Ann Thorac Surg 2000;70:338-339
© 2000 The Society of Thoracic Surgeons
Correspondence
Endarterectomy on a beating heart
Harinder Singh Bedi, MCha,
Maninder Singh Kalkat, MCha
a Tagore Heart Care & Research Centre, 339 GTB Nagar, Jalandhar, Punjab 144 003, India
e-mail: bedi{at}jla.vsnl.net.in
To the Editor
We read with interest the letter by Naseri and Arsan [1] on endarterectomy on the beating heart. We have been successfully using the beating heart technique whenever feasible in elective cases with suitable anatomy, including the high risk cases in which cardiopulmonary bypass is relatively contraindicated (severe chronic obstructive pulmonary disease, advanced renal failure, advanced age, calcified aorta, or severe left ventricular dysfunction) [2]. We have found that coronary endarterectomy is actually technically easier on a beating heart, as the regular contraction of the heart helps greatly in the traction and counter-traction that is essential for the closed technique. We have performed endarterectomy on the beating heart in 18 patients so far. Our indications for endarterectomy are the same as for a conventional (on-pump) coronary artery bypass grafting and are limited to conditions that preclude effective distal bypass to ischemic myocardium (long diffuse disease, 3 patients; distal vessel less than 1 mm in diameter, 5 patients; where distal bypass might prejudice perfusion to isolated proximal major side branches, 2 patients; separation of plaque at site of arteriotomy, 3 patients; and calcified plaque that would not take suturing, 5 patients).
We use our previously described techniques for stabilization and avoidance of ischemia [2]. The right coronary artery (RCA) is incised just above the crux cordis. The length of the arteriotomy measures 3 to 4 cm. A plane of cleavage is then developed using special instruments, which include a dissector, small ball-ended probes, and wire loops. The atheroma is first gently pulled out from the proximal coronary artery by the traction–countertraction technique. The extraction is stopped when resistance is felt or about 5 to 7 cm of atheroma is extracted. The proximal end is then chamfered. A silicone vascular loop (Retract-O-Tape Air Cushion; Deknatel/DSP, Lubeck, Germany) with blunt needle is passed around the proximal coronary artery and tightened if there is excessive bleeding. A plane is then developed distally. Care is taken to dissect the atheromatous core completely including all side branches. An attempt is made to prevent breakage and remove the atheromatous core in one piece. A gentle traction–countertraction technique to evert and peel the atheroma from the distal vessel is used. Care is taken to remove only one major branch at a time. In all cases a smooth-tipped, tapered feathery distal end could be extracted. After endarterectomy the RCA showed a diameter of 3.5 to 4 mm. The coronary artery bypass grafting is then carried out (Fig 1).
View larger version (146K):
[in this window]
[in a new window]
|
Fig 1. Operative photograph showing the endarterectomized core (black arrow), the radial artery grafted to the endarterectomized right coronary artery. The left internal mammary artery is also seen. (R = retrograde cannula; A = antegrade aortic root cannula; Radial = radial artery; LIMA = left internal mammary artery.)
|
|
This technique has been used in 18 patients so far. In all patients the RCA was endarterectomized. There were 14 men and 4 women with an average age of 56 years. Five of the patients had diabetes (3 insulin dependent). The conduit used was a radial artery in 6 patients, an in situ right internal mammary artery in 2, and a saphenous vein graft in 10.
None of the patients had a perioperative myocardial infarction (as judged by electrocardiographic and creatine phosphokinase of MB level criteria). Two patients developed a new onset atrial fibrillation that responded to pharmacological means, and another patient developed a right bundle branch block. Four patients were studied predischarge electively as part of the off-pump protocol. Angiography showed a good distal run-off (Fig 2), although the size mismatch between the conduit (radial artery) and the endarterectomized coronary artery is evident.
View larger version (165K):
[in this window]
[in a new window]
|
Fig 2. Postoperative angiogram showing the radial artery (black arrow) and the endarterectomized right coronary artery (open arrow).
|
|
All patients are angina free and have a normal treadmill test with no changes in the area of the endarterectomized vessel (RCA). Postoperatively the patients are kept on low dose warfarin sodium for 6 months to maintain an international normalized ratio between 1.5 and 2.
We are totally in agreement with Naseri and Arsan [1] that because no extracorporeal circulation is used in this beating heart surgical technique, it is the most physiological way to achieve coronary revascularization. We also agree that diffuse disease requiring endarterectomy is not a contraindication to the beating heart technique. The long-term results of endarterectomy in a beating heart need to be seen and compared with those for the conventional technique—early graft patency of 88.9% and a late (over 1 year) patency rate of 71.1% [3]—before a final conclusion regarding its effectiveness can be made.
References
-
Naseri E., Arsan S. Coronary endarterectomy on beating heart. Ann Thorac Surg 1999;68:630-631.[Free Full Text]
-
Bedi H.S., Suri A., Kalkat M.S., et al. Global myocardial revascularization without cardiopulmonary bypass using innovative techniques for myocardial stabilization. Ann Thorac Surg 2000;69:156-164.[Abstract/Free Full Text]
-
Brenowitz J.B., Kayser K.L., Johnson W.D. Results of coronary artery endarterectomy and reconstruction. J Thorac Cardiovasc Surg 1988;95:1-10.[Abstract]
