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J Thorac Cardiovasc Surg 2006;131:1188-1190
© 2006 The American Association for Thoracic Surgery
Brief Communication |
Department of Cardiac Surgery, Laval Hospital, Québec City, Québec Canada
Received for publication November 25, 2005; accepted for publication January 3, 2006. * Address for reprints: Dr François Dagenais, Department of Cardiac Surgery, Laval Hospital, 2725 Chemin Ste-Foy, Québec, Canada, G1V 4G5 (Email: francois.dagenais{at}chg.ulaval.ca).
Development of new catheters and cannulas has allowed accessing the heart through short incisions. Use of this technology may also be applied for difficult reoperative situations. We herein report the use of the endoclamp in a patient with a previous root and arch replacement requiring mitral surgery for a native mitral endocarditis.
Clinical Summary
A 58-year-old male was admitted with asthenia, weight loss, and fever. His past medical history was positive for hypertension, diabetes, peripheral vascular disease (aortobifemoral graft). The patient had a root replacement with a Bjork-Shiley conduit in 1982 for a type A dissection. The patient also had an arch replacement using an isolated graft to the arch vessels (modified Greipp technique) and an "elephant trunk" procedure in 2001 with a right axillary artery cannulation. The patient also required a replacement of his thoracoabdominal aorta in May 2002.
Transthoracic echocardiography revealed a moderate mitral regurgitation and a 3.5-cm vegetation on the posterior leaflet. No vegetation was documented on the Bjork-Shiley aortic prosthesis. Blood cultures grew Staphylococcus epidermidis. Owing to his poor overall condition, the patient was treated with vancomycin and rifampycin although the embolic risk was present. Absence of dacron graft infection was suggested by a normal gallium scan and magnetic resonance imaging.
Following a 4-week antibiotic course, the patient's overall condition improved and a reoperation was considered. Repeat echocardiography showed similar findings. An approach through the right chest was selected owing to the multiple grafts. To optimize exposure of the mitral valve with an aortic prosthesis, decompression of the aortic root was considered to be preferable. To initiate aortic crossclamping and root decompression, an endoclamp was inserted in the Y port of the arterial cannula (Cardiovations, Somerville, NJ) of the right limb of the aortobifemoral graft (Figure 1). Owing to the limited space to fully inflate the endoclamp between the arch graft and the aortic valve (Figure 2), cerebral perfusion was ensured by recannulating the right axillary artery. A pulmonary vent (Cardiovations) was inserted through the right jugular vein. The endoclamp was inflated under transesophageal echocardiography guidance just above the aortic valve thus covering the arch vessel graft. Cardioplegia and root decompression were conducted through the endoclamp ports. The left atrium was opened and adequate exposure of the mitral valve obtained. The vegetation was localized on the posterior leaflet. The mitral valve was replaced with a mechanical prosthesis. Total aortic crossclamp and cardiopulmonary bypass times were 88 and 113 minutes, respectively. Postoperatively, the patient developed a right pleural effusion necessitating 2 pleurodeses. At 8-month follow-up, the patient is well and free of infection.
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Mideline chest reentry for mitral surgery with previous proximal aortic surgery can be hazardous. In such circumstances, the right anterolateral thoracotomy has been shown to be safe and effective.
1,2
During the last decade, minimal access of the mitral valve has been advocated either with or without the port-access platform. Excellent results have been reported with minimal access mitral procedures even in previously operated patients.
3
The present case illustrates the use of the port-access platform in a complex case with multiple previous thoracic aortic surgeries. Because a redo sternotomy was judged prohibitive, access through the untouched right chest, as opposed to the left chest, seemed the easiest and safest approach. Although mitral surgery through the right chest under ventricular fibrillation or on the beating heart has been reported,
4
the presence of a mechanical valve with a pressurized root may limit exposure of the mitral valve. To obviate this problem, insertion of an endoclamp through the femoral cannula allowed arresting the heart and venting the aortic root. However, the distance between the aortic prosthesis and the takeoff of the arch graft did not permit safe inflation of the endoclamp. To ensure adequate arch vessel perfusion, the right axillary artery was reused. We have previously reported the feasibility and the safety of recannulating the right axillary artery.
5
Other possible options could have been to cannulate the right brachial artery or the left axillary artery.
In summary, we report a unique case of mitral valve surgery with previous multiple aortic surgeries including an arch replacement with a modified Griepp technique. Use of the port-access technology enabled us to arrest the heart and vent the aortic root. In case of an isolated graft to the arch vessel, one should ensure sufficient space to inflate the endoclamp without compromising cerebral perfusion. If uncertain, one should consider cannulating the brachial or axillary artery to perfuse the brain during the endoclamp inflation.
References
This article has been cited by other articles:
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  S. Mohammadi, E. Dumont, P. Voisine, and F. Dagenais Operative strategy for open surgery after failed thoracic aortic stent grafting. J. Thorac. Cardiovasc. Surg., October 1, 2007; 134(4): 1044 - 1046. [Full Text] [PDF]
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