Single-vessel Coronary Artery Bypass Research Articles

Internal thoracic artery graft failure and recurrence of symptoms following single-vessel coronary artery bypass graft surgery

ObjectivesCoronary events and disease recurrence following coronary artery bypass (CABG) surgery could derive from either failure in the internal thoracic artery (ITA) graft, failure in other conduits or progressive disease in the coronaries. We aim to estimate the contribution of ITA graft failure to the recurrence of symptoms after CABG surgery.MethodsWithin the Swedish Web System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies registry, we identified patients who had coronary artery bypass grafting from 1997 to 2020 with a single-vessel ITA graft bypass. Deaths, postoperative incidence of coronary angiography and the presence of a failed graft at the time of the angiography were recorded.ResultsThe study population consisted of 1939 patients with a mean follow-up time (SD) of 17.2 (5.6) years. The cumulative incidence (95% CI) at 20 years for a first clinically-driven postoperative angiography was 38.6% (36.2–41.1). A failed ITA graft was reported in 16.4% of the angiographies.ConclusionsA substantial part of recurrent symptoms of coronary artery disease do not seem to be related to ITA failure. Disease progression in the native coronary vessels may instead be the main driver of symptom recurrence.

Echocardiographic imaging of a bifurcated double barrel coronary sinus

BackgroundThe coronary sinus (CS) is the terminal collecting vessel of the myocardial venous network, which returns deoxygenated blood used by the heart to the right atrium. The advent of high-fidelity imaging via CT and transesophageal echocardiography (TEE) has further defined the anatomy of the CS and its multiple tributaries. Understanding this anatomy is crucial for cardiac surgical cases that require the cannulation of the coronary sinus to deliver retrograde cardioplegia. However, anatomical variants of the CS may frustrate surgical retrograde catheter placement, in turn increasing the risk of CS injury or leading to inadequate cardioplegia delivery. Here, we present an especially unique CS presentation, a bifurcated, double-barrel CS, which was discovered via intraoperative TEE imaging that revealed a CS with two smaller lumens instead of the singular large os.Case presentationA 67-year-old male presented for ascending aortic dissection repair, aortic valve replacement, and single vessel coronary artery bypass graft. On the pre-bypass TEE exam, the anesthesiologist noted a bifurcated CS with two small lumens. The surgeon utilized this information to select a smaller diameter retrograde catheter to avoid damage or perforation of the vessel. With TEE guidance, the surgeon successfully cannulated one of the CS lumens. However, it was noted upon dosing of retrograde cardioplegia that all tributary vessels attached to the non-cannulated lumen remained devoid of cardioplegia. The surgeon was forced to repeatedly administer anterograde cardioplegia via a handheld catheter through the coronary ostium throughout the case. The operative field was also flooded with topical ice saline slush to ensure cardiac protection. Ultimately, the operation was completed without incident despite the non-ideal conditions resulting from this anatomic variant.ConclusionsDiscovery of this patient’s double-barrel CS during the pre-bypass TEE was incidental, showing that such anatomical variants may be completely asymptomatic and benign in the non-operative setting. However, the delivery of cardioplegia proved challenging for this patient, highlighting some degree of risk with certain cardiac interventions. This case demonstrates the utility of intraoperative TEE to quickly ascertain unforeseen anatomical variants of the CS which could compromise the safety of cardiac surgery cases.

Abstract 12319: Open-Heart Surgeries Leading to Unexpected Latent Disease - A Rare Case of Disseminated Mycobacterium Chimaera

Global reports describe several cases of disseminated Mycobacterium chimaera related to surgical field contamination by specific 3T heater-cooler units utilized in open cardiothoracic procedures. Eventual diagnosis leads to aggressive multidrug regimens and possible surgery, resulting in a high, yet potentially avoidable overall mortality rate. A years-long latency period between a patient’s initial exposure and clinical presentation can make this infection extremely challenging to diagnose. A 68-year-old-male with coronary artery disease (CAD) and a bicuspid aortic valve (BAV) suffered from shortness of breath and palpitations for eight years. An extensive cardiac work-up, including a cardiac MRI, revealed aortic root dilatation and significant CAD involving the left anterior descending coronary artery. The patient underwent an elective BAV repair, aortic root replacement, and single vessel coronary artery bypass surgery without any acute post-operative complications. Approximately four years later, he began experiencing fevers, night sweats, and vision changes. Eventually, he was ultimately diagnosed with disseminated M. chimaera confirmed by tissue biopsy. His treatment course of linezolid, moxifloxacin, ethambutol, and rifabutin, was complicated by adverse effects and complex resistance patterns. The complications he experienced secondary to this disease would eventually include long-standing bacteremia, encephalitis, splenic lesions, and aortic root abscess, which ultimately required open sternotomy for AV replacement and aortic root exchange. This patient remains the sole survivor from his home hospital among several other patients who also underwent cardiac surgeries and subsequently developed disseminated M. chimaera. He has since developed additional spinal involvement described as destructive osteomyelitis/discitis and confirmed via biopsy. As he continues to combat this clinically devastating bacterial pathogen, his multi-system complications with such an insidious presentation serve as a reminder to maintain a high clinical suspicion for the possibility of disseminated mycobacterial and other similar infectious processes in the differential diagnoses of all cardiothoracic surgical patients.

