Marginal Artery Research Articles

Coronary and vertebral subclavian steal demonstrated by subclavian angiography

A 60-year-old woman who had previous coronary bypass surgery presented to the emergency room with progressive angina pectoris, left arm claudication, coldness, and intermittent dizziness. On physical examination, left arm pulses were weak and a systolic blood pressure difference of 100 mmHg between the left (50/0 mmHg) and right (150/90 mmHg) arms was noted. Coronary angiography showed totally occluded left anterior descending (LAD) and circumflex artery with normal right coronary artery. Saphenous vein graft to obtuse marginal artery was patent. Left subclavian angiography revealed a severe …

Coronary Artery Bypass Grafting With Y-Saphenous Vein Grafts

The saphenous vein is one of the indispensible grafts for coronary revascularization despite the advantages of arterial grafts over veins. It can be used in different configurations with different anastomosis (eg, sequential, composite, or Y-graft) techniques. Our aim was to investigate early and midterm results of Y-type anastomosis of saphenous vein grafts for complete coronary revascularization. Coronary artery bypass grafting (CABG) with Y-graft technique was performed in 512 patients between February 1998 and June 2007. In total, 608 saphenous Y coronary anastomoses were performed. These anastomoses were on first and second obtuse marginal arteries (n: 323), first diagonal and first obtuse marginal arteries (n: 187), posterolateral and posterior descending artery (n: 79), and right coronary artery and posterior descending artery (n: 19). Endareterectomy was performed in 28 patients with severely calcified coronary arteries. Patients were evaluated for early and late survival, newly developing cardiac events, recurring angina, and reinterventions. In the early postoperative period, new myocardial infarction (MI) occurred in 27 (5.2%) patients and mortality in 13 (2.5%). Follow-up included the results of 487 (98%) patients. Mean follow-up duration was 56 +/- 24 months. Late mortality occurred in 36 (7.3%) patients, and in 13 (2.6%) patients new MI developed in the remote follow-up. Overall survival including all deaths at 3, 5, and 7 years was 94 +/- 0.6%, 86 +/- 1.3%, and 83 +/- 2.1%, respectively, and actuarial freedom from angina recurrence at 3, 5, and 7 years was 95.2 +/- 2.5%, 86.4 +/- 3%, and 84.7 +/- 4.6%, respectively. Among long-term survivors, 116 patients (25.7%), 49 being symptomatic, with 123 saphenous Y-type anastomoses having undergone angiography studies. Saphenous vein Y grafts were completely patent in 94 anastomoses (76.4%). Saphenous vein Y-type anastomosis technique can safely be used in patients with multivessel coronary artery disease (CAD) with successful long-term outcomes. As with sequential anastomosis, the safety of the technique may be attributed to the distribution of inflow from aorta into multiple vessels.

Evaluation of myocardial bridges with 64-slice computed tomography coronary angiography

Objective — The aim of this study is to report the characteristics of myocardial bridging (MB) using 64-slice computed tomography and to demonstrate the association between atherosclerotic coronary artery disease (CAD) and MB.Methods and results — In 990 consecutive patients who underwent multi-slice computed tomography (MSCT) coronary angiography for suspected or known coronary artery disease, myocardial bridge evaluation was performed with axial, curved multiplanar reconstruction and three-dimensional volume-rendered images.265 bridged segments were identified in 223 (22.5%) patients. Multiple MBs on left coronary arteries were found in 41patients. Most of the MBs were in the LAD (62.6%), followed by the obtuse marginal artery (14.7%) and diagonal artery (14.3%). The average length of MBs was 14±7mm, and the average depth was 1.6±1.1mm.No significant difference was observed between patients with and without MB on the middle LAD in respect of age, gender, prevalence of diabetes, hyperlipidaemia, hypertension, current smoking and prevalence of atherosclerotic plaques at the proximal LAD. On the other hand, prevalence of atherosclerotic plaques at the distal LAD were significantly lower in patients with MB on the middle LAD (3.5% vs. 19.7%, P: 0.0001).Conclusions — The presence and morphological characteristics of MB and its relation with atherosclerotic plaques in the involved coronary artery can be comprehensively analysed with 64-slice computed tomography coronary angiography.Atherosclerosis is a common finding in segments proximal to MB, but the prevalence of plaques in equivalent segments (proximal LAD in our study) is not higher than in patients under similar coronary artery disease risk and without MB. On the other hand, prevalence of atherosclerotic plaques at the distal LAD was significantly lower in our patients with MB on the middle LAD. Finally, we suggest that rather than causing proximal atherosclerosis, MB might have a more important role in the protection of distal segments of the bridged arteries from atherosclerosis.

