Intraoperative Epicardial Sonography as a Useful Adjunct to Repair of Coronary Artery Dissection

Abstract

CASE REPORTA 61-year-old man with a past medical history of systemic hyper-tension presented with a 1-month history of exertional chest pain andshortness of breath. A cardiac nuclear stress test showed exercise-induced anteroseptal, apical, and inferoposterior ischemia with a leftventricular ejection fraction of 36%. Coronary arteriography then wasperformed showing triple-vessel coronary artery disease. There werechronic total occlusions of the right coronary artery and the mid-LAD.The obtuse marginal arteries 1 and 2 also were found to have 50% to60% stenosis. No obvious collaterals were shown on the coronaryangiogram. The patient initially refused coronary artery bypass graft(CABG) surgery.The LAD lesion was crossed with a guidewire, but attempts atangioplasty resulted in an iatrogenic LAD dissection (Fig 1). Theprocedure was aborted, and the patient was referred for urgent surgery.He remained hemodynamically stable. Intraoperatively, the transesoph-ageal echocardiogram (TEE) showed 1 mitral regurgitation and in-ferior septal hypokinesis. Upon inspection of the epicardial surface, themidportionoftheLADhadabluishdiscoloration.AnL15-7ioepiaorticprobe (Phillips Medical, Andover, MA) was placed into a sterile sheathand used to evaluate the vessel. A dissection and intramural hematomawere visualized originating in the midportion of the LAD with no flowin the false lumen (Figs 2 and 3). The LAD was stabilized and opened(Fig 4). The layers of the wall at the site of the arteriotomy werereapproximated to eliminate the false lumen. A left internal mammaryartery to LAD anastomosis then was constructed. Repeat ultrasoundevaluation showed excellent laminar flow through the anastomosis andin the distal LAD (Fig 5). The right internal mammary artery then wasanastomosed to the right coronary artery, and vein grafts were placedto the 2 obtuse marginal arteries. The immediate postprocedure TEEshowed no significant change. The patient remained hemodynamicallystable with no postoperative electrocardiographic or enzymatic changesand had an uneventful postoperative recovery. He remains asymptom-atic 3 years after surgery.DISCUSSION