Ann Thorac Surg 2008;85:1110-1112. doi:10.1016/j.athoracsur.2007.06.063
© 2008 The Society of Thoracic Surgeons
How To Do It
A Novel Approach to Surgical Treatment of Diseased Intracavitary Coronary Arteries and Ventriculotomy Closure
Kaya Suzer, MDa,
Oguz Omay, MDb,
Emre Ozker, MDc,*,
Ilhan Ozgol, MDa,
Theodor Stewens Wijers, MD
a Department of Cardiovascular Surgery, Istanbul University, Institute of Cardiology, Istanbul, Turkey
b Department of Cardiovascular Surgery, Baskent University, Istanbul, Turkey
c Gulhane Military School of Medicine, Department of Cardiovascular Surgery, Etlik, Ankara, Turkey
Accepted for publication June 22, 2007.
* Address correspondence to Dr Ozker, Osmanyilmaz MH, Ataturk CD No. 42/9 Gebze Kocaeli, Turkey (Email: dremreozker{at}yahoo.com).
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Abstract
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Inadvertent opening of the right ventricle may occur during dissection of an intracavitary artery. Two patients with stenotic intracavitary left anterior descending arteries were operated on. A right ventriculotomy was performed in the operation. The anastomosis was performed to this intracavitary segment of the artery. The ventriculotomy was closed with a pericardium. There were no ischemic changes or aneurysmal formation in the postoperative follow-ups. This technique may be preferable in the closure of right ventriculotomy without compromise of coronary flow or anastomosis.
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Introduction
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Intracavitary coronary artery is an intramyocardial coronary artery that takes a deep course through the interventricular septum and approaches the right ventricular subendocardium. The incidence of intracavitary left anterior descending coronary artery (LAD) is 0.2% to 0.3% [1, 2].
Inadvertent opening of the right ventricle may occur during dissection of an intracavitary artery. This may cause significant technical problems or increase surgical morbidity and mortality. Herein, we present a surgical technique of ventriculotomy closure and distal anastomosis of the intracavitary LAD.
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Technique
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Two patients were operated on with the method described as follows.
Patient 1
Patient 1, a 70-year-old man, was admitted with effort-related angina who had had a coronary artery bypass grafting x 2 (CABG x 2) (left internal mammary artery to first diagonal, saphenous vein graft to obtuse marginal branch of circumflex) 3 years prior to hospital admission. In his angiography, all of his bypass grafts, including the left internal mammary artery to the diagonal artery were patent, whereas his LAD, circumflex artery, and right posterolateral artery were stenotic. During the operation, after the sternotomy, a right internal mammary artery was harvested, the aorta and the right atrium were cannulated, and cardiopulmonary bypass was initiated. The cross clamp was applied and the cardiac arrest was maintained with isothermic blood cardioplegia.
We performed distal anastomoses to right posterolateral artery and to first and second obtuse marginal branch arteries. The first and second obtuse marginal artery anastomoses were done in sequential fashion (one conduit is used to bypass two coronary arteries). We did not start dissection over the distal LAD because we saw the sutures reinforced with Teflon felt used for repairing at the distal site, indicating an unsuccessful search for distal LAD from the previous operation. We started dissecting the septal fat and myocardium over the septum to reach the LAD in its middle septal position, but we were unable to succeed and suspected a very deep localized LAD or an intracavitary LAD. We then found a diagonal artery and used it as a guide to locate the LAD artery. Unfortunately, the proximal LAD was not suitable for an anastomosis. To avoid accidental entry into the right ventricular cavity, as we had experienced previously, we performed a right ventriculotomy (approximately 4-cm long) parallel to the potential course of the LAD in the interventricular groove. This length of myotomy is sufficient to let the surgeon efficiently perform the distal anastomosis and ventriculotomy closure. We prepared a semicircular pericardial patch (4 x 3 cm) and treated it with glutaraldehyde. The LAD was seen to have an intracavitary course that was located at the junction of the right ventricle and the interventricular septum. We allowed the artery to remain in its original intracavitary position and performed a bypass with the right internal mammary artery to this intracavitary portion with 7-0 Prolene (Ethicon, Somerville, NJ) in an end-to-side fashion. For the right ventriculotomy closure, five double-needled 5-0 Prolene (Ethicon) was reinforced with Teflon pledgets and sutured in horizontal mattress style to the interventricular septum beneath the LAD (Fig 1). Then the two ends of each suture were passed through the pericardial patch and tied down (Fig 2). By using the two sutures located proximally and distally, the pericardial patch and the right ventricular free edge was sutured with continuous stitches and hence the right ventriculotomy was closed (Fig 3).
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Fig 2. Drawing shows the tied down sutures. The proximally and distally placed sutures are used for suturing the pericardial patch in continuous stitches.
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Fig 3. Drawing shows the tied down sutures. The proximally and distally placed sutures are used for suturing the pericardial patch in continuous stitches.