P0451 MYOCARDIAL INFARCTION IN A YOUNG MAN WITH BEHCET DISEASE

Introduction Behcet’s disease is a systemic vasculitis characterized by recurrent oral and genital ulcers, cutaneous lesions,ocular,neurological and vascular manifestations.Vascular involvement affects arteries and veins,and includes thrombophlebitis,arterial obstruction and aneurysms.Arteries are less involved than veins,and coronary artery involvement seems to be rare in Behcet’s disease. Objectives: We report a case of 18-year-old man with Behcet’s disease since the age of seven,presenting with acute myocardial infarction due to occlusion of the left marginal artery. Materials & methods: The patient,from Egyptian and Lebanese parents,born on the 21/12/1991,was followed since his childhood for a chronic relapsing inflammatory disease manifesting with recurrent pericarditis,recurrent uveitis,recurrent mouth and anal aphthous and fever,and was considered to have a periodic disease with positive heterozygous mutation.He was on Colchicine 1-2mg since the age of 6 and received sometimes steroids when feeling not so well. He presented with acute chest pain on the 21/10/2008 and was treated on admission with colchicine and NSAIDS for a suspicion of pericarditis,the cardiac enzymes levels were elevated: Troponin:39.9 μg/l (Normal<0.15 μg/l),the diagnosis of myocardial infarction was considered and a treatment with 1 mg/kg per day Prednisone was started with Aspirin,and Heparin. Results: the coronary angiography revealed thrombotic occlusion of the marginal coronary artery with no other anomaly,the cardiac MRI showed a trans mural infarction of the lateral left ventricular wall.The patient had no chest pain on day 2 and the Troponin level decreased to 3.8μg/l on day 7 of treatment,3 months later the patient is very well with no symptoms,on 10 mg/d prednisone, associated with Aspirin and an ACE inhibitor. Discussion & conclusion: The diagnosis of Behcet’s disease was realized upon the history of the patient and the manifestations of his disease which fulfilled criterion for the diagnosis,(recurrent bipolar ulcerations, recurrent uveitis,orchitis,and recurrent pericarditis).Arterial involvement in Behcet’s disease seems to be rare estimated as 7%,manifesting as thrombosis,stenosis,and/or aneurysms.Cardiac involvement is rare,can manifest as granulomatosis endocarditis, myocarditis,arrhythmias,pericarditis.Coronary artery disease with myocardial infarction in Behcet’s disease was found by reviewing the literature in about 26 cases, many with normal coronary arteries on coronary angiography.We present a review of the literature of coronary artery involvement with myocardial infarction in Behcet’s disesase.

Surgical management of a circumflex aneurysm with fistula to the coronary sinus

We report the successful management of a circumflex coronary artery aneurysm with fistula to the coronary sinus. Our strategy aimed at closing the fistula and grafting the obtuse marginal artery. The calcified aneurysm was left intact, and showed secondary thrombus formation on the postoperative angiogram.

