Ann Thorac Surg 1996;62:877-878
© 1996 The Society of Thoracic Surgeons
Case Report
Emergency Bypass Without Bypass!
Vivek L. Pathi, FRCS,
Paul S. Ramphal, MBBS,
Geoffrey A. Berg, FRCS,
Kenneth J. D. MacArthur, FRCS
Department of Cardiothoracic Surgery, Western Infirmary, Glasgow, Scotland
Accepted for publication March 27, 1996.
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Abstract
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We present 2 cases of failed coronary angioplasty, with hemodynamic compromise, where emergency coronary artery bypass grafting was performed without cardiopulmonary bypass. The hypodynamic nature of the stunned myocardium in this circumstance allows this technique to be applied with relative ease to accessible vessels. As a consequence, reduced morbidity and hospital stay can be anticipated.
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Introduction
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Percutaneous transluminal coronary angioplasty has become established as a useful adjunct in the treatment of symptomatic coronary artery disease. Acute vessel closures or dissections occur in approximately 4% of cases and constitute a medical emergency. Various options have been advocated in an attempt to ameliorate this life-threatening condition, including perfusion catheter or stent insertion and coronary artery bypass grafting [1, 2]. The traditional surgical approach involves the early implementation of cardiopulmonary bypass, thus reducing the workload of the heart, allowing revascularization to be performed. In spite of the use of sophisticated cardioplegic protocols, weaning from bypass can be troublesome with this method as the global ischemia during grafting, following the regional warm ischemia, can severely test the energy stores of the myocardium.
It would seem more logical, if the occluded vessel was accessible, to perform the grafts on the beating heart without the use of cardiopulmonary bypass. We present 2 such cases where acute occlusion of the proximal anterior descending and right coronary arteries was treated in this manner.
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Case Reports
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Patient 1
A 67-year-old man was admitted to the coronary care unit with post-myocardial infarction unstable angina. He was given intravenous heparin and nitrates, in addition to his preoperative ß-blocker, and calcium-channel antagonist and aspirin. In view of the failure to control his symptoms with conservative management, angiography was performed and revealed a severe stenosis in the proximal left anterior descending artery involving a large diagonal branch. Angioplasty of this lesion led to abrupt closure of both the vessels, with a fall in systolic arterial blood pressure to 60 mm Hg. Adrenaline infusion was commenced at 0.2 µg•kg-1•min-1, and an intraaortic balloon pump was inserted percutaneously, leading to hemodynamic stabilization. The patient was transferred to the operating theater and anesthetized, and a median sternotomy was performed. The anterior surface of the heart was virtually immobile, and the left anterior descending and diagonal arteries could easily be visualized by placing a gauze swab beneath the heart. With the use of proximal and distal nonencircling suspending sutures and an intraluminal occluder (Florester; Somatech, Oxford, England), a vein graft was anastomosed to the left anterior descending artery with the heart beating and maintaining the circulation. After attachment of the proximal end of the vein graft to the ascending aorta, reperfusion of this area was achieved within 80 minutes of the occlusion. Visible improvement in contraction was seen in the anterior surface of the heart during this period. A further segment of reversed saphenous vein was anastomosed to the diagonal artery in a similar fashion with the heart beating. The chest was closed and the patient returned to the intensive care unit with a reduction in inotropic requirement. Within 24 hours the intraaortic balloon pump was removed, administration of the inotropes was discontinued, and the patient was weaned from the ventilator. The patient was discharged from the hospital on day 6, asymptomatic, and has remained so at follow-up 3 months later. Electrocardiographic changes seen in the catheterization laboratory resolved by day 4, and no new changes were seen at the time of outpatient follow-up.
Patient 2
A 54-year-old woman with a history of unstable angina was found to have a 90% stenosis of her proximal right coronary artery on angiography. Percutaneous transluminal coronary angioplasty was attempted, but on the second inflation abrupt closure of the vessel occurred with compromise of her arterial blood pressure. Insertion of a perfusion catheter and commencement of dopamine infusion at a dose of 10 µg•kg-1•min-1 produced stabilization of her condition. She was immediately transferred to the operating theater where, using deep suspending sutures and intraluminal occluders, the distal right coronary artery was opened and a segment of vein graft anastomosed to it. Once again the area of evolving infarction was hypodynamic, allowing easy performance of the procedure. Two hours after the operation she was weaned from the inotropes, and she was extubated at 6 hours. The patient was discharged home on day 5, asymptomatic, receiving only aspirin.
