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Extensive Endarterectomy, Onlay Patch, and InternalMammary Bypass of the Left Anterior DescendingCoronary ArteryTo the Editor:

We read with interest the article by Kato and colleagues [1]regarding long segmental reconstruction of the left anteriordescending artery (LAD) using the left internal thoracicartery.

Our group [2] first reported the technique of using theinternal mammary artery as an onlay patch after a long LADarteriotomy in 1996. We have been consistently using thetechnique in our practice whenever we encounter diffuse LADdisease that cannot be treated by conventional revasculariza-tion techniques.

At times, the only alternative has been to perform a long LADendarterectomy and then reconstruct the LAD using an onlaypatch of the left internal mammary artery (LIMA).

In rare cases when the endarterectomy was extensive, we haveused a saphenous vein onlay patch and then grafted the LIMAon to the hood of the vein patch, and we have had excellentresults with the above techniques.

Of 1571 patients undergoing coronary endarterectomy at ourcenter, 368 patients underwent endarterectomy of the LAD(23.4%). Of those patients, 212 received a LIMA graft andincluded 184 patients with a LIMA onlay patch and 28 with theLIMA anastomosed onto the hood of a saphenous vein onlaypatch. Of those presenting for coronary artery bypass grafting,5% to 10% of patients with diffuse coronary artery disease maybe candidates for the above-mentioned technique and canbenefit from use of the LIMA.

We commend Kato and colleagues for using the techniqueand admire their results emphasizing its usefulness in thesurgical armamentarium for tackling diffuse coronary arterydisease affecting the left anterior descending coronary artery.

Suresh Keshavamurthy, MD

Department of Thoracic and Cardiovascular SurgeryCleveland Clinic9500 Euclid Ave, J4-133Cleveland, OH 44195e-mail: skeshavamurthy@gmail.com

Nainar Madhu Sankar, MS, PhD

Advanced Heart, Lung and Vascular InstituteGlobal Hospital and Health CityChennai, India 600100

Kotturathu Mammen Cherian, MS, DSc

International Centre for Cardiothoracic and Vascular Diseases andDr K. M. Cherian Heart FoundationChennai, India 600101

References

1. Kato Y, Shibata T, Takanashi S, Fukui T, Ito A, Shimizu Y.Results of long segmental reconstruction of left anteriordescending artery using left internal thoracic artery. AnnThorac Surg 2012;93:1195–200.

2. Sankar NM, Satyaprasad V, Rajan S, Bashi VV, Cherian KM.Extensive endarterectomy, onlay patch, and internal mam-mary bypass of the left anterior descending coronary artery.

J Card Surg 1996;11:56–60.

© 2013 by The Society of Thoracic SurgeonsPublished by Elsevier Inc

ReplyTo the Editor:

We would like to thank Dr Suresh Keshavamurthy and associ-ates for their comments [1] on our recent article [2], andcongratulate them for their effort to face a difficult group ofpatients with diffusely diseased coronary arteries.

Regarding the reconstruction method of the left anterior de-scending artery (LAD), we believe that onlay patch reconstructionof the LAD using the left internal thoracic artery (LITA) is quiteimportant to achieve a satisfactory long-term outcome. In patientswith LITA onlay patch grafts, the wall of the LITA forms a newcoronary lumen and the atheromatous plaques are almost totallyexcluded from the LAD lumen. Intimal hyperplasia rarely occurs ina LADs reconstructed by the LITA, while vein graft disease hasbeen proven to progress with time. We would like to know thelong-term outcomes and angiographic results after vein patchreconstruction of the LAD as we have no data of this technique.

We also believe that both keeping run-off of the distal LAD bytacking the divided intima of the distal LAD and postoperativeanticoagulation are essential to prevent thrombosis at the anasto-mosis site, which would lead to excellent long-term graft patency.

Yasuyuki Kato, MD

Department of Cardiovascular SurgeryOsaka City General Hospital2-13-22, Miyakojimahondori, Miyakojima-kuOsaka, Japan 534-0021e-mail: kato20001224@gmail.com

References

1. Keshavamurthy S, Sankar NM, Cherian KM. Extensive end-arterectomy, onlay patch, and internal mammary bypass ofthe left anterior descending coronary artery (letter). AnnThorac Surg 2013;95:1136.

2. Kato Y, Shibata T, Takanashi S, Fukui T, Ito A, Shimizu Y.Results of long segmental reconstruction of left anteriordescending artery using left internal thoracic artery. AnnThorac Surg 2012;93:1195–200.

Artificial Chordae or Annuloplasty?To the Editor:

Congratulations to the authors for this study [1]. We also thankthem for giving an opportunity to review this topic, but we wouldlike to emphasize some points that we believe should be consid-ered by the authors.

As it might be seen in Table 1, because artificial chordae do nothave a capability to expand, this technique is to be reviewed ininfants because of fast growing tissues. In our view, the successfuloutcome is related to the annuloplasty technique (Table 2). Thegradual increase in mean transmitral gradient with time (Fig 5D)expresses the efficiency of annuloplasty in repair. The definition ofcoaptation depth in Figure 7 should correspond to the whole lengthof two leaflets in contact to each other.