Novel Treatment of an 11-cm Saphenous Vein Graft Aneurysm

Saphenous vein graft pseudoaneurysms are rare and potentially fatal complications after coronary artery bypass graft surgery. Here we present an 11-cm saphenous vein graft pseudoaneurysm from a 20-year-old vein graft to the obtuse marginal artery. The pseudoaneurysm was directly located beneath the sternum and adjacent to two patent grafts. Therefore, we used a novel approach to access the aorta through a right thoracotomy, and using a pericardial patch, we closed the ostia to the pseudoaneurysm. Postoperatively there was no longer flow into the aneurysm, and at 1-year follow-up the patient is doing well.

Exercise-induced ST-segment elevation during treadmill exercise testing

The exercise electrocardiogram is a commonly used non-invasive and inexpensive method for detection of electrocardiogram (ECG) changes secondary to myocardial ischemia. It has been reported that in patients with a first myocardial infarction and without residual ischemia, exercise-induced ST-segment elevation in Q leads is related to a more damaged coronary microcirculation and to less viable myocardium. Exercise-induced ST-segment elevation is a rare phenomenon in patients without prior myocardial infarction. When occurring purely during exercise, coronary lesions are frequent and often severe, and on the other hand ST-segment elevation of the recovery phase is frequently associated with normal arteries or less severe lesions. We present a case of exercise-induced ST-segment elevation in a 51-year-old Italian man. Coronary angiography revealed a significant left anterior descending coronary artery stenosis, a significant circumflex coronary artery stenosis, a significant first obtuse marginal coronary artery stenosis and a significant second obtuse marginal coronary artery stenosis. Percutaneous transluminal coronary angioplasty with implantation of stents was successfully performed. Also this case is illustrative of the rare phenomenon of exercise-induced ST-segment elevation.

Intrapericardial Paraganglioma With Intratumoral Coronary Arterial Aneurysm and an Arteriovenous Fistula

The authors present the case of a 55-year-old woman with a nonfunctioning intrapericardial paraganglioma. The tumor was incidentally found during transthoracic echocardiography that was performed because an enlarged cardiac silhouette had been noted on a chest x-ray. Transesophageal echocardiography further elucidated that the left circumflex coronary artery branched and traversed into the intrapericardial mass. Coronary angiography and cardiac multislice computed tomography both confirmed the presence of a vascular intrapericardial mass being fed by the obtuse marginal artery. Moreover, an arterial aneurysmal formation and a coronary arteriovenous fistula were noted within the tumor. After "en bloc" tumor resection, histopathologic and electron microscopic examinations established the diagnosis of a nonfunctioning intrapericardial paraganglioma.

Closure of a Giant Saphenous Vein Graft Aneurysm with Embolization Coil

Aneurysms of saphenous vein grafts (SVGs) to coronary arteries are rare, usually asymptomatic and found incidentally. We report a case of an 84-year-old female who was found to have 8.1 × 8.4 cm aneurysm of an SVG to obtuse marginal (OM) artery. The aneurysm was prior to the distal anastamosis but no flow into the OM artery was noted. Cook Tornado Embolization Coils were used successfully to occlude the SVG proximal to the aneurysm. No complications occurred. The use of embolization coils is an effective and safe method for aneurysm occlusion when the anatomy is suitable and especially when patient is high risk for repeat surgical intervention.

Bis-guided evaluation of dexmedetomidine vs. midazolam as anaesthetic adjuncts in off-pump coronary artery bypass surgery (OPCAB)

