Related Experiment Videos
Supraclavicular control of patent internal thoracic artery graft flow during aortic valve replacement
Erkan Kuralay1, Faruk Cingöz, Celalettin Günay
1Department of Cardiovascular Surgery, Gülhane Military Medical Academy, Etlik, Ankara, Turkey. ekural@gata.edu.tr
Insights
Controlling left internal thoracic artery (LITA) flow during aortic valve replacement (AVR) with supraclavicular occlusion improved outcomes. This technique reduced myocardial failure and the need for deep hypothermia in patients with prior coronary artery bypass grafting (CABG).
Area of Science:
- Cardiovascular Surgery
- Cardiac Anesthesia
- Thoracic Surgery
Background:
- Aortic valve replacement (AVR) after coronary artery bypass grafting (CABG) with a patent left internal thoracic artery (LITA) carries significant risks.
- LITA injury and inadequate myocardial preservation during cross-clamping can lead to pump failure.
Purpose of the Study:
- To evaluate a novel technique for managing LITA flow during AVR in patients with prior CABG.
- To compare outcomes between deep hypothermia without LITA clamping and moderate hypothermia with LITA flow control via supraclavicular occlusion.
Main Methods:
- 43 patients with patent LITA grafts undergoing AVR were divided into two groups.
- Group 1 (n=19): AVR with deep hypothermia (20°C) without LITA clamping.
- Group 2 (n=24): AVR with moderate hypothermia (28°C) and LITA flow controlled by supraclavicular occlusion.
Main Results:
- Group 2 showed significantly shorter cardiopulmonary bypass (102.67 vs 118.79 min) and cross-clamp times (49.63 vs 53.79 min).
- Fewer patients required inotropic support (4 vs 12), and ICU (2.29 vs 4.68 days) and hospital stays (8.04 vs 11.84 days) were reduced in Group 2.
- Mortality due to myocardial failure was eliminated in Group 2, compared to 4 deaths in Group 1 (p=0.02).
Conclusions:
- Proximal control of LITA flow using extrathoracic supraclavicular occlusion enhances myocardial protection during AVR.
- This method mitigates risks associated with non-uniform cardioplegia delivery to the anterior heart wall.
- Supraclavicular occlusion with moderate hypothermia improves outcomes and avoids deep hypothermia in AVR patients with patent LITA grafts.
Background:
The mortality and morbidity of aortic valve replacement (AVR) after prior coronary artery bypass surgery (CABG) with patent left internal thoracic artery (LITA) is significant. The risk of LITA injury and inadequate myocardial preservation during the cross-clamp period may cause myocardial pump failure.
Methods:
A total of 43 patients with a patent LITA graft underwent AVR. The patients were divided into the two groups. Group 1 included 19 patients who underwent AVR with deep hypothermia (20 degrees C) without LITA clamping. Group 2 included 24 patients in whom LITA flow was controlled through supraclavicular occlusion and AVR performed with moderate hypothermia (28 degrees C).
Results:
Average cardiopulmonary bypass time (CPB) time was 118.79 +/- 20.36 minutes in group 1 and 102.67 +/- 9.66 minutes in group 2 (p = 0.006). Average cross-clamp time was 53.79 +/- 7.26 minutes in group 1 and 49.63 +/- 6.7 minutes in group 2 (p = 0.022). Inotropic support was required in 12 patients in group 1 and 4 patients in group 2 (p = 0.002). Average intensive care unit stay was 4.68 +/- 2.24 days in group 1 and 2.29 +/- 0.46 days in group 2 (p < 0.001). Average hospital stay was 11.84 +/- 2.91 days in group 1 and 8.04 +/- 2.38 days in group 2 (p < 0.001). Mortality due to myocardial failure developed in 4 patients in group 1 but in none of the patients in group 2 (p = 0.02).
Conclusions:
Proximal control of LITA flow by extrathoracic supraclavicular occlusion reduces the incidence of myocardial failure due to nonhomogenous cardioplegia delivery to the anterior wall of the heart, resulting in improved myocardial protection and the elimination of the need for deep hypothermia.