Ann Thorac Surg 2015;99:1488–92
mitral valve repair. Nonetheless, mitral regurgitation recurrence is more than 7 times higher after repair. Will this trade-off result in lower survival in the long term? We will have to wait for Acker and colleagues’ follow-up results. For whom should we reserve these highly demanding technical procedures of mitral valve repair? Young patients in whom we can avoid placing a mechanical valve are the main beneficiaries of mitral valve repair. These patients should be referred to highly experienced mitral valve centers to decrease the risk of mitral regurgitation recurrence. Until now, the surgeon who replaced the mitral valve instead of repairing it left the operating room unsatisfied with himself or herself. This feeling of low self-esteem might be over. Victor Dayan, MD Cirugia Cardiaca Hospital de Clinicas 26 de Marzo 3459/602 Montevideo 11300, Uruguay e-mail: [email protected]
References 1. Acker MA, Parides MK, Perrault LP, et al. Mitral-valve repair versus replacement for severe ischemic mitral regurgitation. N Engl J Med 2014;370:23–32. 2. Dayan V, Soca G, Cura L, Mestres CA. Similar survival after mitral valve replacement or repair for ischemic mitral regurgitation: a meta-analysis. Ann Thorac Surg 2014;97:758–65.
Anomalous Aortic Origin of the Right Coronary Artery To the Editor:
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
1491
Frank A. Baciewicz, Jr, MD Department of Cardiothoracic Surgery Wayne State University School of Medicine 3990 John R St Brush 3rd Flr #3705 Detroit, MI 48201 e-mail: [email protected]
Reference 1. Izumi K, Wilbring M, Stumpf J, et al. Direct reimplantation as an alternative approach for treatment of anomalous aortic origin of the right coronary artery. Ann Thorac Surg 2014;98:740–2.
Reply To the Editor: We appreciate the very constructive comments from Dr Baciewicz [1] on our recently published simplified technique for the treatment of anomalous right coronary artery [2]. In line with the observations reported by Baciewicz [1], we likewise see an increase in the frequency of patients presenting with incidentally detected anomalies of the coronary arteries. We also see that the advent of computed tomographic angiography, particularly cardiac computed tomography scans, is reasonable for this trend. Anyhow, modern cardiac surgery has to face this and should offer primarily safe treatment strategies for these oftentimes oligosymptomatic or even asymptomatic young and healthy patients. The major concern about actual techniques should be to avoid extensive surgical procedures with the accompanying surgical risk. Our previously reported simplified technique provides a convenient approach, reducing the extent of the operation and the risk for morbidity at the same time. The technique described by Baciewicz is an excellent addition to cardiac surgeons’ repertoire. We agree that the main focus, no matter whether we prefer to use a button or not, should be to avoid kinking of the translocated right coronary artery. For those purposes, accurate dissection of the larger parts of the right coronary artery is essential. Baciewicz proves the needed length and optimal position of the punch hole before arresting the heart. Our approach is to make these measurements after crossclamping. We then first dissect the right coronary artery and subsequently fill the heart during extracorporal circulation to identify the optimal region for central anastomosis. Nonetheless, we appreciate the different approach they report; many roads lead to Rome. The most important thing is safety for the patient, as provided by both variations. Particularly in oligosymptomatic or asymptomatic young patients, operative morbidity or even mortality almost cannot be accepted. In this context, the technique reported by Baciewicz represents an excellent additional approach, likewise aiming for safety and reproducibility. We really enjoyed this precious input. MISCELLANEOUS
I enjoyed the recent article “Direct reimplantation as an alternative approach for treatment of anomalous aortic origin of the right coronary artery” by Izumi and colleagues in a recent issue of The Annals of Thoracic Surgery [1]. With the advent of computed tomographic angiography of the chest, this diagnosis has become more common. In our experience with adult anomalous right coronary from the left sinus, the right coronary always has an intramural course in the aortic wall. I have used the approach the authors have outlined of transplanting the right coronary at the point where it emerges from the aortic wall. The only difference in our technique is that we fashion a small button of aortic wall at the point where the right coronary artery emerges from the aortic wall. Our belief is that this makes the reimplantation of the right coronary artery easier, because the right coronary can be a small vessel when it emerges from the aortic wall. We have closed the defect in the aortic wall with a small bovine pericardial patch. We are in agreement with the authors that it is important to avoid any kinking of the right coronary artery anastomosis. We partially dissect the right coronary before arresting the heart to get a better estimation of its length in the beating heart. It can also help to estimate where the optimal point is for reimplantation. When the heart is arrested, the proximal aorta becomes flaccid, and the location for reimplanting the right coronary artery can be tricky. We mark the point on the right sinus where we believe the punch hole for the anastomosis should be. The right coronary button is reimplanted after complete dissection of the coronary in the arrested heart.
