J Thorac Cardiovasc Surg 2008;136:235-236
© 2008 The American Association for Thoracic Surgery
Reply to the Editor:
Eric E. Roselli, MD
Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
We thank Dr Augoustides for his kind comments and inquiries regarding preparation for reoperative cardiac surgery. Cooperation and coordination of the entire team, especially the cardiothoracic anesthesiologist, is critical to success. Owing to space limitations, specific details regarding our typical approach to cardiac reoperations are included in Appendix E4 instead of within the main body of the manuscript. Some of Dr Augoustides' questions are addressed in Appendix E4, but many are not and we thank him for bringing attention to some of the important considerations from an anesthesiologist's viewpoint. Responses to each of his questions are included below:
- 1. Two units of blood are typically available for all reoperations. For patients undergoing left ventricular assist device explant or open thoracoabdominal aortic aneurysm repair, 4 units are made available.
- 2. Patients typically have external defibrillator pads placed before skin incision. Additionally, sterile pediatric-sized internal defibrillator paddles are available in the room inasmuch as they facilitate access to the partially exposed heart should the external pads not be adequate.
- 3. Large bore intravenous access is routinely obtained on all patients before incision.
- 4. We found no correlation between timing (during sternal re-entry or otherwise) or type of adverse event and outcome because so many of these patients were rescued. This experience differs from historical reports of catastrophic sternal re-entry with mortality approaching 50%. This success is in part due to the ability to predict who may have a difficult re-entry and the preparation to compensate for it with rapid institution of cardiopulmonary bypass (CPB). Should the need for emergency institution of CPB arise, methods of preparation vary depending on patient risk. Cross-sectional imaging with computed tomography (either with or without contrast) and careful review of cardiac catheterization assists in determining this risk. Preemptive right axillary artery and/or femoral vessel access or exposure is performed selectively in at-risk patients. Further details of the operative approach are described in Appendix E4 of the manuscript.
