof CardiacSurgery, Brighamand Women'sHospitaland HarvardMedicalSchool,Boston, Massachusetts
Ten patients underwent mitral valve re-replacement for the third to sixth time through a right thoracotomy using one-lung anesthesia, femorofemoral bypass, profound systemic hypothermia, and low-flow perfusion without aortic cross-clamping or cardioplegia. The indications for this approach were previous mediastinitis, severe right ventricular hypertension with multiple previous sternotomies, intact coronary artery bypass graft, or previous
aortic valve replacement. There was 1 operative death, which was due to end-stage pulmonary hypertension and intractable right heart failure. Blood loss was minimal, and there was no major postoperative morbidity in the 9 surviving patients except for supraventricular arrhythmias.
(Ann Thorac Surg 1989;48:69-71)
Updated in 1997 by Lawrence H. Cohn, MD Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts
he use of a small right anterior thoracotomy, femoro-
T femoral bypass, and deep hypothermia with or without cardioplegia has increased since the report from
our service in 1989 [1]. As originally reported, this modification resulted from the original report by Neptune and Bailey [2l. As increasing numbers of patients return for mitral valve reoperations due to bioprosthetic valve dysfunction; for complications of prosthetic valve replacement, endocarditis of other types of valves, or perivalvular leak; or, more frequently, after previous coronary revascularization, the use of this procedure has expanded. Experience with this procedure now totals 115 patients at the Brigham including the originally reported group. In the past 20 years, this represents about one fourth of all reoperative mitral valves (115/451). The most common current indications are (1) previous coronary bypass operations, especially with patent internal mammary artery-to-left anterior descending artery bypass, (2) prior mediastinitis, (3) prior aortic valve replacement, and (4) multiple early or late reoperations [3]. The ease of this procedure on the patient because of reduced surgical trauma, reduced blood use, and prophylaxis against cardiac structural injury during sternal reentry makes this a desirable approach for almost all complicated mitral reoperations, obviating repeat sternotomy. Deep hypothermia (-20°C) and low-flow femorofemoral bypass perfusion, without the necessity of aortic Address reprint requests to Dr Cohn, Division of Cardiac Surgery, Brigham and Women'sHospital, 75 Francis St, Boston,MA 02115. © 1997 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
cross-clamping, provides adequate myocardial protection. If the patient has mild to moderate aortic regurgitation, aortic cross-clamping can be done and blood cardioplegia administered antegrade through the ascending aorta and retrograde via the right atrium and coronary sinus. Transesophageal echocardiography should be used in all cases for monitoring removal of air from intracardiac structures; this technique allows for reliable air removal given inaccessibility of parts of the heart. We know from many reported series that reoperative coronary bypass surgical manipulation of atherosclerotic bypass grafts, even when they appear to be excellent from an angiographic point of view, can be detrimental to patient outcome due to atherosclerotic emboli with subsequent small or large acute myocardial infarction [3]. The right thoracotomy approach affords complete avoidance of these grafts if a mitral valve operation is needed after coronary artery bypass grafting. Another difficult patient subset are those patients requiring mitral valve replacement after previous implantation of an aortic valve device, making the mitral valve operation via sternotomy dangerous and very difficult in most situations. This approach allows better exposure of the aorticmitral trigone and thus greatly enhances fixation of the valve. Continued evaluation of various approaches for reoperative valve procedures is important, particularly for complicated reoperations, to enhance patient survival and improve long-term outcome. We and others continue to seek optimal solutions for these complex clinical Ann Thorac Surg 1997;64:578-9 • 0003-4975/97/$17.00 Pit S0003-4975(97)00588-2
Ann Thorac Surg 1997;64:578-9
p r o b l e m s that at the s a m e time use strategies that will reduce cost a n d patient morbidity.
References 1. Cohn LH, Peigh PS, Sell J, DiSesa VJ. Right thoracotomy, femorofemoral bypass, and deep hypothermia for re-
UPDATE COHN RE-REPLACEMENT OF MITRALVALVE
579
replacement of the mitra] valve. Ann Thorac Surg 1989;48: 69-71. 2. Neptune WB, Bailey CB. Mitral commissurotomy through the right thoracic approach. J Thorac Surg 1954;27:15-22. 3. Savage EB, Cohn LH. "No touch" dissection, antegraderetrograde blood cardioplegia, and single aortic cross-clamp significantly reduce operative mortality of reoperative CABG. Circulation 1994;90(Suppl 2):140-3.
