| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
| ||||||||||||||||||||||||||||||||||||||||||||||||||
Ann Thorac Surg 1997;64:1654-1655
© 1997 The Society of Thoracic Surgeons
DR ELLIS L. JONES (Atlanta, GA): Doctor Subramanian, this represents a wonderful experience, and we appreciate your bringing it to us.
You mentioned resection of the costochondral area and multiple incisions around the chest wall, and we know that retraction can be quite extensive in this procedure. In as honest a fashion as you can address this audience, tell us about the postoperative pain factor in these patients.
DR SUBRAMANIAN: The pain of the minithoracotomy incision was considerable in some patients early in our experience because of the excision of costal cartilages. In our recent experience, since we have not routinely excised costal cartilage with the IMA access retractor system, very rarely have these patients complained of pain. In addition, we are very aggressive with the use of analgesic medication in all CABG patients.
DR AURELIO CHAUX (Los Angeles, CA): I congratulate you on this extensive experience. What I saw in your slides is that approximately 50% of your patients had double- or triple-vessel disease. Is that correct?
DR SUBRAMANIAN: Yes.
DR CHAUX: And a very great majority of them had lesions in the LAD and you bypassed the LAD alone. So what happened to the other circumflex and right coronary artery lesions?
DR SUBRAMANIAN: It is somewhat difficult to define double- and triple-vessel disease, especially in patients undergoing reoperative CABG with two grafts open and one graft closed. If they still have native coronary artery disease, we classify them as having triple-vessel disease. Many of the patients in this series were in a high-risk group with reoperative CABG. We have performed double-vessel MIDCABG in 28 patients in whom we definitely identified only double-vessel disease. In most of the patients with triple-vessel disease, we have elected to do the single-vessel graft, mainly because of mitigating circumstances in this patient population. If there is triple-vessel disease in a young patient with no other serious contraindications, we would certainly not perform single CABG using the MIDCABG technique at present. We would perform an elective, regular, standard, conventional bypass operation.
DR CHAUX: So what was the average number of incisions that you made per patient?
DR SUBRAMANIAN: Predominantly in the single graft, one; and in the double grafts, two incisions, a bilateral thoracotomy or a subxiphoid and a minithoracotomy.
DR KEVIN D. ACCOLA (Orlando, FL): I enjoyed your presentation. I have a couple of technical questions. With regard to evaluating the LAD, I notice that you took down the mammary artery before you explored the LAD. My first question is: how do you handle a calcified or intramyocardial LAD, and why do you not look at it first to make sure it is feasible to proceed?
The second question is about the so-called complementary PTCA. I am curious; in what sequence do you do this? Do you do the bypass first and then do you have them do the stenting or vice versa?
DR SUBRAMANIAN: I will answer the latter question first. We have done only six complementary PTCAs, even though we have done a lot of MIDCABG procedures. That must tell you something. I am not in favor of complementary PTCAs and neither am I in favor of angioplasty. So we have been conservative so far in doing complementary PTCAs. One of the deaths in this series was in a 90-year-old man who underwent a circumflex angioplasty, a LIMA-LAD MIDCABG, and then complementary RCA stenting. Twenty-four hours after RCA stenting he had an acute abdomen resulting from diffuse atherosclerotic emboli to his entire intestine. I do not think we ought to fool around in these old people too much with manipulating catheters in the vascular system. So I do not advocate complementary PTCA, especially in a high-risk group.
We used to initially open the pericardium and look for the calcified and intramyocardial LAD, but with the immobilization technique I am more comfortable about the intramyocardial LAD. Because the stabilization is good, we dissect the LAD in the intramyocardial tunnel, then put two pledgeted sutures on the tunnel and pull them up laterally to achieve good presentation of the LAD target. So I do not routinely open the pericardium before immobilizing the LIMA.
DR RENEE S. HARTZ (Chicago, IL): Doctor Subramanian, you showed us an example of a patient with a distal anastomotic thrombus, which raises the issue of your anticoagulation policy. I have had a similar experience with a patient in whom the graft flow dramatically decreased just before closing the chest. Simply reheparinizing the patient increased the IMA graft flow. Could you tell us what your policy is now with regard to anticoagulation?
DR SUBRAMANIAN: For heparinization we give a dose of 1.5 mg/kg of body weight. We do not neutralize the heparin routinely. We went through a period of heparin and ticlopidine, all the shotgun therapy used with the stent trials, and we did not see any major beneficial effect with this regimen. Occlusion occurred in spite of these aggressive anticoagulation regimens. I am not sure what exactly is happening in some of these occlusions. We are trying to understand this at present.
DR A. NORMAN LEWIN (Buffalo, NY): I enjoyed your talk very much. I have one question. In patients with multivessel disease, do you use radioisotope studies to define ischemia in other areas or you just do not do that? What is your practice?
DR SUBRAMANIAN: Practically speaking, in most of them, if they have ischemic evidence shown by thallium stress testing, especially in high-risk patients, it facilitates our approach in choosing the target vessel.
DR LEWIN: But if there is more than one vessel involved?
DR SUBRAMANIAN: If there is ischemia in more than one vessel and if there are no high-risk comorbid factors, we do a standard bypass.
DR LEWIN: Thank you.
DR AUBREY C. GALLOWAY (New York, NY): I think Dr Subramanian should certainly be congratulated on being a part of a very new, innovative approach to cardiac surgery. The one thing that was not clear from your data was the number of angiograms performed. Certainly, when we scrutinize angioplasty data, we depend on angiographic results as the gold standard. It was not clear to me that you routinely performed angiography, which I think is necessary if one is to accurately assess results. I do not think Doppler is a good test for this. It may be very good if the vessel is clearly closed or open, but it may not detect a 50% or 60% stenosis. How many people had angiograms, and what was the anastomotic patency in those tested?
DR SUBRAMANIAN: One hundred eleven underwent angiography of the LIMA-LAD anastomosis. The overall angiographic patency was 91%. Since April 1996 when we started to use regional cardiac wall immobilization, we have done routine postoperative angiography in 67 of the 72 patients. We performed routine angiography in everybody early in our experience, then we went through a brief period in which only echo Doppler alone was done, upon Dr Calafiore's suggestion. Then we went back to performing routine angiography within 36 hours after operation. Currently, routine angiography is done in all MIDCABG patients within 36 hours after the operation.
DR GALLOWAY: Again, I congratulate you very much on your excellent work. I do think it is very important, as we embark on a new technical aspect of cardiac surgery, that we get angiograms in virtually all of the patients, not in only 60% to 70% of the patients, as this may underestimate any anastomotic problems that may be occurring.
DR SUBRAMANIAN: A final word. We do not know what the early angiographic appearance of an LIMA–LAD anastomosis should be, even after a conventional bypass operation with cardiopulmonary bypass. We are now embarking on looking at what the angiographic appearance of an LIMA–LAD anastomosis after a conventional bypass operation should be at 36 hours.
Related Article
Ann. Thorac. Surg. 1997 64: 1648-1653.
| ||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
