Staged Sternal Opening for sternal-adhering aneurysm repair and mitral valve replacement

P0311 

Case Video Submission 

Yu Hohri (1), Megan Chung (1), Hiroo Takayama (1)

(1) NewYork- Presbyterian/Columbia University Medical Center, New York, NY

Yu Hohri    -  Contact Me
NewYork- Presbyterian/Columbia University Medical Center

Megan Chung    -  Contact Me
NewYork- Presbyterian/Columbia University Medical Center

*Hiroo Takayama    -  Contact Me
NewYork- Presbyterian/Columbia University Medical Center

Yu Hohri    -  Contact Me
N/A

Objective
The incidence of re-entry injury is low in redo cardiac surgery, but it is associated with a significant increase in-hospital mortality. Hypothermic circulatory arrest with cardiopulmonary bypass (CPB) before resternotomy is often performed in these cases. However, in anticipation of a prolonged circulatory arrest period, lack of myocardial protection or left ventricular (LV) venting during cooling can pose great concern. Herein we describe a staged sternotomy strategy that facilitates insertion of an LV vent and retrograde cardioplegia cannula via a lower hemi-sternotomy, followed by upper sternotomy with circulatory arrest in complex redo aortic aneurysm repair and mitral valve replacement (MVR).
Case Video Summary
The case was a 42-year-old male who had undergone 4 prior open cardiac operations. The echocardiogram showed severe paravalvular leak of the mitral valve and reduced right ventricular function with a left ventricular ejection fraction of 55%. Computed tomography showed a proximal arch pseudoaneurysm with severe adhesions to the sternum. The patient was taken to the operating room for a planned MVR and proximal aortic repair. During surgery, a lower partial sternotomy was performed by transecting the sternum, and adhesions were taken down from around the heart. With femoral aortic and central venous cannulation, CPB was initiated with systemic cooling. An LV vent was inserted via the right upper pulmonary vein as well as a retrograde cardioplegia catheter into the coronary sinus. Once the target temperature was reached, circulatory arrest was induced, and an upper hemisternotomy was quickly performed with anticipated entry into the proximal aorta/graft. The heart was arrested with retrograde cardioplegia. Following aortic repair, MVR was performed with a Commando procedure. CPB time and aortic cross clamp time were 367 and 266 min, respectively. The patient was discharged on postoperative day 15 without any complications.
Conclusion
We reported a case of complex redo aortic aneurysm repair and MVR for which staged sternal opening was used. In redo cases where there is concern for aortic injury upon sternotomy and long myocardial ischemia, a staged sternal opening facilitates heart dissection, LV venting and coronary sinus cannulation prior to circulatory arrest.

Other - Redo aortic surgery