The Fourth International Conference on Circulatory Support Devices for Severe Cardiac Failure Westin Galleria Hotel Houston, Texas, October 3-5, 1997 Circulatory Support 1997 will be a comprehensive multidisciplinary meeting focusing on clinical applications for the entire spectrum of circulatory support devices. Surgeons, cardiologists, anesthesiologists, intensivists, perfusionists, engineers, and operating and intensive care nurses are e n c o u r a g e d to a t t e n d as individuals or as a team. The m e e t i n g is s p o n s o r e d b y The Society of Thoracic Surgeons u n d e r the direction of its A d Hoc C o m m i t t e e on Circulatory S u p p o r t a n d Thoracic Transplantation. A n additional, optional p r o g r a m will be s c h e d u l e d for Friday, O c t o b e r 3, that will feature a site visit to the Texas Medical Center including the Texas Heart Institute a n d Baylor College of Medicine. It will be c o n d u c t e d on Friday afternoon, October 3. A d v a n c e d registration for the tours is a d v i s e d as space will be limited. Friday evening a session on "The Economics of a Clinical Device P r o g r a m " will be h e l d for all attendees. It will feature l e a d i n g authorities to discuss this i m p o r t a n t topic. The general p r o g r a m will begin on Saturday, October 4, at 7:45 AM a n d will conclude on Sunday, O c t o b e r 5, at 1:15 PM. General session topics will include "Patient
© 1997 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
M a n a g e m e n t a n d Device Selection for A c u t e / T e m p o r a r y Support," "Description of Devices a n d Surgical Techniques," "The REMATCH Trial," "Preventing, Minimizing, a n d M a n a g i n g Postoperative Complications," "Alternatives to Transplant," "Patient M a n a g e m e n t a n d Device Selection for Long-Term Support," a n d "Innovative Circulatory S u p p o r t Systems." A n u r s i n g / p e r f u s i o n session will be held on S u n d a y m o r n i n g in parallel with the r e g u l a r program. There will also be receptions on both Friday a n d S a t u r d a y evening, as well as continental breakfasts on S a t u r d a y a n d S u n d a y morning. C o m m e r c i a l exhibits will cover the p r o d u c t s and services of special i m p o r t a n c e to the professionals involved in circulatory support. This i n v o l v e m e n t will give attendees an o p p o r t u n i t y to review a n d critique commercial offerings for use in their programs. Further details on this m e e t i n g will be m a i l e d to all m e m b e r s of The Society in the future a n d m a y be r e q u e s t e d from The Society H e a d q u a r t e r s at 401 N Michigan Ave, Chicago, IL 60611.
Ann Thorac Surg 1997;64:579 • 0003-4975/97/$17.00 PII S0003-4975(97)00727-3
Right Thoracotomy, Femorofemoral Bypass, and Deep Hypothermia for Re-replacement of the Mitral Valve L a w r e n c e H. C o h n , MD, P a m e l a S. Peigh, MD, Jeffrey Sell, MD, a n d Verdi J. DiSesa, MD Department of SurgeD'. Divisionof CardiacSurgery, Brighamand Women'sHospitaland HarvardMedicalSchool,Boston, Massachusetts
Ten patients underwent mitral valve re-replacement for the third to sixth time through a right thoracotomy using one-lung anesthesia, femorofemoral bypass, profound systemic hypothermia, and low-flow perfusion without aortic cross-clamping or cardioplegia. The indications for this approach were previous mediastinitis, severe right ventricular hypertension with multiple previous sternotomies, intact coronary artery bypass graft, or previous
aortic valve replacement. There was 1 operative death, which was due to end-stage pulmonary hypertension and intractable right heart failure. Blood loss was minimal, and there was no major postoperative morbidity in the 9 surviving patients except for supraventricular arrhythmias.
(Ann Thorac Surg 1989;48:69-71)
Updated in 1997 by Lawrence H. Cohn, MD Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts
he use of a small right anterior thoracotomy, femoro-
T femoral bypass, and deep hypothermia with or without cardioplegia has increased since the report from
our service in 1989 [1]. As originally reported, this modification resulted from the original report by Neptune and Bailey [2l. As increasing numbers of patients return for mitral valve reoperations due to bioprosthetic valve dysfunction; for complications of prosthetic valve replacement, endocarditis of other types of valves, or perivalvular leak; or, more frequently, after previous coronary revascularization, the use of this procedure has expanded. Experience with this procedure now totals 115 patients at the Brigham including the originally reported group. In the past 20 years, this represents about one fourth of all reoperative mitral valves (115/451). The most common current indications are (1) previous coronary bypass operations, especially with patent internal mammary artery-to-left anterior descending artery bypass, (2) prior mediastinitis, (3) prior aortic valve replacement, and (4) multiple early or late reoperations [3]. The ease of this procedure on the patient because of reduced surgical trauma, reduced blood use, and prophylaxis against cardiac structural injury during sternal reentry makes this a desirable approach for almost all complicated mitral reoperations, obviating repeat sternotomy. Deep hypothermia (-20°C) and low-flow femorofemoral bypass perfusion, without the necessity of aortic Address reprint requests to Dr Cohn, Division of Cardiac Surgery, Brigham and Women'sHospital, 75 Francis St, Boston,MA 02115. © 1997 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