Background. To assess the efficacy of midazolam and dexmedetomidine as induction agents and adjuncts to anaesthesia during OPCAB surgery. Patients and Methods. 107 patients scheduled for elective OPCAB surgery between 1st of January 2005 to 31 st of December 2007 were enrolled. Patients were randomly allocated into two groups Midazolam group (Group M, n=57) and Dexmedetomidine group (Group D, n=50). Patients in Group D (Dexmedetomidine group) received dexmedetomidine as initial i.v loading dose of 1 µg kg -1 over 1 minute (min) before induction of anaesthesia and 60 µg hr -1 continuous infusion thereafter until the end of surgery. Patients in group M (Midazolam group) received midazolam 0.1 mg kg -1 over 1 min before induction of anaesthesia and 2.5mg hr­ 1 continuous infusion thereafter until the end of surgery. Anaesthesia was maintained with continuous i.v infusion of sufentanil 0.2 µg kg -1 h -1 , study drug infusion at a rate of 10 ml h -1 , and rocuronium 0.5 mg kg-1 h -1 supplemented with sevoflurane as required. Induction doses as well as anaesthetic maintenance supplementation doses were guided by the BIS reading near 50. Data collection included haemodynamic parameters (HR, MAP, CI & SVR), BIS readings (T0-T7) and sevoflurane concentrations (T3-T7) were recorded at the following data points, T0= baseline pre-induction, T1= immediately post-induction T2= during laryngoscopy & intubation, T3= skin incision, T4= sternotomy, T5= during revascularization of the left anterior descending (LAD) artery, T6= during revascularization of the obtuse marginal (OM) artery, T7= with chest closure at conclusion of surgery. Results. 5 patients in Group M and 3 patients in group D were excluded due to diversion to on pump technique. All baseline parameters were comparable among both groups. In group M (52 patients) SVR and BP had significantly decreased following induction (T1) compared to baseline (T0, p<0.0001), while HR and CI had significantly increased during T1 compared to baseline (T0, p<0.0001). Also parameters recorded thereafter were comparable to baseline values. In Group D (47 patients) all parameters recorded were comparable to baseline values with exception of HR that decreased significantly from T1-T7 compared to T0. BIS values recorded were comparable among both groups, however sevoflurane concentrations was significantly higher in Group M compared to group D (P<0.0001). Conclusion. Midazolam can alter hemodynamic response following induction of anaesthesia; however such changes are reversible and returned to baseline. Dexmedetomidine is more haemodynamic stable and more potent anaesthetic adjuvant compared to midazolam in patients undergoing OPCAB surgery.

An unusual case of spontaneous multi vessel coronary artery dissection in an elderly patient: a case report

IntroductionSpontaneous coronary artery dissection is an uncommon cause of acute coronary syndrome and sudden cardiac death. We report an unusual case of multi vessel spontaneous coronary artery dissection in an elderly woman with successful medical management.Case presentationA 65 year-old woman with hypertension and Parkinson's disease presented with sudden onset severe chest pain. Electrocardiogram showed ischemic ST-segment elevation in inferior and lateral leads. Urgent cardiac catheterization revealed focal dissections in four small caliber coronary arteries in right and left coronary systems including right posterior decending, posterolateral, obtuse marginal and septal arteries. Angiography demonstrated no significant atherosclerotic coronary artery disease. The patient was medically managed with Eptifibatide, Aspirin, Clopidogrel and β blocker since dissected vessels were not technically suitable for percutaneous coronary intervention. Antiparkinson medications were held as a potential cause of dissection. She responded well to medical management.ConclusionCoronary dissection should be considered in all patients with an acute coronary syndrome. Medical management is an effective therapeutic option for the patient with small vessel dissections.

The Clinical Outcomes of Transcatheter Microcoil Embolization in Patients with Active Lower Gastrointestinal Bleeding in the Small Bowel

ObjectiveTo assess the clinical outcomes of the transcatheter microcoil embolization in patients with active lower gastrointestinal (LGI) bleeding in the small bowel, as well as to compare the mortality rates between the two groups based on the visualization or non-visualization of the bleeding focus determined by an angiography.Materials and MethodsWe retrospectively evaluated all of the consecutive patients who underwent an angiography for treatment of acute LGI bleeding between January 2003 and October 2007. In total, the study included 36 patients who underwent a colonoscopy and were diagnosed to have an active bleeding in the LGI tracts. Based on the visualization or non-visualization of the bleeding focus, determined by an angiography, the patients were classified into two groups. The clinical outcomes included technical success, clinical success (no rebleeding within 30 days), delayed rebleeding (> 30 days), as well as the major and minor complication rates.ResultsOf the 36 patients, 17 had angiography-proven bleeding that was distal to the marginal artery. The remaining 19 patients did not have a bleeding focus based on the angiography results. The technical and clinical success rates of performing transcatheter microcoil embolizations in patients with active bleeding were 100% and 88%, respectively (15 of 17). One patient died from continued LGI bleeding and one patient received surgery to treat the continued bleeding. There was no note made on the delayed bleeding or on the major or minor complications. Of the 19 patients without active bleeding, 16 (84%) did not have recurrent bleeding. One patient died due to continuous bleeding and multi-organ failure.ConclusionThe superselective microcoil embolization can help successfully treat patients with active LGI bleeding in the small bowel, identified by the results of an angiography. The mortality rate is not significantly different between the patients of the visualization and non-visualization groups on angiography.

