Redo-aortic valve replacement after previous bilateral internal thoracic artery bypass grafting

Aortic valve replacement (AVR) after coronary artery bypass using bilateral internal thoracic arteries (ITAs) is a challenge. Management of these patent grafts and myocardial protection are important issues. Moreover the risk and outcome of these complex operations have not been clearly defined.

Eighteen consecutive patients (all male) who exhibited previous bilateral ITA grafts underwent subsequent AVR surgery from 1990-2001 at the Cleveland Clinic Foundation. Their medical records were retrospectively analyzed.

At the time of reoperation, the mean age of the patients was 67 +/- 6.4 years and 33 out of 36 (92%) ITAs were patent. The interval between previous coronary bypass and aortic valve surgery was 10.3 +/- 5.3 years. All patients underwent redo-median sternotomy with aortic cannulation in 12 patients (67%) and femoral or axillary artery cannulation in 6 patients (33%). The patent ITAs were clamped during aortic cross-clamping in 15 patients. In 3 patients the ITAs were not dissected. These 3 patients underwent deep hypothermic arrest for myocardial protection. Concomitant coronary revascularization was performed in 8 patients (44%). There were no hospital deaths. One stroke occurred but there were no other major complications. Average intubation time was 23.1 +/- 27.1 hours, intensive care unit stay was 2.3 +/- 3.1 days, and postoperative hospital stay was 10.3 +/- 7.6 days.

Reoperative aortic valve surgery in the patients with patent bilateral ITA grafts can be performed safely.