[Aortic valve replacement and ventricular septal defect closure after previous bilateral internal thoracic artery...

Area of Science:

• Cardiovascular Surgery
• Cardiac Anesthesia
• Medical Imaging

Background:

• A 74-year-old male with a history of ventricular-septal defect (VSD) underwent coronary artery bypass grafting (CABG) using bilateral internal thoracic artery (ITA) grafts 9 years prior.
• The patient developed heart failure in 2009 and was treated with tolvaptan starting in 2011.

Observation:

• In 2011, the patient presented with fever, echocardiography revealed moderate aortic regurgitation, and vegetation was noted around the VSD and aortic valve.
• This necessitated a redo-aortic valve replacement (AVR) and VSD closure.

Findings:

• Both bilateral internal thoracic artery (ITA) grafts were carefully dissected and clamped during cardiac arrest.
• The patent ITA grafts required occlusion during aortic cross-clamping to prevent cardioplegia washout, a critical step in managing patients with midline-crossing ITA grafts.
• Multi-detector-row computed tomography (MDCT) proved valuable for precise imaging and dissection of the ITA grafts.

Implications:

• Redo-aortic valve replacement (AVR) and ventricular-septal defect (VSD) closure following bilateral internal thoracic artery (ITA) bypass grafting presents significant surgical challenges, particularly when patent ITAs cross the midline.
• Effective management hinges on meticulous surgical technique, including the identification and occlusion of patent ITA grafts to ensure adequate cardioplegia delivery.
• Advanced imaging modalities like MDCT are crucial for pre-operative planning and intraoperative guidance in complex cardiac reoperations involving arterial grafts.