Total Aortic Arch Replacement in a Patient with a Patent Right Internal Thoracic Artery Graft Crossing between the Sternum and the Ascending Aortic Aneurysm / 日本心臓血管外科学会雑誌

We report a case of 76 year-old woman who had previously undergone coronary artery bypass grafting (CABG) with the right internal thoracic artery (RITA) bypassed to the left anterior descending artery. Six years after CABG, she developed acute type A aortic dissection, and she was medically treated because the false lumen was thrombosed and it was considered that surgical intervention would be high risk for the patent RITA graft crossing between the sternum and the ascending aorta. During follow-up, her aortic aneurysm enlarged to 57 mm in diameter, and finally she was referred to our hospital for surgical intervention. In this case, preservation of the patent RITA graft was thought to be critical because the RITA graft was the only blood source for the left anterior descending artery. Prior to re-median sternotomy, we performed a right anterior minithoracotomy to make sufficient space between the sternum and the RITA graft, and then instituted peripheral cardiopulmonary bypass to decompress the heart. After re-sternotomy, we ensured minimum dissection of the RITA graft, and we successfully accomplished graft replacement of the ascending aorta to the aortic arch without injuring the patent RITA graft. In cases with a patent RITA graft and an ascending aortic aneurysm close to the sternum, our strategy is considered to be efficient for re-median sternotomy.

Strategies, Risks, and Outcomes in Cardiac and Aortic Reoperations / 日本心臓血管外科学会雑誌

Cardiovascular reoperations involve high-risk because of adhesions. We examined the strategies and clinical outcomes of the reoperations in our institute. From January 2003 to December 2008, 52 patients underwent reoperations, accounting for 4.5% of all adult patients. The duration from the previous surgery was 10.1±9.3 years. Reoperations were performed due to infection (<i>n</i>=10), after valve surgery (<i>n</i>=16), after coronary surgery (<i>n</i>=9), due to Marfan syndrome (<i>n</i>=3), after aortic surgery (<i>n</i>=7), after congenital surgery (<i>n</i>=4), and for other reasons. In the reoperations, the same surgical site was exposed in 65%, the femoral vessels were exposed before re-sternotomy in 77%, the inflow was on the ascending aorta in 35%, and cardiopulmonary bypass was initiated before re-sternotomy in 37%. Systemic cooling was needed in 4 patients and some maneuvers for patent internal thoracic artery grafts in 6 patients. The operation time of 9.6±2.5 h and the cardiopulmonary bypass time of 295±111 min, respectively. We experienced intraoperative injuries in 16 patients (31%). Platelet transfusion was needed in 90% and a second CPB in 15%. Postoperative complications included hemorrhage (14%), infection (13%), stroke (4%), respiratory failure (44%), and renal failure (1%). The hospital mortality was 7.7% (4/52) due to uncontrolled infection, liver failure, pulmonary hemorrhage, and left ventricular rapture. The 2-year survival rate was 83.1% with the mean follow-up of 24±18 months. In conclusion, although the risk of injuries at re-sternotomy was not high, limited surgical field due to adhesions resulted in fatal injuries and in the cardiac reoperations we experienced. We need to improve our strategies for further reduction in mortality and morbidities in reoperations.