CORRESPONDENCE
Manuel Wilbring, MD Department of Cardiac Surgery University Heart Center Dresden Fetscherstrasse 76 Dresden, Germany 01307 e-mail: [email protected]
0003-4975/$36.00
mitral valve repair. Nonetheless, mitral regurgitation recurrence is more than 7 times higher after repair. Will this trade-off result in lower survival in the long term? We will have to wait for Acker and colleagues’ follow-up results. For whom should we reserve these highly demanding technical procedures of mitral valve repair? Young patients in whom we can avoid placing a mechanical valve are the main beneficiaries of mitral valve repair. These patients should be referred to highly experienced mitral valve centers to decrease the risk of mitral regurgitation recurrence. Until now, the surgeon who replaced the mitral valve instead of repairing it left the operating room unsatisfied with himself or herself. This feeling of low self-esteem might be over. Victor Dayan, MD Cirugia Cardiaca Hospital de Clinicas 26 de Marzo 3459/602 Montevideo 11300, Uruguay e-mail: [email protected]
References 1. Acker MA, Parides MK, Perrault LP, et al. Mitral-valve repair versus replacement for severe ischemic mitral regurgitation. N Engl J Med 2014;370:23–32. 2. Dayan V, Soca G, Cura L, Mestres CA. Similar survival after mitral valve replacement or repair for ischemic mitral regurgitation: a meta-analysis. Ann Thorac Surg 2014;97:758–65.
Anomalous Aortic Origin of the Right Coronary Artery To the Editor:
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
1491
Frank A. Baciewicz, Jr, MD Department of Cardiothoracic Surgery Wayne State University School of Medicine 3990 John R St Brush 3rd Flr #3705 Detroit, MI 48201 e-mail: [email protected]
Reference 1. Izumi K, Wilbring M, Stumpf J, et al. Direct reimplantation as an alternative approach for treatment of anomalous aortic origin of the right coronary artery. Ann Thorac Surg 2014;98:740–2.
Reply To the Editor: We appreciate the very constructive comments from Dr Baciewicz [1] on our recently published simplified technique for the treatment of anomalous right coronary artery [2]. In line with the observations reported by Baciewicz [1], we likewise see an increase in the frequency of patients presenting with incidentally detected anomalies of the coronary arteries. We also see that the advent of computed tomographic angiography, particularly cardiac computed tomography scans, is reasonable for this trend. Anyhow, modern cardiac surgery has to face this and should offer primarily safe treatment strategies for these oftentimes oligosymptomatic or even asymptomatic young and healthy patients. The major concern about actual techniques should be to avoid extensive surgical procedures with the accompanying surgical risk. Our previously reported simplified technique provides a convenient approach, reducing the extent of the operation and the risk for morbidity at the same time. The technique described by Baciewicz is an excellent addition to cardiac surgeons’ repertoire. We agree that the main focus, no matter whether we prefer to use a button or not, should be to avoid kinking of the translocated right coronary artery. For those purposes, accurate dissection of the larger parts of the right coronary artery is essential. Baciewicz proves the needed length and optimal position of the punch hole before arresting the heart. Our approach is to make these measurements after crossclamping. We then first dissect the right coronary artery and subsequently fill the heart during extracorporal circulation to identify the optimal region for central anastomosis. Nonetheless, we appreciate the different approach they report; many roads lead to Rome. The most important thing is safety for the patient, as provided by both variations. Particularly in oligosymptomatic or asymptomatic young patients, operative morbidity or even mortality almost cannot be accepted. In this context, the technique reported by Baciewicz represents an excellent additional approach, likewise aiming for safety and reproducibility. We really enjoyed this precious input. MISCELLANEOUS
I enjoyed the recent article “Direct reimplantation as an alternative approach for treatment of anomalous aortic origin of the right coronary artery” by Izumi and colleagues in a recent issue of The Annals of Thoracic Surgery [1]. With the advent of computed tomographic angiography of the chest, this diagnosis has become more common. In our experience with adult anomalous right coronary from the left sinus, the right coronary always has an intramural course in the aortic wall. I have used the approach the authors have outlined of transplanting the right coronary at the point where it emerges from the aortic wall. The only difference in our technique is that we fashion a small button of aortic wall at the point where the right coronary artery emerges from the aortic wall. Our belief is that this makes the reimplantation of the right coronary artery easier, because the right coronary can be a small vessel when it emerges from the aortic wall. We have closed the defect in the aortic wall with a small bovine pericardial patch. We are in agreement with the authors that it is important to avoid any kinking of the right coronary artery anastomosis. We partially dissect the right coronary before arresting the heart to get a better estimation of its length in the beating heart. It can also help to estimate where the optimal point is for reimplantation. When the heart is arrested, the proximal aorta becomes flaccid, and the location for reimplanting the right coronary artery can be tricky. We mark the point on the right sinus where we believe the punch hole for the anastomosis should be. The right coronary button is reimplanted after complete dissection of the coronary in the arrested heart.
CORRESPONDENCE
Manuel Wilbring, MD Department of Cardiac Surgery University Heart Center Dresden Fetscherstrasse 76 Dresden, Germany 01307 e-mail: [email protected]
0003-4975/$36.00
