Catastrophic Consequence of Hypoperfusion Syndrome after Redo Off-Pump Internal Thoracic Artery Grafting

Abstract

Hypoperfusion syndrome may be defined as non-functioning of bypass graft, despite a patent graft lumen and presence of myocardial ischemia, and typically occurs in operation room or intensive care unit after coronary artery bypass grafting(CABG). A 33-year-old woman had exertional chest pain. She had previously undergone modified Bentall operation using a mechanical valve for annuloaortic ectasia at the age of 20 years. Coronary angiography showed that the left coronary artery had severe stenosis at the the origin. She underwent CABG with the left ITA to the anterior descending artery bypass through left anterior thoracotomy. At the 7th day, she had severe dyspnea and hypotension. Emergent catheter angiography showed that the ITA was patent, but blood flow into left anterior descending branch looked extremely poor. Finally intraaortic balloon pumping and cardiopulmonary circulatory support were introduced. At 11th postoperative day, she was transferred to our hospital to receive implantation of left ventricular assist device. Contrast-enhanced computed tomography revealed broad subendocardial myocardial infarction in the territory of left coronary artery. The emergent implantation of assist devise was successfully done through a median sternotomy, as preparation for receiving heart transplantation. In-situ ITA grafting implies the risk of hypoperfusion syndrome. Bilateral ITAs or concomitant aortocoronary bypass may ensure postoperative coronary circulation, especially for a young patient without chronic atherosclerotic coronary artery disease.