Which test, coronary angiography or colonoscopy?

A 87-year-old man was conducted to the Emergency Unit after a syncope. At admittance, the patient was awake, asymptomatic for chest pain, Troponin I values were 0.02 lg/L, Glasgow coma scale (GCS) score was 15, the blood pressure 110/ 55 mmHg, the pulse 90 beats per minute, the peripheral oxygen saturation 98%. Laboratory tests only showed microcytic hypochromic anemia [hemoglobin level 9.8 g/dL; hematocrit 31.1%; mean cell volume (MCV) 77.7 fL; mean cell hemoglobin (MCH) 24.3 pg; mean concentration of hemoglobin per volume of red cells (MCHC) 31.3 g/dL]. He reported assumption of sublingual nitrates some minutes before the syncope for chest pain caused by a mild effort (Valsalva). Six hours after admittance, the patient was still asymptomatic, his conditions appeared stable, Troponin I values remained within the normal range and he was transferred to our medical ward to complete the diagnostic and therapeutic work-up. Relevant past history included, 11 years before, demonstration of coronary artery disease (CAD) [75% stenosis of left circumflex and first obtuse marginal arteries, 50% stenosis of mid left anterior descending artery, and subcritical stenosis (\50%) of second obtuse marginal artery], treated with medical therapy. Few months after diagnosis of CAD, acetylsalicylic acid (ASA) was substituted by ticlopidine because of melena and heartburn; at that time an esophagogastroduodenoscopy (EGDS) showed no lesions. Thereafter the patient suffered from chronic angina with stable threshold (functional classification class II of the Canadian Cardiovascular Society) relieved by nitrates. Five years before the admission a microcytic hypochromic anemia was demonstrated, an EGDS was repeated and showed chronic atrophic gastritis with Helicobacter-like organism (HLO) ?, eradication therapy was started but discontinued for adverse effects. A contemporary gradual reduction of the anginal threshold was noted. Six months before the admission anorexia, with weight loss of about 7 kg, and constipation developed. Physical examination revealed: pale discoloration of skin, high-frequency low-grade systolic murmur audible on all cardiac auscultation areas, a non-tender non-pulsatile roundish mass deeply palpable in the right iliac fossa of several (6–8) centimetres of diameter, of increased consistency and preserved mobility on abdominal wall. Ultrasound examination of the abdomen was performed and revealed a kidney-shaped mass of 7 9 7 9 8 cm dimensions, suggesting a right colon cancer. Colonoscopy showed an ulcerated cauliflower-shaped lesion in the cecum occupying the whole intestinal lumen. The histological examination of a biopsy specimen confirmed the diagnosis of the adenocarcinoma of the colon. CT scan of the abdomen showed a large irregular thickening of the cecum wall with regional lymph nodes involvement without signs of distant metastases. I. Cecioni F. Fassio C. Alamanni F. Almerigogna Division of Immunology and Cellular Therapies, Department of Internal Medicine, University of Florence, Florence, Italy

Left Internal Mammary Artery Atherosclerosis: Twenty-Three Years After Repair of Aortic Coarctation

Atherosclerosis of the internal mammary artery is a rare disease. We describe a case in which a 41-year-old man underwent coronary artery bypass surgery 23 years after repair of aortic coarctation. The diseased mammary artery was used to graft the left anterior descending coronary artery after intraoperative confirmation of good patency. Early graft occlusion occurred a few days after the operation. This case demonstrates that atherosclerosis affects mammary arteries after long-term repair of aortic coarctation. Such conduits should not be used, even in the presence of good blood flow.

