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Ann Thorac Surg 1997;64:591-592
© 1997 The Society of Thoracic Surgeons
Departments of Cardiothoracic Surgery and Anaesthesia, Sree Uthradom Thirunal Hospital, Po Box 1052, Pattom, Trivandrum, Kerala 695 004, India
To the Editor:
We read with great interest the report of 2 cases by Pathi and associates [1] titled "Emergency Bypass Without Bypass!" We recently had occasion to perform a similar operation with equally gratifying results.
A 67-year-old man was admitted with acute-onset shortness of breath. He had a history of anterior wall myocardial infarction 3 weeks previously (thrombolysis was performed at another hospital) and had been discharged 3 days before the present episode. Chest roentgenography at the time of admission showed features of pulmonary edema, and echocardiography showed severely depressed left ventricular function. He was treated with diuretics, oxygen inhalation, intravenous heparin, and nitroglycerin and required inotropic support with dopamine and dobutamine. His condition improved on this regimen and he was discharged from intensive care unit after 5 days. However, the following morning he suffered a cardiac arrest requiring external cardiac massage and multiple defibrillations for resuscitation and was ventilated after this. He continued to suffer frequent episodes of ventricular fibrillation while on the ventilator, requiring multiple defibrillations and intravenous amiodarone. Renal function was deteriorating with rising urea and creatinine levels.
Emergency coronary angiography was performed, which showed total occlusion of the left anterior descending coronary artery soon after its origin with severely depressed left ventricular function. The rest of the coronary arteries were normal except for some minor irregularities in the proximal right coronary artery. Angioplasty of the left anterior descending artery was considered, but it was not possible to pass a guidewire across the lesion in the left anterior descending artery. An intraaortic balloon pump was positioned in the descending aorta under fluoroscopy in the catheterization laboratory, and the patient was transferred for emergency coronary artery bypass grafting. A median sternotomy was performed. As the patient's condition was stable, the left internal thoracic artery was prepared. The heart was elevated on gauze swabs placed behind it, and the left anterior descending artery was snared with 2-0 Prolene (Ethicon, Somerville, NJ) both proximal and distal to the proposed arteriotomy. Heart rate was controlled with intravenous esmolol. Hemodynamic stability was maintained and the left internal thoracic artery was anastomosed to the left anterior descending artery with two continuous sutures of 7-0 Prolene commencing at the heel and toe of the anastomosis. The patient was returned to the intensive care unit in a hemodynamically stable condition, receiving inotropic and intraaortic balloon pump support. His condition remained stable with no further arrhythmias. He was weaned off the ventilator over 48 hours, and the intraaortic balloon pump was disconnected soon after. His postoperative course was uncomplicated except for swallowing difficulty, probably due to glottic injury during intubtion. This recovered gradually and he was discharged home on the 25th postoperative day.
Coronary artery bypass grafting without use of cardiopulmonary bypass, both through a sternotomy and through a small anterior thoracotomy, is now being reported from different centers all over the world [2, 3] with good results. Our previous experience with this technique, through both routes, although always as a planned procedure, encouraged us to preform it in this emergency situation. In this particular case we believe that cardiopulmonary bypass and cardioplegic arrest would have carried unacceptable risks. The technique is particularly useful in high-risk patients such as those with renal failure, respiratory problems, advanced age, cerebrovascular accidents, and other systemic diseases [4]. Although technically demanding, coronary artery bypass grafting without cardiopulmonary bypass is a useful tool in the cardiac surgeon's armamentarium. The excellent recovery of this high-risk patient is testimony to the usefulness of this procedure. We congratulate Pathi and associates on an excellent report.
References
Department of Cardiac Surgery, Western Infirmary, Dumbarton Rd, Glasgow G11 6NT, Scotland
Reply To the Editor:
We thank Dr Jayakrishnan and colleagues for their comments and congratulate them on an excellent salvage procedure. We are delighted they were able to use the internal mammary artery, which should ensure a good long-term result.
In reply to Dr Pfister [1], we apologize if our statement was misleading. We merely intended to allay the theoretic fears of many surgeons who like ourselves may believe that the pressure exerted on the vessel wall by completely encircling a coronary artery with a suture may produce intimal injury. Although in the experience of Dr Pfister this has not been borne out, we prefer the use of intraluminal occluders as an alternative to allow us to continue using this extremely valuable technique. We have also had excellent results with beating-heart operations in both elective and emergency cases, and agree that when possible, it benefits the patient greatly. It is the important detail of excluding blood from the operative field that differs between surgeons and must be an individual decision. Therefore, unless angiographic or angioscopic evidence to the contrary can be produced, we like many others will continue to search for alternative methods of controlling blood flow during beating-heart operations [2].
References
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