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Ann Thorac Surg 1999;68:630-631
© 1999 The Society of Thoracic Surgeons

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Correspondence

Coronary endarterectomy on beating heart

^a Academic Hospital, Nuhkuyusu Cad. No 88, Altunizade, Istanbul>, Turkey 81190

e-mail: arsan{at}sim.net.tr

To the Editor

As it is known the "beating heart technique" expanded the domain of coronary artery bypass grafting in high-risk patients [1]. Later, the technique of aortocoronary bypass through a limited incision was adopted [2]. Because no extracorporeal circulation is used in this method, it is arguably the most physiologic way to achieve coronary revascularization.

Main indications for beating heart coronary bypass are severe left ventricular dysfunction, recent history of cerebrovascular accident, and chronic renal failure. In some of our patients undergoing the beating heart technique we encountered diffuse atherosclerosis of the coronary arteries necessitating endarterectomy. We decided to continue with the beating heart technique in 7 of these patients because of the presence of left ventricular dysfunction and either of the following conditions: recent history of cerebrovascular accident in 3 patients, severe chronic obstructive pulmonary disease in 2 patients (forced expiratory volume in 1 second less than the expected value despite full medical treatment), chronic renal failure, and advanced age in 2 patients. Midline sternotomy was the incision of choice. A retrocardiac sponge pad, two pericardial traction sutures on the edge of pericardium, and one proximal suture around the coronary artery were the only methods of immobilization. Two epicardial silk sutures on both sides of the artery facilitated better exposure. After the distal extent of the endarterectomy was reached, a circular suture around the coronary artery was used for better exposure and limiting the amount of bleeding. Heparin (1.5 mg/kg) was given before tightening the coronary traction sutures. Half of the heparin was neutralized after the completion of the anastomosis. The left internal mammary artery was the graft of choice for the left anterior descending coronary artery. A total of 10 endarterectomies were done (7 left anterior descending coronary artery, 3 right coronary artery). In 3 patients (2 left anterior descending coronary artery, 1 right coronary artery) closed endarterectomy (blind endarterectomy) was converted to an open technique because of lack of a smooth-tipped distal end. In two open left anterior descending coronary artery endarterectomies the coronary artery was reconstructed using saphenous vein patch angioplasty and the left internal mammary artery was anastomosed to the reconstructed vessel. Perioperatively no patient had electrocardiographic changes or myocardial enzymatic surges. No deterioration from the preoperative state occurred in the vital organs. The amount of blood loss during the operation never exceeded 500 mL. Low-dose heparin (5,000 U/day twice daily) was continued up to the fifth postoperative day. All of the patients received oral anticoagulants from the first postoperative day up to the third month. No patients had chest pain and 5 of the 7 patients had the reversal of the ischemic pattern at first year examination. Control coronary angiography in 2 patients showed three open endarterectomy bypasses in the second postoperative year.

We concluded that coronary endarterectomy on a beating heart can be done safely in a selected group of patients with left ventricular dysfunction and severe dysfunction of one of the vital organs of the body. If performed by a surgical team with good experience with the beating heart technique, morbidity and mortality will be comparable with other methods of coronary bypass.

References

1. Benetti F.J. Direct coronary artery surgery with saphenous vein without either cardiopulmonary bypass or cardiac arrest. J Cardiovasc Surg 1985;26:217-222.[Medline]
2. Gandjbakhch A.C. Left thoracotomy approach for coronary bypass grafting in patients with pericardial adhesions. Ann Thorac Surg 1989;48:711-713.

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Naseri, E. Articles by Arsan, S. Search for Related Content PubMed Articles by Naseri, E. Articles by Arsan, S.