Reoperative median sternotomy following the use of a right internal mammary artery pedicle graft crossing the midline to the left anterior descending artery.

BACKGROUND AND AIM

The purpose of the present study was to examine the outcomes of cardiac reoperations for the patients with a previously placed pedicled graft of the right internal thoracic artery (RITA) to the left anterior descending artery (LAD).

METHODS

Of 1002 consecutive patients who underwent isolated coronary bypass surgery, 612 patients received pedicled grafts of skeletonized RITA to the LAD crossing the midline over the aorta. Of this cohort, seven patients underwent cardiac reoperations via a median resternotomy including aortic valve replacement, mitral valve plasty, and total arch replacement. Covering the RITA with pericardium and mediastinal tissue had been routinely performed in the initial operation.

RESULTS

Preoperative computed tomography (CT) angiography showed the RITA at a safe distance from the sternum in six patients. No graft injury occurred during dissection. The patient who underwent emergent total arch replacement died from global brain ischemia at postoperative day 11. The remaining six patients recovered well without major complication and survived at 7.5 ± 4.5 years after reoperations.

CONCLUSIONS

Cardiac reoperation via a median sternotomy can be performed at acceptable risk in patients with the RITA graft crossing the midline. Specific maneuvers should be applied in the first coronary artery bypass grafting to keep the RITA at the level of the aortic plane and prevent migration toward the sternum. Preoperative CT angiography is an important tool to understand the surgical anatomy and determine the safety of reoperation.