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Ann Thorac Surg 2001;72:1380-1382
© 2001 The Society of Thoracic Surgeons
a Division of Cardiothoracic Surgery, University of Pittsburgh Medical Center and Veterans Affairs Healthcare System, Pittsburgh, Pennsylvania, USA
b Department of Anesthesiology, University of Pittsburgh Medical Center and Veterans Affairs Healthcare System, Pittsburgh, Pennsylvania, USA
Accepted for publication September 26, 2000.
Address reprints request to Dr Zenati, Division of Cardiothoracic Surgery, University of Pittsburgh Medical Center, 200 Lothrop St, Suite C-700, Pittsburgh, PA 15213
e-mail: zenatim{at}msx.upmc.edu
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Abstract |
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Introduction |
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A 51-year-old man with anterior left ventricular ischemia by stress thallium scintigraphy underwent a coronary angiography, demonstrating aggressive in-stent restenosis of the proximal left anterior descending coronary artery. The left ventricular ejection fraction was 56%. The patient had a history of cigarette smoking (2 packs per day for 32 years). His pulmonary function tests showed a forced expiratory volume (1 second) of 2.9 L (78% of predicted), forced vital capacity of 4.6 L (89% of predicted) and diffusion limited carbon monoxide of 20.5 mL/mm Hg/min (75% of predicted). The patient was referred for a MIDCAB.
After access lines were placed, a 17-gauge Tuohy needle was used to localize the epidural space at T2/3 interspace using a midline loss of resistance technique in the sitting position. A 19-gauge epidural catheter was then inserted 3 cm into the epidural space and a test dose (3 mL 1.5% lidocaine with epinephrine 1:200,000) was administered to rule out intravascular or intrathecal migration. The patient was then placed recumbent, and invasive hemodynamic monitoring lines were placed, including a pulmonary artery catheter. Three mL to 5 mL boluses of 2% lidocaine were injected through the epidural catheter (total dose 20 mL/400 mg) over the next 30 minutes resulting in an epidural anesthetic block extending from C6 to T8. The lower level of the epidural block was tested by assessing temperature and pinprick discrimination. The objective of this approach was to achieve somatosensory and motor block between C7 and T7 levels while preserving diaphragmatic breathing (at C4 level diaphragmatic breathing will be affected). No muscle relaxant drugs were used. Midazolam and fentanyl were administered during epidural catheter and invasive monitoring placement, and propofol infusion was used for ansiolysis and light sedation. For additional epidural local anesthetic, we used 3 mL to 5 mL of 0.5% bupivacaine titrated boluses (total 30 mL/150 mg over 150 minutes). The time between the epidural placement and heparin administration was 120 minutes. Patient was given 100% oxygen (O2) through a face mask and maintained an arterial oxygen saturation of 93% to 100%.
Through a left 3-inch thoracotomy, the fourth intercostal space was entered and the pleural space was exposed to the atmosphere. The left lung collapsed partially, but the patient reported no trouble breathing. A reusable retractor (LIMAvator, Genzyme Surgical Products, Tucker, GA) was inserted, and the left internal thoracic artery was mobilized for its entire length (14 cm). Heparin (1,000 IU/Kg) was used. The left anterior descending coronary artery was intramyocardial up to the distal third of its course. An elongation of the left internal thoracic artery was performed using a segment of saphenous vein. A MIDCAB retractor and stabilizer (CAB Super-Slide Retractor, Koros Surgical Instruments, Moorpark, CA) was positioned, and the left anterior descending coronary artery was snared only proximal to the anastomotic site. No electrocardiographic changes were detected. The anastomosis time was 9 minutes. The operative time was 2 hours.
The patient’s pain on a visual analog scale (zero = no pain, 10 = worst possible pain) was zero. The arterial blood gases during the operation were remarkable only for hypercarbia (Fig 1). The heart rate was always between 55 and 60 beats per minute, the mean arterial blood pressure remained between 65 and 75 mm Hg, and the respiratory rate was between 6 and 14 breaths/min. For postoperative pain management, we used 0.125% bupivacaine with fentanyl 5 µg/mL infusion at 4 mL/hr through the epidural catheter.
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Comment |
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Based on this first successful case, we conclude that MIDCAB without general endotracheal anesthesia is feasible. Further experience is necessary to understand the safety and impact on outcome.
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