Routine Intensive Care May Be Selectively Skipped After Robotic Coronary Bypass

Intensive Care Unit Bypass for Robotic-Assisted Single-Vessel Coronary Artery Bypass GraftingThe Annals of Thoracic SurgeryPreviewFast-track and enhanced recovery after cardiac surgical procedures have shown reductions in intensive care unit (ICU) and hospital lengths of stay, with unchanged outcomes. However, cost reduction by an ultra-fast-track protocol after minimally invasive cardiac operations, without compromising clinical benefits, has yet to be demonstrated. Full-Text PDF

Reduced Morbidity and Mortality Associated With Minimally Invasive Single-vessel Coronary Artery Bypass Compared With Conventional Sternotomy.

We aimed to describe the safety and clinical benefits of minimally invasive, nonsternotomy coronary artery bypass grafting (MICABG) using data from The Society of Thoracic Surgeons (STS) National Database. MICABG has gained popularity, owing to expected lower perioperative morbidity and shorter recovery. Despite this, concerns remain regarding anastomotic quality and the validity of proposed perioperative benefits. We queried the STS National Database for all patients who underwent single-vessel coronary artery bypass grafting (CABG) from January 2014 to December 2016 to compare outcomes of MICABG with conventional CABG. Patients who underwent concomitant or emergent procedures were excluded. Propensity-weighted cohorts were compared by operative approach with adjustment for variability across institutions. Of 12,406 eligible patients, 2688 (21.7%) underwent MICABG, and 9818 (78.3%) underwent conventional CABG. Propensity weighting produced excellent balance in patient characteristics, including completeness of revascularization, body mass index, and STS predictive risk scores. MICABG was associated with significant reduction of in-hospital mortality [odds ratio (OR)=0.32, absolute reduction (AR)=0.91%, P <0.0001]; 30-day mortality (OR=0.51, AR=0.88%, P =0.001), duration of ventilation (8.62 vs 12.6 hours, P <0.0001), prolonged hospitalization (OR=0.77, AR=1.6, P =0.043), deep wound infection (OR=0.33, AR=0.68, P <0.004), postoperative transfusions (OR=0.52, AR=7.7%, P <0.0001), and STS composite morbidity (OR=0.72, AR=1.19%, P =0.008). Subgroup analysis of only off-pump left internal mammary artery-left anterior descending CABG showed similar findings. Major adverse cardiac events and graft occlusion did not differ between groups. MICABG is associated with lower mortality and perioperative morbidity compared with conventional sternotomy CABG. MICABG may have a role in treating single-vessel disease.

New trend: Surgical correction of Ebstein's anomaly using modified cone repair and a combination of different techniques.

Ebstein's anomaly,a rare cardiac disease that accounts for <1% of all congenital heart diseases, is a right ventricular myopathy with varying degrees of delamination in the endocardium under the tricuspid valve. Cone reconstruction, first described by da Silva in 2004, is a modification of the Carpentier technique. An alternative surgical treatment for Ebstein's anomaly, it is now the preferred surgical corrective technique. This study demonstrates that our modifications of the cone repair procedure to correct Ebstein's anomaly improve valve coaptation and stabilization in the early and midterm. Of the 134 patients diagnosed with Ebstein's anomaly in our clinic between January 2012 and October 2020, 10 underwent a cone procedure and its modifications and were thus included in the study. The mean age of these patients was 28.6 ± 18.79 years and ranged from 1 to 61 years. Thirty percent of the patients were male and 70% were female. The additional procedures performed were an isolated cone procedure (two patients), anomalous pulmonary venous return repair in addition to a cone procedure (one patient), single-vessel coronary artery bypass (one patient), Glenn procedure (two patients), and tricuspid ring annuloplasty (four patients). Based on the results of this study, which assesses the outcomes of patients who underwent cone repairs with surgical modifications, we argue that right ventricular oblique plication, tricuspid valve delamination, surgical valve rotation, and tricuspid ring annuloplasty protect valve coaptation and function in the early and midterm, thereby having beneficial effects on right ventricle remodeling.

