Asian Cardiovasc Thorac Ann 1998;6:62-63
© 1998 Asia Publishing EXchange Pte Ltd
Minimally Invasive Coronary Artery Bypass as a Salvage Procedure
Rajneesh Malhotra, MCh,
Yugal Mishra, PhD,
Pankaj Maheshwari, MCh,
Yatin Mehta, MD,
Naresh Trehan, MD
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Escorts Heart Institute and Research Centre New Delhi, India
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For reprint information contact: Rajneesh Malhotra, MCh Escorts Heart Institute and Research Centre Okhla Road New Delhi 110025, India Tel:91 11 684 4820 Fax:91 11 683 2605 Email: ehirc{at}giasdl0l.vsnl.net.in
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ABSTRACT
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A 58-year-old male patient undergoing for coronary reoperative surgery had hemodynamic instability associated with intractable ventricular fibrillation after induction of anesthesia before starting the surgery. Minimally invasive coronary artery bypass surgery with left internal mammary artery-to-left anterior descending coronary artery anastomosis under percutaneous left femoral artery-to-left femoral vein cardiopulmonary bypass was employed successfully as a life saving measure.
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INTRODUCTION
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Reoperative coronary artery bypass grafting (CABG) has a higher mortality and morbidity than primary CABG.1 Several risk factors for operative mortality in reoperative CABG have been identified but the major risks are in reopening the sternum and manipulating the heart and the old grafts.2 In recent reports, minimally invasive direct coronary artery bypass grafting has been described as an ideal technique for reoperative CABG operations if only the left anterior descending coronary artery (LAD) needs to be revascularized and the left internal mammary artery (LIMA) has not been used in previous surgery.3 We describe a case of coronary artery bypass grafting through an anterolateral minithoracotomy with percutaneous cardiopulmonary bypass as a salvage procedure in a coronary reoperative patient who had intractable ventricular fibrillation after anesthetic induction before starting the surgery.
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CASE REPORT
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A 58-year-old male hypertensive and diabetic patient was operated for CABG 12 years previously with reverse saphenous vein grafts to the LAD, right coronary artery, first diagonal branch of the LAD, and first obtuse marginal branch of the left circumflex artery. He was admitted to our institute after experiencing New York Heart Association class III angina for one month. His exercise test was positive with changes in ST and T waves in the anterolateral electrocardiogram leads. Coronary angiography revealed native triple-vessel disease with occlusion of all the reverse saphenous vein grafts to the coronary vessels and a left ventricular ejection fraction of 50%. He also had acid peptic disease with severe upper gastrointestinal bleeding 6 years previously for which endoscopic sclerotherapy was performed. He had dyspeptic symptoms along with angina during this admission.
In view of his symptomatic status, upper gastrointestinal endoscopy was planned under general anesthesia, followed by reoperative CABG. After induction of anesthesia, endotracheal intubation and endoscopy were carried out. Ten minutes later the patient had sudden bradycardia and cardiac arrest. During resuscitation he developed ventricular fibrillation and severe hypotension. Pharmacological measures and external cardioversion failed to stabilize his hemodynamic status. An intra-aortic balloon was inserted through the right femoral artery and intra-aortic balloon counterpulsation was started. However, the patient's hemodynamic status did not improve.
With external cardiac massage, cardiopulmonary bypass was established percutaneously through the left femoral artery and the left femoral vein. After 30 minutes of cardiopulmonary bypass and balloon pump support with cardioversion, the ventricular fibrillation reverted to normal sinus rhythm but with ST-segment elevation in the anterior chest electrocardiogram leads. Transesophageal echocardiography demonstrated hypokinesia of the anterior wall of the left ventricle and the interventricular septum. Minimally invasive direct coronary artery bypass with LIMA-to-LAD grafting on the beating heart under cardiopulmonary bypass support was planned as a salvage procedure because it would reduce the ischemic time necessary to access the heart through sternal reentry. The LIMA was dissected under direct vision from the 3rd to the 6th intercostal space through an anterolateral minithoracotomy in the 4th intercostal space. Direct LIMA-to-LAD anastomosis using 7/0 continuous polypropoline suture was performed on the beating heart. On completion of the anastomosis, the ST-segment changes settled and the patient was hemodynamically stable with moderate inotropic and intra-aortic balloon pump support. After 181 minutes of cardiopulmonary bypass support, the patient was successfully weaned off the pump. He had an uneventful postoperative recovery with extubation and discontinuation of balloon pump support on the 1st postoperative day. He was discharged on the 8th postoperative day and was asymptomatic.
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DISCUSSION
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Reoperative CABG carries a higher mortality than primary CABG, ranging from 3.4% to 12.5%.4,5 One of the important factors in redo CABG is the time taken for sternal reentry and gaining access to the heart for cannulation, particularly in an emergency situation. For this reason we employed minimally invasive direct LIMA-to-LAD anastomosis through an anterolaternal minithoracotomy with percutaneous cardiopulmonary bypass support as a life saving procedure. However, the patient was not completely revascularized and it was considered that this could be dealt with at a later date by percutaneous transluminal coronary angioplasty with or without a coronary stent. In view of the asymptomatic status at the time of discharge, it was decided to restress the patient after 4 weeks to evaluate the need for further intervention.
The LIMA was mobilized from the 3rd to the 6th intercostal space and the intercostal, muscular, and sternal collaterals were not occluded in this procedure. During the systolic phase, the LIMA graft supplies blood to the side branches, whereas the flow in the coronary artery is mainly during diastole and there is thought to be no competition between the different teritories.6,7 Therefore, the steal phenomenon should not apply in the setting of a LIMA graft but this remains controversial.6,8
Myocardial revascularization through minimally invasive and video-assisted surgical techinques, port-access minimally invasive cardiac surgery, and total endoscopic myocardial revascularization are evolving procedures. These developments should have a wider clinical application in the future and could be applied to coronary reoperative surgery and other complicated procedures. Our experience demonstrates the usefulness of minimally invasive coronary artery surgery as a salvage procedure in an emergency situation.
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REFERENCES
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Petrov I, Dzhorgova IU, Dimitrov N, et al. The anatomical characteristics of the a. mammaria interna and their importance for the surgical results in aortocoronary bypass (a report on 2 clinical cases with large intercostal branches of the a. mammaria interna). Khirurgiia (Sofia)
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ABSTRACT
INTRODUCTION