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Comment
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There is general agreement that emergency coronary artery bypass grafting performed within 3 hours of failed percutaneous transluminal coronary angioplasty results in optimal myocardial salvage and improved survival [3]. Although elective coronary artery bypass grafting on the beating heart has been performed with low morbidity and mortality in some centers, it has failed to gain acceptance in the rest of the cardiac surgical community [4]. The greatly improved conditions provided by cardioplegic techniques, together with some reports of late stenoses at the sites of the anastomoses and encircling sutures used to exclude blood from the operative field, have led to abandonment of this method by many centers [5]. However, the avoidance of the systemic insult of cardiopulmonary bypass and the myocardial depressant effects of global ischemia would be a definite advantage in the setting of an evolving myocardial infarction, where preservation of myocardial function is a major concern [6]. Particularly after failed angioplasty, when this occurs in a hospital, only a bypass operation can provide complete and reliable revascularization with the minimum of delay, thus maximizing the myocardial salvage. The rapidity of recovery of these 2 patients after coronary artery bypass grafting without cardiopulmonary bypass supports this view, and may have been largely due to the promptness of revascularization. Although more complete resting of the heart would have been achieved by using cardiopulmonary bypass and retrograde blood cardioplegia, the time to implement these would undoubtedly have been much longer than that of the simpler technique.
The use of soft silicone intraluminal occluders has provided a blood-free field without the need for completely encircling suspension sutures, which have been shown to cause late stenoses in the distal coronary artery. The hypodynamic nature of the "stunned" myocardium soon after failed percutaneous transluminal coronary angioplasty requires only deep sutures to maintain the vessel in the operative field. Angiographic follow-up is required to establish whether this method can avoid this long-term complication.
Obviously, the patients in whom cardiogenic shock unresponsive to intraaortic balloon pumping and inotropes develops would require cardiopulmonary bypass to support the circulation until recovery occurs. However it is in those who can be stabilized without resort to this and whose pattern of disease is amenable to an operation on the beating heart that this method may provide the greatest benefit.
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Footnotes
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Address reprint requests to Dr Berg, Department of Cardiac Surgery, Western Infirmary, Dumbarton Rd, Glasgow, Scotland G11 bNT.
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References
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- Bredee JJ, Bavinck JH, Berreklouw E, et al. Acute myocardial ischemia and cardiogenic shock after percutaneous transluminal coronary angioplasty; risk factors for and results of emergency coronary bypass. Eur Heart J 1989;10(Suppl H):104–11.[Abstract/Free Full Text]
- Vaishnav S, Aziz S, Layton C. Clinical experience with the Wiktor stent in native coronary arteries and coronary bypass grafts. Br Heart J 1994;72:288–93.[Abstract/Free Full Text]
- Craver JM, Weintraub WS, Jones EL, Guyton RA, Hatcher CR. Emergency coronary artery bypass surgery for failed percutaneous coronary angioplasty: a 10 year experience. Ann Surg 1992;215:425–34.[Medline]
- Buffolo E, Andrade J, Branco J, Aguiar L, Ribiero E, Jatene AD. Myocardial revascularization without extracorporeal circulation. Eur J Cardiothorac Surg 1990;4:504–8.[Abstract/Free Full Text]
- Pfister AJ, Salah Z, Garcia JM, et al. Coronary artery bypass without cardiopulmonary bypass. Ann Thorac Surg 1992;54:1085–92.[Abstract/Free Full Text]
- Moshkovitz Y, Sternik L, Hod H. Coronary artery bypass without cardiopulmonary bypass for patients with severe left ventricular dysfunction. J Cardiovasc Surg Torino 1994;35(Suppl 1):227–31.[Medline]
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Abstract
Introduction
