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Ann Thorac Surg 1997;64:843-844
© 1997 The Society of Thoracic Surgeons

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Case Report

Arrhythmia/Ischemia Management During Minimally Invasive Cardiac Operation

Dameron Hospital Heart Institute, Stockton, California

Accepted for publication April 19, 1997.

	Abstract

Top Footnotes Abstract Introduction Comment References

 
We present a case of severe arrhythmia and hemodynamic compromise in a patient undergoing minimally invasive coronary artery bypass grafting without cardiopulmonary bypass. This was successfully treated via an extracorporeal shunt from a femoral artery cannnula.

	Introduction

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Minimally invasive coronary artery bypass grafting is gaining acceptance as a new surgical technique for the treatment of heart disease [1, 2]. It involves exposure of the heart through a small right or left anterior thoracotomy with removal of costal cartilage and preparation of an in situ mammary artery for anastomosis. The technique offers many advantages to the patient in terms of potential for lower morbidity, mortality, and shortened hospital stay. This technique also offers many new challenges including avoidance of cardiopulmonary bypass and potential for life-threatening arrhythmias. We present a case of severe arrhythmia and hypotension that developed after occlusion of the right coronary artery (RCA) and was successfully treated by placement of an external shunt from the left femoral artery to the RCA.

A 76-year-old, 54-kg, 152.4-cm, American Society of Anesthesiologists physical status 4 woman was referred for surgical treatment of coronary artery disease. Relevant medical history included a history of diabetes and exertional angina, but she denied any history of orthopnea or paroxysmal nocturnal dyspnea. The patient had been admitted 1 week preoperatively with acute pulmonary edema, small bilateral pleural effusions, and congestive heart failure. The patient underwent cardiac catheterization, which demonstrated a 95% proximal stenosis of the left anterior descending artery, 90% obstruction of the first diagonal branch, and 70% obstruction of the RCA (which was noted to be nondominant). Ejection fraction was estimated at 0.30. Angioplasty of the left anterior descending artery was attempted, but the cardiologist was not able to pass a wire. With angioplasty no longer an option, we decided to pursue coronary bypass grafting to the RCA and left anterior descending artery via the minimally invasive approach using the respective right and left internal mammary arteries as grafts.

After placement of a large peripheral intravenous line, right radial artery catheter, and external defibrillation pads, the patient was preoxygenated, anesthesia was induced with fentanyl and midazolam, and the patient was relaxed with rocuronium. Anesthesia was maintained with oxygen, air, and isoflurane. The patient was intubated with a 37F double-lumen endotracheal tube, and a Pace-Port (Baxter-Edwards, Irvine, CA) Swan-Ganz catheter was placed after intubation. A low-dose infusion of dopamine (2 µg/kg) and nitroglycerin (0.1 µg/kg) was started and maintained during the course of the operation.

The patient was prepared and draped, and the operation proceeded. An incision was made exposing the right fourth costal cartilage, which was then removed. The right internal mammary artery was identified and dissected free. The pericardium was opened and the RCA identified. Next, the left fourth costal cartilage was exposed and removed. The left internal mammary artery was dissected free, and the left anterior descending artery was identified. The patient then underwent prophylactic cannulation of the left femoral artery and vein for possible cardiopulmonary bypass if needed. Of note, the femoral artery was cannulated with a 21F DLP (Grand Rapids, MI) cannula with a Luer-Lok side port. The patient was heparinized after the left radial artery was dissected out for use as graft extensions for the internal mammary arteries.

The right coronary artery was then exposed and controlled with silicone tapes. Blood flow through the RCA was occluded to see if the patient would tolerate the loss of myocardial perfusion. Within 1 minute severe arrhythmias marked by premature ventricular and atrial contractions, junctional beats, and prolonged compensatory pauses occurred. The patient quickly deteriorated hemodynamically with profound hypotension from systolic pressures of 105 to 130 mm Hg down to 60 to 80 mm Hg. Pacing was attempted using alligator clips applied directly to the myocardium via the left anterior thoracotomy, and pressor support was instituted, but the patient did not stabilize hemodynamically. The silicone band occluding the RCA was released, and the patient quickly improved. We decided to attempt to perfuse the RCA via a shunt from the femoral artery. We hoped that maintaining perfusion to the coronary artery during the suturing of the right internal mammary artery-to-RCA anastomosis would prevent the use of cardiopulmonary bypass during the procedure.

A Cobe (Lakewood, CO) male-male adapter was fitted to the Luer side port on the femoral artery DLP cannula. This was connected to a 30-inch B-D (Franklin Lakes, NJ) roentgenography set tubing, which had a 2-mm DLP arteriotomy catheter fitted at the end. This system was then flushed free of air with blood from the femoral artery. The RCA was isolated and opened, and the DLP catheter was inserted into the vessel under direct visualization, enabling perfusion of the RCA with shunted blood from the femoral artery. The RCA was then occluded and anastomosis with the right internal mammary artery proceeded uneventfully with complete hemodynamic stability. This process was repeated for the left internal mammary artery-to-left anterior descending artery anastomosis with excellent results.

After completion of the operation, the patient was reintubated with a single-lumen endotracheal tube and taken to the intensive care unit in stable condition. The patient had an unremarkable postoperative course.

