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J Thorac Cardiovasc Surg 2007;133:277-278
© 2007 The American Association for Thoracic Surgery

Letter to the Editor

Ascending–descending aortic bypass with the aid of a heart-lifting device

Ganapathy Subramaniam Krishnan, MCh, Ravi Agarwal, MCh, Kotturathu M. Cherian, FRACS

Frontier Lifeline and Dr. K. M. Cherian, Heart Foundation, Mogappair, Chennai, India

To the Editor:

We read with interest the article "Ascending–descending aortic bypass with the aid of a heart-lifting device" by Aris and associates.1Go We had an opportunity to use the technique in the management of a 15-year-old girl. She had arch reconstruction with pulmonary artery banding through a thoractomy at the age of 8 months for type B interruption with ventricular septal defect. Six months after the procedure, she had undergone pulmonary artery debanding with ventricular septal defect closure. She had narrowing across the arch repair site, with a gradient of 80 mm Hg across the stenosed segment and significant left ventricular hypertrophy.

In view of her previous operation, it was decided to perform ascending–descending aortic bypass during cardiopulmonary bypass with a beating heart. An 18-mm Dacron tube graft was anastomosed to the descending aorta with a heart-lifting device (Starfish 2; Medtronic, Inc, Minneapolis, Minn) to keep the ventricular mass out of the way during the operation (Figure 1). The descending aorta was approached from the posterior pericardium. The stays on the margins of the pericardium can also be used to provide additional retraction during exposure. We placed the graft lateral to the right atrium within the pericardium because we considered that the lie of the graft would be better in this position. The patient had uneventful postoperative recovery with no residual gradient between the upper and lower limbs at the time of discharge.


Figure 1
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  		Figure 1. Use of the Starfish 2 device (Medtronic, Inc) for ascending–descending aortic bypass for retracting the ventricle.

 
Other techniques have been described for performing bypass in the management of complex recoarctation. The lateral isthmic bypass2Go between the left subclavian artery and the descending aorta has the advantage of being an "anatomic" bypass. The disadvantage of the technique in our patient was that it would require a repeat thoracotomy, and there was concern about the adequacy of the subclavian artery as the inflow segment. Moreover, we would be lacking the safety afforded by cardiopulmonary bypass. Ascending–descending aortic bypass has also been described by using the right thoracotomy approach.3Go

We believe that cardiopulmonary bypass provides safety in the presence of significant left ventricular hypertrophy. Use of a heart-lifting device makes the operation simpler by freeing the assistant’s hand and by enabling the procedure to be performed with a beating heart. Strategically placed pericardial stays can also help in keeping the heart mass out of the way during the procedure.

References

  1. Aris A, Cobiella J, Maestre ML, Subirana MT. Ascending–descending aortic bypass with the aid of a heart-lifting device. J Thorac Cardiovasc Surg 2006;132:433-434.[Free Full Text]
  2. Grinda JM, Mace L, Dervanian P, Folliguet TA, Neveux JY. Bypass graft for complex forms of isthmic aortic coarctation in adults. Ann Thorac Surg 1995;60:1299-1302.[Abstract/Free Full Text]
  3. Arakelyan V, Spriridonov A, Bockeria L. Ascending–descending aortic bypass via right thoractomy for complex (re-) coarctation and hypoplasic aortic arch. Eur J Cardiothorac Surg 2005;27:815-820.[Abstract/Free Full Text]

Related Article

Reply to the Editor
Alejandro Aris, Maria Luz Maestre, and Maria Teresa Subirana
J. Thorac. Cardiovasc. Surg. 2007 133: 278. [Extract] [Full Text] [PDF]




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Ravi Agarwal
Kotturathu M. Cherian
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