How-To Session Offers Tips on CABG, Aortic Surgery

Richard Lee, MD, MBA discusses skeletonized internal mammary artery harvests during Sunday’s How To session on Technical Tricks and Pitfalls to Simplify Cardiac Surgery Procedures.

By nature, cardiothoracic surgeons do not rest on their laurels. They inherently look for ways to be more efficient in their surgeries and optimize outcomes.

This was clear when nearly two dozen private practice and academic surgeons helped attendees refine and improve their techniques in four common adult cardiac areas: coronary artery bypass grafting (CABG) surgery, mitral valve surgery, aortic valve surgery, and aortic surgery. They shared their expertise during Sunday’s How To: Technical Tricks and Pitfalls to Simplify Cardiac Surgery Procedures, a new session this year.

Richard Lee, MD, MBA first saw surgeons perform skeletonized internal mammary artery harvests during his fellowship at the Cleveland Clinic Foundation 14 years ago. He now skeletonizes all his CABG patients.

“When you skeletonize the internal mammary artery, the blood supply to the chest is better preserved than when you take the artery with a pedicle of surrounding tissue. Some people worry about damaging the mammary more, but that is not my experience. I don’t think the injury rate is any higher with skeletonized than with the pedicle,” said Dr. Lee, Co-Director of the Center for Comprehensive Cardiovascular Care at St. Louis University Hospital and Vice Chair and Professor of Surgery at St. Louis University.

The real value is that a skeletonized internal mammary artery harvest better preserves blood supply to the sternum.

“We think it may decrease the risk of sternal infection, which is useful for people who are diabetic because they have a higher risk of sternal infection,” Dr. Lee said.

In videos, he showed attendees how the procedure extends the length of the internal mammary artery.

“When you skeletonize it, it tends to stretch more, and it’s not confined by the surrounding tissue of a pedicle. I’d say you probably gain 25% more length,” said Dr. Lee, adding that the extra length of a skeletonized bilateral mammary artery is ideal for obese patients undergoing CABG.

Wilson Y. Szeto, MD, Associate Professor of Surgery at the University of Pennsylvania School of Medicine and Chief of Cardiovascular Surgery at Penn Presbyterian Medical Center in Philadelphia, tackled complex valve-sparing surgery for aortic root aneurysms.

Demonstrating the procedure through videos, he noted that the risk of patients needing a permanent pacemaker is higher with aortic valve replacement than with repair. Beyond avoiding the need for lifelong anticoagulation measures after mechanical valve replacement or a second surgery to replace a degenerated bioprosthetic valve, both prosthetic valve types have a higher risk of endocarditis compared to a native repaired valve.

A patient with an aortic aneurysm and a relatively normal aortic valve may be a good candidate for valve-sparing root repair, said Dr. Szeto, although he cautioned against repairing severely damaged valves or ones with large perforations.

“The patient keeps his or her valve and the hemodynamics that go with that valve. That’s much better than any valvular prosthesis,” Dr. Szeto said.

In Aortic Centers of Excellence, valve-sparing operations have been shown to be associated with a greater than 90% freedom from reoperation at 10 years after surgery.

“Valve-sparing root replacement is associated with a less than 3%-5% mortality in most centers. In our center, this operation is associated with a less than 1% mortality,” Dr. Szeto said. “These are good results, and these repairs last. My recommendation for surgeons who are starting to do this complex procedure is to be conservative and only repair and spare valves that are almost near normal.”