Hypothermia is not necessary. Canulation of the Groin, go to ECC. Short pump stop during last steps of sternotomy. Have a large foley catheter and 3 suction tubes connected to the HLM at hand. If there is a smal opening of the aneurysm put the foley in, inflate balloon and give gentel tension for haemostasis. If the aneurysm is opend wide during sternotomy put al 3 succers in and open the chest/aneurysm further. Find the inflow to the pseudoaneurysm at the aorta/Graft. Put the foley into the Aorta and inflate the Balloon. Let one of your assistants keep slight tension on the foley to achive haemostatsis. Go ahead with disection of the situs until crossclamp is possible. Repair the Problem.

Sometimes you are lucky and the inflow is smal and can be closed over the Foley ballon. Be caerful to not touch the balloon with the needle! Better to have a spare foley at hand...

Dont forget to put a clamp on the proxymal tube of Foley.

Thank you very much for your comment, Dr Hakim-Meibodi. Putting foley catheter to aneurysm and/or aorta seems to be a very good option to achieve redosternotomy. Though I might not be brave enough to put a foley into a bleeding point, this technique must be one of the useful option we have to consider when we try to perform redo median sternotomy. Thank you very much.

Dr Numata,

I happen to have published a paper regarding this topic including about 20 patients in Nagoya University Hospital as the first author.

We used pre-sternotomy deep hypothermia in two patients whose aneurysms were so huge that re-entry injury was judged to be absolutely inevitable.

Though I personally did not attend those two operations, Professor Ueda told me that left ventricular distention was not a problem because we used vacuum assisted venous drainage.

I think you can probably cool the patient down to the level of deep hypothermia without LV venting, safely, if your patient does not have significant aortic regurgitation.

Feel free to contact me if you would like a copy of operation record. I just know these two patients did well after surgery by medical records.

Reoperation of the proximal aorta: impact of presternotomy extracorporeal circulation on clinical outcomes.

Abe T, Usui A, Yoshikawa M, Oshima H, Akita T, Ueda Y.

Gen Thorac Cardiovasc Surg. 2009 Sep;57(9):458-62. doi: 10.1007/s11748-009-0432-2. Epub 2009 Sep 13.

Thank you very much for your suggestion Dr Abe. I read your article and impressed with very good surgical results. And also I read couple of papers describing methodology of redosternotomy using hypothermic circulatory arrest, however no one concerned about decompression of ventricle during cooling after Vf so far. In our experience, after the patient became Vf, pulmonary artery and left artial pressure became high and TEE showed distended left ventricle. Venous drainage was well. Therefore we thought pt may have some degree of aortic regurgitation. At that time, we do not have a choice for left ventricular veniting and postoperative wall motion was suboptimal. We think ventricular distention might be one of the cause of postoperative ventrcicular failure.

I think in some cases or situation, left ventricle may distend during pre-sternotomy FF bypass with hypothermia. When this happens, we might have to consider alternative venting method probabaly. Through LV apex? PV through thoracotomy?

We do not do too many of them. But we do put a LV apical vent in especially if there is St Jude valve in or something like that. It is not so easy to put in an apical vent. Nowadays, TAVI people have got that stream lined to an art form with accurate thoracotomy with the help of imaging either echo or fluoscopy or both. It does give one a peace of mind.

Dear Dr Lin

Thank you for your comment. I think putting a vent tube through LV apex is very good idea. And we think it is difficult to perform this venting as well. At the operation, we considered to put vent in through apex. We examined echocardiography before surgery, which showed apex was located at far lateral side of the body, probably because pectus. So we abandaned to put tube in.

Thank you

This is an interesting problem.

However with appropriate preoperative imaging which includes a CT it is possible to assess accurately how close the aneurysm is to the posterior border of the sternum. From the description given I gather this is a redo following a previous Bentall. Now the issue of ventricular distension is worrisome only if the patient has Aortic incompetence.

Possible suggestions for safe sternal entry would be:

-retain posterior part of sternal wire; i.e., after untwisting or cutting sternal wire do not pull it out but keep in stretched out to afford some semblance of protection.

-if worried about proximity of aneurysm to sternum a reasonable option is to cannulate the right axillary artery and right femoral vein and go on pump. Open the sternum while on CPB with the heart well decompressed.

-if there is significant AI and worry regarding distension then a small left anterolateral thoracotomy can be performed in order to access the left ventricular apex for insertion of a LV vent.

- a small right anterolateral thoracotomy can be performed and the posterior part of the sternum can be freed from the aneurysm/cardiac structures before performing a redo sternotomy with an oscillating saw.

These are some helpful hints.

I would like to add that we have on occasion used a large Foley catheter as described earlier to obtain control when we have had to open the aneurysm. It would definitely help to cool the patient in that situation.

Dr. Numata,

This is an interesting discussion thread. I personally had a fear amont of resternotomy cases, including your case. How close is the pseudo aneurysm to the retrosternum? Are there any mediastinal fat tissue between the aneurysm and the sternum? In my own experience, sometime rupture is not avoidable especially when pseudo aneurysm or artificial grafts are sitting just behind the sternum without any tissue around.

Our strategy in your case is as follows:

1. To go on CPB with a femoral or the right subclavian artery cannulation and the right femoral to RA venous cannulation, and start to cool down.

2. To cut sternum with the oscillating saw as usual.

3. If we think the rupture is unavoidable, 28 degree of tympanic temperature is achieved then sternal reentry is performed.

4. You can liberally use short period of circulatory arrest or low flow during injury.

But I wonder you mentioned that your patient had pectus, and redo Bentall for peudoaneurysm. When prosthetic aortic valve is competent and venous drainage is adequate, I would not worry LV distension during mild hypothermia even with Vf. Also the mediastinal organs are mostly shifted to the left chest. I hope your case will be done well. Let us know how it goes. Good luck!

Tohru Asai

  Thank you very much for your important comment, Prof. Asai. I am big fan of your surgical videos uploaded on the web sites.  

  We applied femoro-femoral bypass and the core temperature was cooled down. During cooling, left ventricle was distended on TEE, therefore we have tried to decompress LV by pushing sternum but we could not decompress LV nicely. Pt had bentall procedure with mechanical valve previously, so there should not be significant aortic regurgitation, but there was some amout of blood flow going from AscAo to LV. Probably mechanical valve leaflet was fixed at opened position and that caused regurgitation, we thought. As a result, LV was distended for some duration.

 We could have opened sternum without rupture of the pseudoaneurysm, and successfuly performed redo bentall procedure. However, when we tried to wean off bypass, lentricular function was very poor. We send this patient to ICU with PCPS and IABP. Ventricular function did not recover at all and pt passed away a week later.

 Although cardiac arrest time was approximately 4 hours long,  LV and RV dysfunction was very severe for that cardiac arrest time. We suspected distended LV during cooling before sternotomy might influence this series ventricular dysfunction. Now we have to rethink about management of CPB for such difficault case.

 Thank you very much for your comment again

Satoshi Numata

Just a small point. My understanding is that all mechanical valves have to be assumed to leak, as there is inherant washing mechanism in all.

Thank you for your comment Dr Zaw Lin. We knew that mechanism, but regurgitation should not be siginificant enough compromise the hemodynamics.

 Anyway I am working with Dr. Kiyoshi Doi one of your friend in Waikato.

Thank you  again.

Thank you for your input. Sorry to hear the whole course. This topic was discussed at the Heart Surgery Forum a while ago. One suggestion may be a small left thoracotomy for direct apical venting in such a case. Anyway, it was a tough situation for anybody. I appreciate it very much for this important thread.

Femoral-femoral canulation as a inevitable.