A Randomized Double-Blind Controlled Trial to Assess the Efficacy of Ultrasound-Guided Erector Spinae Plane Block in Cardiac Surgery

Cardiac surgical pain is of moderate-to-severe intensity. Ineffective pain control may lead to increased cardiopulmonary complications and poor surgical outcomes. This study aimed to assess the efficacy of ultrasound-guided erector spinae plane block in providing analgesia in adult cardiac surgeries. Prospective, randomized, double-blinded clinical trial. Single-center, tertiary care hospital with university affiliation. Thirty patients of either sex, aged 18-to-60 years, body mass index 19-to-30 kg/m2, undergoing elective on-pump single-vessel coronary artery bypass grafting or valve replacement under general anesthesia. Patients were randomly categorized into two groups of 15 patients each to receive bilateral erector spinae plane block with 20 mL per side of 0.25% levobupivacaine (group E) or sham block with 20 mL of normal saline (group C). Mean analgesic requirement in terms of fentanyl equivalents (µg) in the first 24 hours postoperatively was 225 ± 112 in group E and 635 ± 145 in group C (95% confidence interval, 313.10-506.90; p < 0.05). Mean time to first rescue analgesia was 356.9 ± 34.5 in group E and 123.9 ± 13.1 minutes in group C (p < 0.05). Cox proportional hazard ratio for rescue analgesic requirement in group E-to-group C was 5.0. Duration of mechanical ventilation was 88.4 ± 17 and 103.5 ± 18 minutes in groups E and C, respectively (p < 0.05). Ramsay sedation score at six hours postextubation was 1.45 ± 0.53 in group E and 3.19 ± 0.62 in group C (p < 0.05). Mean numerical rating score was 3.67 ± 1.41 in group E and 4.50 ± 1.00 in group C (p = 0.17). No significant differences were observed in the incidences of postoperative nausea vomiting, pruritus, and erector spinae plane block-related infection and pneumothorax. Single-shot erector spinae plane block provides superior analgesia as compared with sham block. It decreased the first 24-hour postoperative analgesic consumption by 64.5% and risk of pain by five times in the authors' population. It also reduced the sedation and duration of mechanical ventilation in postcardiac surgery patients.

HYBRID CORONARY REVASCULARIZATION VERSUS CORONARY ARTERY BYPASS GRAFT IN PATIENTS WITH MULTIVESSEL CORONARY ARTERY DISEASE: A META-ANALYSIS

Hybrid coronary artery revascularization (HCR) refers to complete or near complete revascularization using the combination of single vessel coronary artery bypass graft (CABG) with left internal mammary artery (LIMA) to left anterior descending (LAD) and percutaneous coronary intervention (PCI) of

Surgical Outcomes of Minimally Invasive vs Sternotomy Approaches to Single-Vessel Coronary Artery Bypass Grafting: A Study from The Society of Thoracic Surgeons National Database

Surgical Outcomes of Minimally Invasive vs Sternotomy Approaches to Single-Vessel Coronary Artery Bypass Grafting: A Study from The Society of Thoracic Surgeons National Database

Coronary artery bypass grafting in a renal transplant patient: case report

The patients with end-stage renal disease have an increased risk of atherosclerosis and the probability of cardiovascular diseases. Due to the use of immunosuppressive agents, the patients having renal graft carry an additional risk of atherosclerosis or endocarditis. A 67-year-old male patient with a history of renal transplantation was referred to our hospital with a severe chest pain and dyspnea. After diagnosing severe ischemic coronary artery disease by coronary angiography, the patient underwent a successful operation of a single vessel coronary artery bypass grafting (CABG) in beating heart. Up to 20% of post-renal transplantation mortality is attributed to cardiovascular diseases. Graft rejection, the need of hemodialysis, perioperative infection are some of the major complications for renal transplant patients undergoing CABG surgery. Off-pump CABG (OPCABG) surgery is a less invasive technique in comparison with CABG with cardiopulmonary bypass (CPB), and protects the patient from negative effects of CPB such as complement system activation, inflammatory mediator secretion, thrombocytopenia, clotting disorders. We recommend to prefer OPCABG and have preoperative prophylaxis in order to avoid both perioperative infection and renal graft rejection in renal transplant patients undergoing CABG surgery.

Cost and Outcome of Minimally Invasive Techniques for Coronary Surgery Using Robotic Technology.