	Comment

Top Footnotes Abstract Introduction Comment References

 
Minimally invasive coronary artery bypass grafting offers many new challenges. Ideally the operation is carried out on a beating heart, avoiding any potential morbidity from cardiopulmonary bypass [3]. Cardiac surgery without cardiopulmonary bypass is not a new concept [4, 5]. However, avoidance of cardiopulmonary bypass brings forth many considerations for the management of cardiac rhythm and arrhythmia. These include pharmacologic means of slowing the heart to optimize the surgical field during anastomosis. Also, a stepwise approach to management of life-threatening arrhythmia must be developed. First and foremost is good communication and vigilance. Some means of pacing the heart must be readily available. Because the anterior thoracotomy does not allow room for passage of defibrillation paddles, external defibrillation pads can be placed before incision. Appropriate pharmacologic agents for management of hypotension and arrhythmia should be close at hand.

The relationship of right or left coronary artery occlusion and ventricular ectopy is well established [6–8]. In our experience, occlusion of a coronary artery for the brief period it takes to complete the anastomosis often has minimal sequelae other than an occasional premature ventricular contraction and mild ST changes. These resolve quickly once blood flow is reestablished to the coronary artery. We commonly see arrhythmias in patients undergoing anesthesia, but they rarely necessitate treatment [9]. Manipulation of the heart during cardiac operations often causes transient episodes of ventricular ectopy and hypotension, but these generally resolve once any pressure on the heart is released.

In this patient a severe arrhythmia and hypotension developed during manipulation of the RCA. Conventional management with pressors, pacing, and pharmacologic agents failed to stabilize the patient. Ordinarily, this would have necessitated the use of cardiopulmonary bypass to safely carry out the remainder of the operation. We have presented a method by which perfusion can be maintained to the coronary arteries while the surgeon sutures the anastomosis. This shunt from the femoral artery is somewhat analogous to the shunt used for cerebral perfusion during a carotid endarterectomy in that the perfusing catheter is placed into the anastamotic site, and the surgeon sutures around the catheter. Just before the anastomosis is complete, the perfusing catheter is removed and the suture line is rapidly completed. Having the catheter in place until the final suture also ensures a patent lumen is present.

A potential drawback to this technique is the need to cannulate a peripheral artery. In this case, we used a large perfusion cannula that was placed prophylactically. Although the patient never went on cardiopulmonary bypass, this does represent potential for significant trauma to the femoral artery. However, this system probably would work well using a 14-gauge femoral artery catheter, with the same connection apparatus, causing significantly less vascular trauma.

In conclusion, we have presented a means of perfusing the coronary arteries during coronary artery bypass grafting in patients not undergoing cardiopulmonary bypass. In our patient this technique worked well in preventing the onset of severe arrhythmias and hypotension secondary to occlusion of the RCA.

	Footnotes

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Address reprint requests to Dr Coulson, Dameron Hospital Heart Institute, 525 W Acacia St, Stockton, CA 95203 (e-mail: dmrn_hrt{at}inreach.com).

	References

Top Footnotes Abstract Introduction Comment References

 

1. Lytle BW. Minimally invasive cardiac surgery. J Thorac Cardiovasc Surg 1996;111:554–5.[Medline]
2. Acuff TE, Landreneau RJ, Griffith BP, Mack MJ. Minimally invasive coronary artery bypass grafting. Ann Thorac Surg 1996;61:135–7.[Abstract/Free Full Text]
3. Buss MI, McLean RF, Wong BI, et al. Cardiopulmonary bypass, rewarming, and central nervous system dysfunction. Ann Thorac Surg 1996;61:1423–7.[Abstract/Free Full Text]
4. Buffolo E, Andrade JC, Branco JN, Teles CA, Aguiar LF, Gomes WJ. Coronary artery bypass grafting without cardiopulmonary bypass. Ann Thorac Surg 1996;61:63–6.[Abstract/Free Full Text]
5. Calafiore AM, Di Giammarco G, Teodori G, et al. Left anterior descending artery grafting via left anterior small thoracotomy without cardiopulmonary bypass. Ann Thorac Surg 1996;61:1658–65.[Abstract/Free Full Text]
6. Airaksinen KEJ, Ikaheimo MJ, Huikuri HV. Stenosis severity and the occurrence of ventricular ectopic activity during acute coronary occlusion during balloon angioplasty. Am J Cardiol 1995;76:346–9.[Medline]
7. Tennant R, Wiggers CJ. The effect of coronary occlusion on myocardial contraction. Am J Physiol 1935;112:351–61.[Free Full Text]
8. Goldstein JA, Butterfield MC, Ohnishi Y, Shelton TJ, Corr PB. Arrhythmogenic influence of intracoronary thrombosis during acute myocardial ischemia. Circulation 1994;90:139–47.[Abstract/Free Full Text]
9. Katz RL, Bigger JT. Cardiac arrhythmias during anesthesia and operation. Anesthesiology 1970;33:193–213.[Medline]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Michael F. Borges Alan S. Coulson Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Borges, M. F. Articles by Coulson, A. S. Search for Related Content PubMed PubMed Citation Articles by Borges, M. F. Articles by Coulson, A. S.