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1. Sundt TM, Mora BN, Moon MR, Bailey M, Pasque MK, gayWA Jr. Options for repair of a bicuspid aortic valve andascending aortic aneurysm. Ann Thorac Surg 2000;69:1333–7.
2. Pachulski RT, Weinberg AL, Chan KL. Aortic aneurysm inpatients with functionally normal or minimally stenotic bi-cuspid aortic valve. Am J Cardiol 1991;67:781–2.
3. Parai JL, Masters RG, Walley VM, Stinson WA, Veinot JP.Aortic medial changes associated with bicuspid aortic valve:myth or reality? Can J Cardiol 1999;15:1233–8.
4. De Sa M, Moshkovitz Y, Butany J, David TE. Histologicabnormalities of the ascending aorta and pulmonary trunk inpatients with bicuspid aortic valve disease: clinical relevanceto the Ross procedure. J Thorac Cardiovasc Surg 1999;118:588–94.
ReplyTo the Editor:
We appreciate Dr Veinot’s interest in our manuscript and aregrateful to him for bringing to our attention the results of hisown study of the pathology of the aortic media in patients withbicuspid aortic valves. Their histologic demonstration of abnor-malities of elastin in aortas from patients with congenitallybicuspid aortic valves is consistent with the data recently re-ported from Toronto, as he noted, and with histologic andbiochemical data from our own laboratory (unpublished data).
Although we are pleased that he supports our argument forthe continued selective application of the separate valve andgraft technique for repair of this condition, we confess uncer-tainty as how to reconcile our clinical observations with thehistopathologic data. Although there is a dearth of informationon the root itself, the presence of significant architectural disar-ray in the adjacent ascending aorta suggests similar abnormal-ities may well be present in the sinuses. Do we endanger ourpatients by leaving such tissue behind? Indeed, if the ascendingaorta is abnormal, should it be replaced prophylactically inpatients with bicuspid valves even in the absence of dilatation?
Clearly, the universe of patients with bicuspid aortic valvesincludes phenotypically, and likely genotypically, distinct sub-groups. Clinically, we encounter young men in their third orfourth decade with bicuspid valves, annular dilatation, andpredominant functional regurgitation whose roots have thesame flask-shape as a Marfan’s aorta, as well as the octogenarianwith calcific stenosis of a bicuspid valve and an otherwisenormal appearing root and aorta, or perhaps normal sinuseswith a distinct sinotubular ridge and what appears to be post-stenotic dilatation of the ascending aorta. Soon, our surgicalpractice may be guided by genetic analysis to predict the risk offuture dilatation or dissection of the aorta left behind. Until suchgenotypically tailored therapy is upon us, however, we agreewith Dr Veinot, that we must rely on judgment in the operatingroom, and serial imaging studies in the follow-up clinics.
Thoralf M. Sundt III, MDMarc R. Moon, MD
Division of Cardiothoracic SurgeryWashington University School of Medicine3108 Queeny Tower1 Barnes Hospital PlazaSt. Louis, MO 633110e-mail: [email protected].
Complications on Sternal ReentryTo the Editor:
We read with great interest the article by Follis and colleagues[1]. This excellent work examines the role of resternotomy incardiac reoperations to define the incidence of catastrophichemorrhage.
In this study they reviewed their experience using the tech-nique described by Akl and associates [2] in 1984, utilizing asagittal oscillating saw. The results were compared with thepractice of 1,116 surgeons contacted by questionnaire.
We appreciated very much the way the discussion was con-ducted, and particularly the review of the literature on theavailable methods of resternotomy. We agree that as operativetechniques evolve and survival after cardiac operations im-proves the number of patients undergoing repeat sternotomyinevitably will continue to rise.
In this context we would like to make some comments.Cardiac reoperations represent 18% (10% valvular and 8%coronary) of our daily activity. Since January 1980, more than 800cardiac reoperations were done at our institution. Resternotomywas performed utilizing a swiveling plaster saw with a 3 cm deepblade. Neither deaths, nor complications as defined by Follis andcolleagues as catastrophic hemorrhage, were observed. Thisswiveling sagittal saw operates by vibrating action at more than20,000 cycles/min. The higher vibrating frequency of the steelblade results in a less traumatic action on smooth tissue withoutlosing effectiveness on bone tissue.
We stress the importance of using a vibrating saw with ahigher rate of vibration than the sagittal oscillating saw. More-over, the good results encouraged us to use it as a routine devicefor both first and redo sternotomies because of its safety andeffectiveness.
Piergiorgio Bruno, MDMassimo Massetti, MDGerard Babatasi, MD, PhDAndre Khayat, MD
Department of Thoracic and Cardiovascular SurgeryUniversity HospitalCHU Ave de la “Cote de Nacre”14033 Caen, Francee-mail: [email protected].
References
1. Follis FM, Pett SB, Miller KB, Wong RS, Temes RT, Wernly JA.Catastrophic hemorrhage on sternal reentry: still a dreadedcomplication? Ann Thorac Surg 1999;68:2215–9.
2. Akl BF, Pett SB, Wernly JA. Use of sagittal oscillating saw forrepeat sternotomy: a safer and simpler technique. Ann Tho-rac Surg 1984;38:646–7.
Postoperative Drug Therapy and Survival AfterCoronary Artery Bypass GraftingTo the Editor:
In his editorial in the May 2000 issue of The Annals [1], DrRoberts points out the importance of multimodal therapy inorder to achieve optimal results of coronary artery bypassgrafting (CABG). To this end, Dr Roberts cites large-scalestudies implicating benefits of lipid-lowering drugs, statins inparticular; antiplatelet drugs; angiotensin-converting enzyme-
1068 CORRESPONDENCE Ann Thorac Surg2001;71:1065–73
© 2001 by The Society of Thoracic Surgeons 0003-4975/01/$20.00Published by Elsevier Science Inc