Totally endoscopic coronary artery bypass (TECAB) with robotic distal anastomosis and robotic-assisted minimally invasive coronary artery bypass (RA-MIDCAB) with robotic internal mammary artery harvest and direct hand-sewn distal anastomosis via an anterior thoracotomy have both been reported as safe and efficacious. We compared hospital cost and short-term outcomes between these techniques. Patients who underwent robotic-assisted minimally invasive single-vessel Coronary artery bypass grafting (2011-2014) were retrospectively reviewed. One hundred consecutive patients underwent either TECAB (n = 50) or RA-MIDCAB (n = 50). The two groups were sequential with TECAB performed by one surgeon in the first portion of the study interval and RA-MIDCAB by another surgeon in the latter. Demographics, short-term outcomes, and hospital cost data were compared between the two groups. Patient demographics and preoperative risk factors were similar between the TECAB and RA-MIDCAB groups, as total operating room time. Cardiopulmonary bypass was used for 56% of TECAB and 0% of RA-MIDCAB cases (P < 0.001). Intensive care unit and hospital lengths of stay, along with postoperative morbidities, were similar between the two groups. Operative mortality was 2% in the TECAB and 0% in the RA-MIDCAB group (P = NS). Total hospital cost was significantly higher with TECAB compared with RA-MIDCAB (US $33,769 vs. $22,679, P < 0.001), which was primarily driven by operative costs (US $17,616 vs. $26,803, P < 0.001). Totally endoscopic coronary artery bypass and RA-MIDCAB both demonstrated excellent short-term clinical outcomes. However, TECAB was associated with significantly higher hospital costs. Further comparisons, including long-term outcomes, patient satisfaction, and functional status, are needed to evaluate whether this additional cost is justified.

Minimally Invasive Valve Surgery and Single Vessel Coronary Artery Bypass via Limited Anterior Right Thoracotomy.

Coronary artery bypass grafting with aortic valve replacement (AVR) or mitral valve replacement (MVR) is traditionally performed via sternotomy. Minimally invasive coronary surgery (MICS) and minimally invasive valve surgery have been successfully performed independently. Patients with critical right coronary artery (RCA) stenosis not amenable to percutaneous intervention are candidates for valve replacement and single vessel coronary artery bypass. We present our series of six patients who underwent a concomitant valve and single vessel intervention via right thoracotomy. Between January 2011 and June 2013, six patients underwent right thoracotomy with valve replacement and single vessel bypass. Four aortic and two mitral valves were replaced and all received single vessel RCA bypass using reversed saphenous vein graft. Thoracotomy was via right anterior approach for AVR and right lateral for MVR. The patients were assessed postoperatively for overall outcomes. The average age was 74 years (range 69-81); two patients were elective (AVR-1; MVR-1) and four were urgent (AVR-3; MVR-1). For MICS AVR and MICS MVR, the average cardiopulmonary bypass time was 171 ± 30 and 169 ± 7 minutes and the average aortic cross-clamp time was 122 ± 36 and 112 ± 2 minutes, respectively. Three patients were discharged home, one patient to a nursing home, and two to rehab. No patients required conversion to sternotomy; one patient developed atrial fibrillation, and one sepsis. Concomitant valve replacement and single bypass grafting via right anterior mini-thoracotomy is a viable option for select patients, particularly in non-stentable RCA stenosis. In the appropriate patient population, combined coronary artery bypass grafting and valve surgery can be safely performed via right thoracotomy.

Left Ventricular Pseudoaneurysm: “To-and-Fro” Flow

![Figure][1] [![Graphic][3] ][3][![Graphic][4] ][4] An 81-year-old man with known coronary disease and prior single-vessel coronary artery bypass grafting surgery presented with shortness of breath on moderate exertion. An extensive lateral wall infarct with free wall rupture

Accessory Attachment

A 60-YEAR-OLD MAN with a past medical history significant for obesity, hypertension, hypercholesterolemia, and a longstanding murmur presented with shortness of breath and fatigue with exertion over a period of 1 week. A transthoracic echocardiogram showed moderate aortic stenosis. A cardiac catheterization was performed and showed severe aortic stenosis (peak gradient of 70 mmHg and valve area of 0.64 cm2), single-vessel coronary artery disease (60%-70% occlusion of mid-left anterior descending artery), and dilation of the ascending aorta (5 cm). Given these findings in a symptomatic patient, the decision was made to proceed to the operating room for a biologic Bentall procedure and single-vessel coronary artery bypass graft surgery.

Robotic Mammary Artery Harvest and Anastomotic Device Allows Minimally Invasive Mitral Valve Repair and Coronary Bypass

We report the case of a 60-year-old man requiring combined mitral valve repair and coronary artery bypass grafting. A unique minimally invasive approach was used combining robotic internal mammary artery harvesting, partial lower sternotomy, and single vessel coronary artery bypass grafting using an automated distal coronary artery anastomotic device. Issues in approaching the commonly encountered patient with mitral valve disease and coronary artery disease using minimally invasive techniques are discussed.