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Patient 2
Patient 2 was a 54-year-old man with resting chest pain. Three-vessel disease was detected by angiography. On the right anterior oblique view, the LAD was suspected to dip into the septum and follow an intramuscular route (Fig 4). At the operation the LAD was not detected in the epicardium. In the distal groove, we determined a distal LAD, but the diminutive coronary size forced us to carry on the dissection to the middle and proximal septum; hence direct dissection over the interventricular groove was performed. After the dissection, when the LAD was exposed, the right ventricle wall at the junction of the septum was found to have a very thin texture. Therefore, to avoid an accidental entry into the right ventricle cavity, we performed a right ventriculotomy. The LAD had intracavitary localization such as that in patient 1. The patient had coronary artery bypass grafting surgery x 5 (CABG x 5) with aforementioned procedure but the left internal mammary artery was used instead.
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Fig 4. Angiographic view of patient 2 shows the dipping of the left anterior descending arteries (LAD) into the myocardium after an intramyocardial course. (*Indicates the intracavitary segment of the LAD.)
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Postoperative Follow-Up for Both Patients
The postoperative periods for both patients previously described were uneventful. Six-month postoperative, follow-up magnetic resonance angiographies were obtained for both patients. The grafts were found to be patent and there was no aneurysm formation at the right ventricular outflow reconstruction area.
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Comment
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Intracavitary LAD generally enters the right ventricle early in its descending course with an acute entrance, and it emerges to the surface subtly in a long curve [2]. The diminutive size of the epicardiac coronary artery may dictate use of an intracavitary segment. Both of our patients had arteriosclerotic lesions in the proximal segments of the LADs, forcing us to perform the distal anastomosis beyond the lesions where the LADs became intracavitary. Although we managed to find the LADs in the both patients, the size of the arteries were insufficient for anastomosis; therefore, we chose to dissect the intracavitary portions.
During intramyocardial dissection of an artery, a cardiac chamber may be opened where the vessel traverses the cavity. Repair of a right ventriculotomy has traditionally been a simple closure performed with buttressed horizontal mattress sutures passed beneath the coronary artery. However, damage to the septal branches may occur due to the sutures placed beneath the LAD, which may compromise the septal flow in the short term. On the other hand, left ventricular aneurysm is a long-term complication of this procedure. The surgeon may also choose to leave the artery in its intracavitary position, close the myocardium, and perform bypass distally to the intracavitary site, or can perform bypass at the intracavitary position. Ochsner and collegues [2] applied several techniques, such as simple closure, moving the artery into an aerial position and closing the ventriculotomy beneath it, anastomosing in the intracavitary position with closure of the ventriculotomy around the graft with the pericardium, or performing the anastomosis at a distal site. These authors [2] reported 13 patients with intracavitary LADs among 4,414 patients who had been operated on. There were no reports of any aneurysms [2].
In our routine practice, when we can not locate the LAD artery in the epicardial groove, we start dissecting the interventricular septum. We prefer to use a diagonal branch as a guide to finding the location of the LAD artery. We usually dissect the septal myocardium until we reach the intramyocardial LAD. If we can not detect the LAD in the apical half of the septal wall, we suspect an intracavitary or very deep intramyocardial LAD artery and quit searching. Unlike the other authors who deal with accidentally opened ventricles and perform anastomosis on intracavitary coronary arteries, we voluntarily open the right ventricles to avoid some technical obstacles and unfavorable outcomes, which we experienced beforehand. Prior to the 2 patients previously described, another patient with intracavitary LAD was operated on by Dr Wijers. In this patient, we entered the right ventricle during the dissection in the interventricular groove. The right ventricle myocardium in the right ventricle outflow tract was very thin in texture. After the left internal mammary artery bypass was accomplished, we closed the ventriculotomy by a simple closure technique with interrupted sutures. After the patient was weaned from cardiopulmonary bypass, the increased right ventricle pressure led to bleeding from the ventriculotomy repair site. Subsequently, the patient was placed on cardiopulmonary bypass again, and the ventriculotomy was reclosed with the aforementioned method. With this incident in mind, we then performed a ventriculotomy intentionally in the following two cases thereafter.
With our technique, a segment of intracavitary LAD is exteriorized through a sliding right ventricular myocardium outflow track patch of glutaraldehyde-treated pericardium sutured beneath the LAD, where the patch is used for closure of the right ventriculotomy without compromise of coronary flow or anastomosis. The technique that one can keep in his technical armamentarium is reliable with satisfying early-term and long-term outcomes.
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Acknowledgments
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We are indebted to Dr Theodor S. Wijers who first performed this operation in 1988 and taught us how to deal with this obstacle.
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References
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- In: McAlpine WA, editor. Heart and coronary arteries: an anatomical atlas for clinical diagnosis, radiological investigation, and surgical treatment. New York, NY: Springer-Verlag; 1975. pp. 186-187.
- Ochsner JL, Mills NL. Surgical management of diseased intracavitary arteries Ann Thorac Surg 1984;38:356-362.[Abstract/Free Full Text]
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Abstract
Introduction