Ismail Yurekli, MDMert Kestelli, MDMuhammet Akyuz, MD

Izmir Ataturk Education and Research HospitalDepartment of Cardiovascular Surgery6436 sok 82/3 35540 Karsiyaka-Izmir, Turkey

e-mail: ismoyurekli@yahoo.com

Ann Thorac Surg 2013;95:1136–40 • 0003-4975/$36.00http://dx.doi.org/10.1016/j.athoracsur.2012.08.108

1137Ann Thorac Surg CORRESPONDENCE2013;95:1136–40

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1. Murashita T, Hoashi T, Kagisaki K, et al. Long-term results ofmitral valve repair for severe mitral regurgitation in infants: fateof artificial chordae. Ann Thorac Surg 2012;94:581–6.

Computed Tomography in Aid to Direct Aortic AccessTo the Editor:

We read with interest the recent article by Bruschi and colleagues[1] concerning the new technique of direct aortic access through aminithoracotomy for transcatheter self-expanding aortic biopros-thetic valves implantation. One of the first surgical steps of thistechnique is an intraoperative ascending aortography to appreciatethe anatomy of the ascending aorta; this guarantees, at first, adistance of at least 6 cm between the aortic annulus and theselected site of entry incision in the ascending aorta.

We think that in these high-risk patients who are eligible forthis surgical procedure, a preoperative, contrast-enhanced, com-puted tomographic (CT) image of the chest can demonstratepossible anatomic contraindications to this procedure. It couldpermit the measurement of the length of the ascending aorta,from the aortic anulus to the brachiocephalic trunk and itsdistance from the sternum manubrium and the right ribs cage,to assess possible associated pathology of the ascending aorta,especially calcified plaques and lesions of the lung, pleura,pericardium, anterosuperior mediastinum, and supra-aorticvessels, that can make a minimal access procedure difficult orcontraindicated. All these different pathologic conditions can beeasily demonstrated by CT, especially if contrast-enhanced andfollowed by coronal and sagittal reconstructions (Fig 1). Otherdiagnostic evaluations can be drawn from CT, regarding the sizeof the aortic annulus, although echocardiography can be con-sidered the first choice for a diagnostic [2–4]. In this way, theintraoperative radiologic procedure could be restricted to thefinal aortography, to control the implanted valve.

The experience reported by the authors we have mentionedmust be considered of great value.

Antonio Manenti, MDDario Colasanto, MDClaudio Morandi, MD

Departments of Surgery and RadiologyUniversity of Modena and Reggio EmiliaPoliclinico, via del PozzoI-41100 Modena, Italye-mail: antonio.manenti@unimore.it

© 2013 by The Society of Thoracic SurgeonsPublished by Elsevier Inc

References

1. Bruschi G, de Marco F, Botta L, et al. Direct aortic access fortranscatheter self-expanding aortic bioprosthetic valves im-plantation. Ann Thorac Surg 2012;94:497–503.

2. Plass A, Scheffel H, Alkadhi H, et al. Aortic valve replacementthrough a minimally invasive approach: preoperative plan-ning, surgical technique, and outcome. Ann Thorac Surg2009;88:1851–6.

3. Blanke P, Euringer W, Baumann T, et al. Combined assess-ment of aortic root anatomy and aortoiliac vasculature withdual-source CT as a screening tool in patients evaluated fortranscatheter aortic valve implantation. Am J Roentenol 2010;195:872–81.

4. Schultz CJ, Moelker A, Piazza N, et al. Three dimensionalevaluation of the aortic annulus using multislice computedtomography: are manifacturer’s guidelines for sizing for per-cutaneous aortic valve replacement helpful? Eur Heart J2010;31:849–56.

ReplyTo the Editor:

We thank Dr Manenti and colleagues [1] for their interestingcomments about our article “Direct aortic access for transcath-eter self-expanding aortic bioprosthetic valves implantation” [2].

We completely agree with their comments about the useful-ness of preoperative multislice computed tomography (MCT).Our entire patient population, as standard screening protocol,underwent transthoracic echocardiography, complete left heartcatheterization, and coronary angiography’ moreover, all alsounderwent chest and aortic-iliac-femoral CT not only forevaluation of the access site but also to study the aorticannulus and to evaluate correct valve size. We consider MCTuseful in the screening protocol of all patients evaluated fortranscatheter aortic valve implantation, and mandatory inpatients evaluated for a direct aortic approach, exactly for allthe reasons considered by Manenti and colleagues: to evalu-ate the anatomy of the ascending aorta, the presence andlocation of calcifications, and eventually, if the patient haspreviously undergone myocardial revascularization, the loca-tion of proximal graft anastomosis.

Dr Bruschi discloses a financial relationship withMedtronic.

Fig 1. Contrast-enhanced computed tomo-graphic (A) coronal and (B) sagittal reformat-ted images. There are no thoracic, mediastinal,or pericardial abnormalities. The appearanceof the ascending aorta and of the brachioce-phalic trunk is normal. The distance from theaortic annulus and the most suitable site ofaortic incision is superior to 6.3 cm.

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