Massive systemic air embolism during off-pump coronary artery surgery

In OPCAB (off-pump coronary artery bypass) operations, development of cardiac arrest during the distal anastomosis to obtuse marginal coronary artery leads to significantly low blood pressure in the ascending aorta. Therefore, blowing of compressed air in high flow on not-slinged coronary artery may cause air mobilization from the coronary artery system into the ascending aorta that may result in severe brain damage.

Anomalous Origin of the Marginal Tentorial Artery: Detection by Contrast-Enhanced Angiographic Computed Angiography (CE-ACT)

Anomalous Origin of the Marginal Tentorial Artery: Detection by Contrast-Enhanced Angiographic Computed Angiography (CE-ACT)

Effect and Mechanism of Intermittent Myocardial Ischemia Induced by Exercise on Coronary Collateral Formation

To hypothesize that appropriate intermittent myocardial ischemia induced by exercise could safely promote coronary collateral formation in the ischemic area through the increased expression of vascular endothelial growth factor (VEGF) and its receptor fetal liver kinase-1 (Flk-1). A balloon constrictor was surgically implanted in the first obtuse marginal coronary artery (OM1) of Guangxi BA-MA miniature pigs. The subjects were divided into three groups: sham-operated (SO), pure ischemia (PI), and exercise training (ET). Subjects in the ET group performed individualized treadmill programs with two episodes of exercise-induced ischemia for 8 wks; two preexercise episodes of pure ischemia induced by brief OM1 occlusion were also conducted. Only pure ischemia was induced in the PI group, and the SO group remained sedentary for the experimental period. VEGF and Flk-1 expression levels were measured by Western blot and real-time reverse transcription polymerase chain reaction analyses; capillary density by immunohistochemistry; relative myocardial blood flow by microspheres; and cardiac troponin I by enzyme-linked immunosorbent assay. The relative myocardial blood flow, VEGF, Flk-1, and capillary density in the ET group were statistically higher than those in the PI and SO groups. All parameters in the PI group were statistically higher than those in the SO group. There was no myocardial damage in the ET or PI groups by cardiac troponin I. Intermittent myocardial ischemia induced by exercise with optimal stimulation safely promotes coronary collateral formation through increased VEGF and Flk-1 expression in a porcine model.

Adenoma related pituitary apoplexy disclosed by ptosis after routine cardiac surgery: occasional reappearance of a dismal complication

