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Ann Thorac Surg 2001;72:620-621
© 2001 The Society of Thoracic Surgeons

Case report

Double coronary endarterectomy on the beating heart in two patients with porcelain aorta

Mohammed Tamim, MDa, Nevzat Erdil, MDa, Ufuk Demirkilic, MDa, Harun Tatar, MDa

a Department of Cardiac Surgery, Alkan Hospital, Ankara, Turkey

Accepted for publication July 15, 2000.

Address reprint requests to Dr Tamim, Alkan Hospital, Birlik Mahallesi, 8.cadde 103 St No.10, 06552, Ankara, Turkey
e-mail: mtamim99{at}netscape.net


   Abstract
Top
 Abstract
Introduction
 Comment
 References
 
Patients with porcelain aorta carry a high risk of systemic embolism during coronary artery bypass grafting. Avoiding manipulation of the aorta during operation using the beating heart approach can prevent atheroemboli. In patients with diffuse atherosclerotic coronary artery disease who require endarterectomy, coronary bypass operations can be done safely on the beating heart.


   Introduction
Top
 Abstract
 Introduction
Comment
 References
 
A heavily calcified aortic wall, which is also known as porcelain aorta, is still a challenging dilemma for the surgeon, with respect to bypass technique, choice of conduit, and handling of diffusely diseased atherosclerotic coronary arteries. Patients with porcelain aorta carry a high risk of systemic embolism during coronary artery bypass grafting [1]. The beating heart of these patients can be revascularized heart without using cardiopulmonary bypass with good results [2]. We present 2 patients with diffuse atherosclerotic coronary artery disease and porcelain aorta who underwent coronary artery bypass grafting. To avoid manipulation of the heavily calcified ascending aorta in both patients, we first performed endarterectomy of both the left anterior descending (LAD) and right coronary (RCA) arteries. After endarterectomy, left and right mammary arteries were anastomosed to the LAD and RCA, respectively, using the beating heart method without cardiopulmonary bypass.

The patients were 62- and 67-year-old men admitted to Alkan Hospital for unstable angina. Both had a history of acute myocardial infarction. Chest roentgenograms showed relatively normal heart size with no evidence of calcification in descending or transverse aortic arch. Coronary angiographies were performed and surgical lesions were found in the LAD and RCA arteries of both patients. At operation, after midline sternotomy, the left internal mammary artery and a saphenous vein were harvested for coronary arterial bypass. Heparin was given (1.5 mg/kg), and the pericardium was opened. The aorta was found to be heavily calcified, extending from the proximal portion of the ascending aorta to the origin of the innominate artery. We decided to use the beating heart approach without cannulating the aorta to avoid manipulation of the calcified aorta and to prevent atheroemboli. To bypass the RCA we chose the right internal mammary artery, which was rapidly prepared. Immobilization was achieved with two epicardial traction sutures placed on the edge of epicardium during RCA handling and a glove full with saline placed under the heart while bypassing the LAD. After making the coronary incisions, extensive atherosclerotic plaques were found in the LAD and RCA and required endarterectomy. A dissection plane was developed in the outer third of the media and carried around the vessel. Plaque was fully dissected and extracted. The right and the left internal mammary arteries were anastomosed directly to the RCA and LAD in a standard fashion. There was no need to reconstruct the coronary arteries with a saphenous vein patch.

Neither patient needed any inotropic or intraaortic balloon pump support. The postoperative course of 2 patients was uneventful. Postoperative electrocardiograms showed no changes and myocardial enzymes did not increase. Neither patient experienced a cerebrovascular accident. Oral anticoagulation (Warfarin) was started to both patients from the first postoperative day to 6 months, Ticlopidin HCl (Ticlid) was given up to 2 months. Patients were discharged on the fifth postoperative day. Both patients were free from angina at 1 week and at 1 month. Six months later coronary angiograms were performed. Both the RCA and the LAD were open beyond the anastomotic site.


   Comment
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 Abstract
 Introduction
 Comment
References
 
Patients with porcelain aorta have high risk of systemic embolism during coronary artery bypass grafting [1]. Management of these patients is a challenge regarding bypass technique, choice of conduit, and handling of diffusely diseased coronary arteries. The beating heart approach is a method of choice for treating patients with porcelain aorta undergoing coronary artery bypass grafting. This approach avoids aortic manipulation and reduces the chance of a postoperative embolic event [2]. Leyh and colleagues [1] described a new surgical protocol to manage patients with porcelain aorta undergoing coronary artery bypass grafting by arterial cannulation of the axillary artery, hypothermic fibrillation arrest during the distal anastomosis, and attachment of the proximal anastomosis to the innominate artery during hypothermic circulation arrest. No patient experienced a cerebrovascular accident or visceral organ injury. Nottin and colleagues [3] reported on an alternative technique in which inflow is provided by a native normal proximal coronary artery (coronary-to-coronary arteries bypass) with early patency rate of 98% and good late results.

The coronary lesions of both patients necessitated endarterectomy. Using the beating heart approach blind endarterectomies were successfully performed to both LAD and RCA and then the left and right internal mammary arteries were anastomosed. Postoperative courses were uncomplicated.

Coronary artery bypass grafting with coronary endarterectomy in patients with porcelain aorta and diffuse coronary atherosclerotic disease can be performed safely using the beating heart approach without cardiopulmonary bypass to prevent the atheroemboli associated with manipulation of the aorta.


   References
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 Abstract
 Introduction
 Comment
 References
 

  1. Leyh R.G., Bartels C., Notzold A., Sievers H.H. Management of porcelain aorta during coronary artery bypass grafting. Ann Thorac Surg 1999;67:986-988.[Abstract/Free Full Text]
  2. Accola K.D., Jones E.L. Coronary revascularization in a patient with porcelain aorta and calcified great vessels. Ann Thorac Surg 1993;55:514-515.[Abstract/Free Full Text]
  3. Nottin R., Grinda J.M., Anidjars S., Folliqute T., Detroux M. Coronary–coronary artery bypass graft: an arterial conduit-sparing procedure. Ann Thorac Surg 1996;112:1223-1230.



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This Article
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Right arrow Author home page(s):
Mohammed Tamim
Nevzat Erdil
Ufuk Demirkilic
Harun Tatar
Right arrow Permission Requests
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Right arrow Coronary disease

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