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Department of Cardiothoracic Surgery, Catharina Hospital, Eindhoven, the Netherlands
Accepted for publication December 16, 2008.
* Address correspondence to Dr Sanders, Department of Cardiothoracic Surgery, Catharina Hospital, Michelangelolaan 2, Postbus 1350, Eindhoven, 5602 ZA, the Netherlands (Email: lucmedi{at}hotmail.com).
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Abstract |
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Introduction |
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We recently encountered a patient with an intracavitary (right ventricular) LAD. The only visible distal subepicardial LAD appeared small. During superficial exploration in the anterior interventricular fat groove, the right ventricle was entered after dissection of only 3 mm of epicardial fat and 1 to 2 mm of muscle. Further dissection was abandoned and the proximal segment of the LAD was located using distal arteriotomy and retrograde probing. The LAD wall and the intraluminal probe could be detected in the right ventricle through the inadvertent right ventriculotomy.
The probe was left in the LAD lumen to provide visual and tactile feedback, while the ventriculotomy was closed with horizontal pledgeted mattress sutures beneath the LAD. The left internal mammary artery was anastomosed to the proximal LAD and the distal arteriotomy was closed by indirect approximation of the arteriotomy edges (adventitia and epicardium).
After weaning from cardiopulmonary bypass, a troublesome ooze of dark blood was present that originated either from the right ventricle or cardiac veins. Ischemia developed after blind placement of an additional deep horizontal mattress suture intended to be beneath the LAD. This suture was removed and the ischemia disappeared. The bleeding was arrested by application of a TachoSil patch (Nycomed Laboratory, Roskilde, Denmark).
Postoperatively there were no signs of myocardial ischemia or infarction, and the maximum aspartate aminotransferase was 66 U/L on postoperative day 2. An echocardiogram showed improvement in left ventricular function from moderate to slight impairment.
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Localization of an intramyocardial LAD can be a technical challenge. Dissection can cause injury to diagonal and septal branches, coronary veins, and right ventricle leading to prolonged cross-clamp times [1–8]. Right ventricular injury causes additional problems of introduction of air, difficulty in exposure due to blood, postoperative bleeding, and obstruction of the LAD during closure of the ventriculotomy. These complications are more often seen when the LAD is anastomosed proximally due to the higher incidence of an intramyocardial LAD [8]. A proximal anastomosis does allow antegrade flow through the entire vessel and the largest lumen possible for anastomosis.
In 1973, Robinson first presented the technique of identifying the proximal intramuscular LAD by palpation of a retrogradely inserted probe through a distal arteriotomy [11]. Subsequently Fisk and colleagues [3] presented a series of 18 cases using this technique, later followed up by Fisk [7] with 117 cases without ischemia in the LAD territory. They believe that this technique is safe and reduces the risk of inadvertent injury.
Few reports have dealt with the issue of management of inadvertent right ventricular injury during localization of the LAD. Ochsner and Mills [2] report that McAlpine was the first to describe the existence of an intracavitary artery. They subsequently present a series of 13 patients with intracavitary coronary arteries and discuss the options for closure of either inadvertent right atriotomy or right ventriculotomy [2].
For closure of the ventriculotomy, we used mattress sutures below the LAD, analogous to the standard technique for traumatic ventricular injury, similar to reports by Oz and colleagues [4] and Fisk [7]. As described by Barner [9], this technique can potentially result in LAD obstruction if not all the overlying muscle fibers have been divided. At the proximal and distal edges of the ventriculotomy closure site, the overlying muscle fibers or right ventricle wall can compress the LAD. Ochsner and Mills [2] present three solutions and provide illustrative graphs. The safest solution is closure of the ventriculotomy above the LAD and selection of an alternative site for anastomosis [9]. Whether this is possible depends on the site of the stenosis, the vessel diameter of the alternative site, and whether the muscle layer above the LAD is thick enough for closure. The second option is complete division of the muscle above the LAD and approximation of the right ventricular free wall to the interventricular septum below the LAD. This could involve a significant amount of dissection and damage to numerous septal perforators, as well as diagonal branches during closure. The mattress sutures pass from the right ventricular wall either through the septum only [8] or to the left ventricular epicardium on the left side of the LAD. Approximation is enough and sutures do not need to be tight [9]. A pericardial patch can be used with this technique [10]. The third solution described by Ochsner and Mills [2] is closure of the ventriculotomy using a pericardial patch through which the graft to the LAD traverses.
In our case, closure of the ventriculotomy above the LAD either directly or with the use of a patch was not possible due to the thin right ventricular wall. Fortunately placement of the initial mattress sutures below the LAD did not cause ischemia. Possibly the risk of compression of the LAD due overlying undivided tissue is small when the right ventricle wall is thin.
With any of the techniques described, the inherent danger of blind passage of needles, presumably below the LAD, is injury to the LAD itself. The use of an intraluminal probe, during placement of sutures close to the LAD, reduces the risk of damage by providing visual and tactile feedback. This has not been described before.
In conclusion, inadvertent right ventriculotomy during localization of the LAD present a technical challenge. We have discussed the different techniques for closure, including a literature review. We believe we are the first to describe the use of an intraluminal probe to provide visual and tactile feedback during placement of mattress sutures beneath the LAD.
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This article has been cited by other articles:
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  M. H. Mandegar, F. Roshanali, and B. Saidi New Technique for Localizing Intramyocardial Left Anterior Descending Artery Ann. Thorac. Surg., April 1, 2010; 89(4): 1342 - 1342. [Full Text] [PDF]
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L. H.A. Sanders, M. A. Soliman Hamad, and A. H. van Straten Reply Ann. Thorac. Surg., April 1, 2010; 89(4): 1342 - 1343. [Full Text] [PDF]
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