Sir: Pituitary apoplexy is characterized by a sudden onset of headache, visual symptoms, altered mental status, and hormonal dysfunction. This condition usually stems from an acute expansion of a pituitary adenoma, which may deprive the anterior pituitary gland and the tumor itself of vascular supply, thus causing ischemia and subsequent necrosis [1, 2]. During cardiac surgery, cardiopulmonary bypass-induced cerebral edema may contribute to the critical enlargement of silent pituitary adenomas [3]. Cardiopulmonary bypass may also cause infarction and/or hemorrhage in pituitary adenomas in view of an increase susceptibility to hypoperfusion or ischemia of the abnormal pituitary tissue and/or to an increased risk of bleeding as a result of anticoagulation [4, 5]. We present herein the case of a 70year-old man with exertional angina and diagnosis of three-vessel coronary artery disease admitted for elective coronary bypass surgery. Past medical history revealed hypercholesterolemia, peripheral vascular disease and chronic obstructive pulmonary disease. Neurological examination on admission was normal. After conventional general anesthesia and systemic heparin administration, on cardiopulmonary bypass, myocardial revascularization was achieved by anastomosis of the left internal mammary artery to the left anterior descending coronary artery, and vein grafts to the first diagonal, obtuse marginal, and right coronary arteries, respectively. Aortic cross clamp time and total cardiopulmonary bypass time were 64 and 118 min, respectively. In view of an initial uneventful post-operative course, the patient was awakened and extubated 4 h later. Soon thereafter, he started complaining of headache and visual field defects, with diplopia. Neurological examination revealed initially sole ptosis of the left eye, followed by unilateral dilated pupil with a left globe deviated inferiorly and laterally with inability to adduct or abduct. Funduscopy revealed neither papilloedema nor hemorrhage. He was conscious at all time, with no evidence of hypotension or shock, requiring volume and/or inotropic adjustment. An urgent brain CT-scan demonstrated a sellar mass with suprasellar extension. Magnetic resonance imaging confirmed the sellar tumor suggestive of pituitary macroadenoma extended to the left cavernous sinuses (Fig. 1a, b). On T2-weighted images, the lesion was isointense but showed increased signal intensity on T1-weighted images, suggestive of hemorrhage. There was no infarct or hemorrhage seen elsewhere in the brain. Tests of serum at early morning showed the following levels: thyroxine 0.8 lg/L (normal range 0.9–1.8 lg/L), luteinizing hormone 0.9 IU/L (normal range 2.4–15.9 IU/L), prolactin 0.7 lg/L (normal range 2.8–29.9 lg/ L), cortisol 5 lg/dL (normal range 5–25 lg/dL), TSH 0.5 mIU/L (normal range 0.4–4 mIU/L), ACTH 7 ng/L (normal range 9–52 ng/L), FSH 1.3 IU/L (normal range 1–14 IU/L), GH 0.9 ng/mL (normal

Video‐Assisted Thoracoscopic Implantation of the Left Ventricular Pacing Lead for Cardiac Resynchronization Therapy

To study the feasibility and efficacy of video-assisted thoracoscopic (VAT) placement of the left ventricular pacing lead for cardiac resynchronization therapy (CRT) where the conventional transvenous coronary sinus approach has failed. Seventeen patients underwent the VAT procedure. Indications for CRT were ischemic cardiomyopathy in six patients and nonischemic cardiomyopathy in 11. The procedure was performed under general anesthesia with single-lung ventilation. Three 2-cm incisions were used on the left chest wall to place the screw-in lead near the obtuse marginal arteries high on the lateral wall of the left ventricle (LV). The VATS approach was successful in 13/17 (76%) patients. Median procedure time was 75 minutes (range 55-135). A learning curve was observed that appeared to plateau at 75 minutes procedure time after four cases. Median length of hospital stay was 2 days (range 2-8) with one patient requiring intensive care. Satisfactory thresholds and impedances of 2.3 +/- 0.9 V/0.5 ms and 560 ohms, respectively, were achieved at mean follow-up of 226 days. All patients reported symptomatic benefit with reduction in New York Heart Association score from III preoperatively to II postoperatively. VAT placement of the epicardial pacing lead is feasible, safe, and efficacious. It should be considered in cases where the transvenous route has failed or as an alternative in prolonged or hazardous transvenous procedures.

Endarterectomy and Surgical Angioplasty Without Cardiopulmonary Bypass

Surgical angioplasty for ostial stenosis of the major coronary arteries is a well-established treatment modality. Management of discrete stenoses of distal coronary arteries in the presence of mild proximal disease is a challenging task. Percutaneous intervention or grafting beyond the diseased segment may be limited by size of the target vessel, whereas endarterectomy followed by graft placement may result in graft occlusion due to competitive native flow. Patch angioplasty with or without endarterectomy is an effective option in this setting, which can be performed without cardiopulmonary bypass in the appropriate group of patients. A patient with triple vessel coronary artery disease and a discrete lesion in the posterior descending artery underwent off-pump endarterectomy with vein patch angioplasty in combination with bypass grafting to left anterior descending and obtuse marginal arteries. Operative technique and intraoperative strategies are discussed.