cross-clamping, provides adequate myocardial protection. If the patient has mild to moderate aortic regurgitation, aortic cross-clamping can be done and blood cardioplegia administered antegrade through the ascending aorta and retrograde via the right atrium and coronary sinus. Transesophageal echocardiography should be used in all cases for monitoring removal of air from intracardiac structures; this technique allows for reliable air removal given inaccessibility of parts of the heart. We know from many reported series that reoperative coronary bypass surgical manipulation of atherosclerotic bypass grafts, even when they appear to be excellent from an angiographic point of view, can be detrimental to patient outcome due to atherosclerotic emboli with subsequent small or large acute myocardial infarction [3]. The right thoracotomy approach affords complete avoidance of these grafts if a mitral valve operation is needed after coronary artery bypass grafting. Another difficult patient subset are those patients requiring mitral valve replacement after previous implantation of an aortic valve device, making the mitral valve operation via sternotomy dangerous and very difficult in most situations. This approach allows better exposure of the aorticmitral trigone and thus greatly enhances fixation of the valve. Continued evaluation of various approaches for reoperative valve procedures is important, particularly for complicated reoperations, to enhance patient survival and improve long-term outcome. We and others continue to seek optimal solutions for these complex clinical Ann Thorac Surg 1997;64:578-9 • 0003-4975/97/$17.00 Pit S0003-4975(97)00588-2
Ann Thorac Surg 1997;64:578-9
p r o b l e m s that at the s a m e time use strategies that will reduce cost a n d patient morbidity.
References 1. Cohn LH, Peigh PS, Sell J, DiSesa VJ. Right thoracotomy, femorofemoral bypass, and deep hypothermia for re-
UPDATE COHN RE-REPLACEMENT OF MITRALVALVE
579
replacement of the mitra] valve. Ann Thorac Surg 1989;48: 69-71. 2. Neptune WB, Bailey CB. Mitral commissurotomy through the right thoracic approach. J Thorac Surg 1954;27:15-22. 3. Savage EB, Cohn LH. "No touch" dissection, antegraderetrograde blood cardioplegia, and single aortic cross-clamp significantly reduce operative mortality of reoperative CABG. Circulation 1994;90(Suppl 2):140-3.
The Fourth International Conference on Circulatory Support Devices for Severe Cardiac Failure Westin Galleria Hotel Houston, Texas, October 3-5, 1997 Circulatory Support 1997 will be a comprehensive multidisciplinary meeting focusing on clinical applications for the entire spectrum of circulatory support devices. Surgeons, cardiologists, anesthesiologists, intensivists, perfusionists, engineers, and operating and intensive care nurses are e n c o u r a g e d to a t t e n d as individuals or as a team. The m e e t i n g is s p o n s o r e d b y The Society of Thoracic Surgeons u n d e r the direction of its A d Hoc C o m m i t t e e on Circulatory S u p p o r t a n d Thoracic Transplantation. A n additional, optional p r o g r a m will be s c h e d u l e d for Friday, O c t o b e r 3, that will feature a site visit to the Texas Medical Center including the Texas Heart Institute a n d Baylor College of Medicine. It will be c o n d u c t e d on Friday afternoon, October 3. A d v a n c e d registration for the tours is a d v i s e d as space will be limited. Friday evening a session on "The Economics of a Clinical Device P r o g r a m " will be h e l d for all attendees. It will feature l e a d i n g authorities to discuss this i m p o r t a n t topic. The general p r o g r a m will begin on Saturday, October 4, at 7:45 AM a n d will conclude on Sunday, O c t o b e r 5, at 1:15 PM. General session topics will include "Patient
© 1997 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
M a n a g e m e n t a n d Device Selection for A c u t e / T e m p o r a r y Support," "Description of Devices a n d Surgical Techniques," "The REMATCH Trial," "Preventing, Minimizing, a n d M a n a g i n g Postoperative Complications," "Alternatives to Transplant," "Patient M a n a g e m e n t a n d Device Selection for Long-Term Support," a n d "Innovative Circulatory S u p p o r t Systems." A n u r s i n g / p e r f u s i o n session will be held on S u n d a y m o r n i n g in parallel with the r e g u l a r program. There will also be receptions on both Friday a n d S a t u r d a y evening, as well as continental breakfasts on S a t u r d a y a n d S u n d a y morning. C o m m e r c i a l exhibits will cover the p r o d u c t s and services of special i m p o r t a n c e to the professionals involved in circulatory support. This i n v o l v e m e n t will give attendees an o p p o r t u n i t y to review a n d critique commercial offerings for use in their programs. Further details on this m e e t i n g will be m a i l e d to all m e m b e r s of The Society in the future a n d m a y be r e q u e s t e d from The Society H e a d q u a r t e r s at 401 N Michigan Ave, Chicago, IL 60611.
Ann Thorac Surg 1997;64:579 • 0003-4975/97/$17.00 PII S0003-4975(97)00727-3