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Ann Thorac Surg 2004;78:387-388
© 2004 The Society of Thoracic Surgeons

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Correspondence

Gas embolization from the left ventricle and aortic root: A possible side effect of high-flow gas insufflation during coronary artery surgery

St Thomas' Hospital, London, King's College Hospital, Department of Cardiothoracic Surgery, Denmark Hill, London, UK SE5 9RS

e-mail: kbrown{at}doctors.org.uk

To the Editor:

High-flow gas insufflation is used routinely in off-pump coronary operations to maintain a bloodless field and facilitate the performance of the anastomoses. Its widespread use is recent, and concerns have been raised regarding the effect on the coronary endothelium, with implications for future graft patency [1]. However, no significant side effects of this method have been reported.

We describe the case of a 76-year-old patient undergoing 4-vessel coronary artery bypass grafting, on bypass, in which the high-flow gas insufflation may have caused CO₂ and possibly air to reach the aortic root and left ventricle. This patient's coronary arteries were extremely calcified, and we were therefore reluctant to place periarterial slings to minimize blood flow. We therefore decided to use high-flow CO₂ insufflation (3 to 5 L/min gas flow and normal saline 1 to 5 mL/min per the manufacturer's instructions [Medtronic Clearview]) to facilitate the performance of the distal anastomoses. After completion of the aortosaphenous anastomoses, and before terminating bypass, sounds were heard indicative of the presence of gas in the left ventricle. On placement of a root vent, air was immediately released under some pressure. The patient was placed in the Trendelenberg position and the root vented for a prolonged period before bypass was stopped and the left ventricle was allowed to eject in the typical manner. An intraoperative tranoesophageal echocardiogram (TOE) showed no intracardiac lesion that may have predisposed to gas accumulation from the right heart. Myocardial preservation was achieved by using the intermittent aortic cross-clamping and ventricular fibrillation method. Thus the insertion of the cardioplegia cannula into the aortic root as the source of air was eliminated.

After the operation a further TOE was obtained that confirmed the absence of any intracardiac defect. The patient had no focal signs but was confused for 10 days before slowly recovering function. A brain computed tomographic scan was normal. Because the heart had been neither opened nor vented, we can only assume that the coronary arteries were held patent by their extremely calcified walls and that high-flow gas insufflation may have forced CO₂ and possibly air by the Venturi effect retrogradely into the aortic root and left ventricle. Although no regurgitation was seen on TOE, the aortic valve could have been "tripped" and rendered incompetent while the heart was positioned for the circumflex graft.

During off-pump operations, the aortic root pressure is higher compared with on-pump operations, in which the heart and root are decompressed and in which it would be more difficult for gas to travel retrogradely.

However, this may provide a reasonable explanation for the presence of neurologic impairment after coronary artery bypass grafting with the "no touch of the aorta" technique, in which no aorto graft anastomoses are performed.

Surgeons using this helpful device should be aware that this major complication might occur.

References

1. Burfeind W.R., Jr, Duhaylongsod F.G., Samuelson D. High-flow gas insufflation to facilitate MIDCABG: effects on coronary endothelium. Ann Thorac Surg 1998;66:1246-1249.[Abstract/Free Full Text]

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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 Author home page(s): Karen M. Brown Graham E. Venn Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Brown, K. M. Articles by Venn, G. E. Search for Related Content PubMed Articles by Brown, K. M. Articles by Venn, G. E. Related Collections Coronary disease