Left Ventricular Outflow Tract to Right Atrial Fistula Diagnosed by Intraoperative Transesophageal Echocardiography

A 68-yr-old male with increasing shortness of breath and a history of aortic stenosis was admitted. A transthoracic echocardiographic examination (TTE) revealed an aortic valve (AV) area of 0.62 cm2. The patient was subsequently scheduled for an AV replacement (AVR). Cardiac catheterization performed on the morning of surgery demonstrated single vessel coronary artery disease involving the right coronary artery. The patient underwent an uncomplicated AVR (#23 Carpentier-Edwards Magna) with a single vessel coronary artery bypass graft. His initial postoperative course was uncomplicated, but on postoperative day 3 he became febrile to 38.7°C. Blood cultures were positive for Staphylococcus aureus and antibiotic therapy was initiated. TTE at that time was inconclusive, however transesophageal echocardiography (TEE) performed in the intensive care unit on postoperative day 7 was interpreted as a fistulous communication between the aorta and right atrium (RA) associated with a periannular abscess in the vicinity of the AVR. The patient returned to the operating room where intraoperative multiplane TEE demonstrated that the fistula actually communicated between the left ventricular outflow tract (LVOT) and the RA. In the midesophageal four-chamber view at 0° rotation, the diameter of this tract was approximately 0.5–0.8 cm. (Fig. 1 Top). Color flow Doppler in the midesophageal (Fig. 1 Bottom) and deep transgastric long-axis (Fig. 2) views confirmed the presence of turbulent flow from the LVOT to the RA just above the tricuspid valve (see video loop for midesophageal TEE views available at www.anesthesia-analgesia.org). Therefore, the surgical approach was changed to a replacement of the original AV prosthesis and aortic root with a #22 homograft (LifeNet), and the fistula closed by sewing bovine pericardial patches to both sides of the tract. The patient was discharged from the hospital in good condition after a subsequent uneventful postoperative course.Figure 1.: Top: Midesophageal four-chamber transesophageal echocardiographic (TEE) view at 0° rotation demonstrating a fistula (→) from the left ventricular outflow tract (LVOT) to the right atrium (RA). Bottom: Midesophageal four-chamber TEE view at 0° rotation with color flow Doppler showing turbulent flow from the LVOT into the RA.Figure 2.: Deep transgastric transesophageal echocardiographic (TEE) view at 0° rotation showing a communication between the left ventricular outflow tract (LVOT) and right atrium (RA). Turbulent flow from the LVOT into the RA at the level of the tricuspid valve is demonstrated (→).Communications between the LVOT and RA are mostly congenital and are known as “Gerbode's defect” (1). This anomaly accounts for <1% of all congenital heart lesions. Similar acquired shunts may develop after chest trauma, mitral and AV replacement, or infective endocarditis (2). The communication results from a defect in the interventricular septum, inferior to the crista supraventricularis. Patients with this lesion can present with hemodynamic deterioration, myocardial injury, prosthetic valve dysfunction, or perivalvular leaks. Symptoms of right-sided heart failure dominate the clinical picture and depend on the magnitude of the shunt as a reflection of the size of the defect. Physical findings include a harsh holosystolic murmur and right ventricular heave. Only patients with small shunts remain asymptomatic. Collateral injury associated with a perivalvular infection can involve the subannular region and membranous interventricular septum (3). TTE often fails to identify the involvement of these subaortic structures (4). The creation of a TTE window to visualize the membranous septum can be technically challenging because of patient anatomy and beam orientation. An overlying aortic prosthesis that overshadows the lesion can also complicate transthoracic imaging. Therefore, a comprehensive TEE examination using two-dimensional and color flow Doppler imaging can be useful for delineating the location of the pathology and for guiding the surgical procedure.

The Management of a Patient With Tracheal Compression Undergoing Combined Resection of an Anterior Mediastinal Mass and Aortic Valve Replacement With Coronary Artery Bypass Graft Surgery: Utility of the Laryngeal Mask Airway and Aintree Intubation Catheter

T HAS LONG BEEN recognized that the presence of an anterior mediastinal mass can lead to respiratory and cardiovascular collapse. Importantly, the severity of airway compromise may not be apparent in the awake patient. There have been numerous reports in the literature of life-threatening complications or death during anesthetic induction, maintenance, and emergence, as well as in the early postoperative period. 1,2 Symptoms attributable to anterior mediastinal masses include airway compression with obstruction, obstruction of the major vessels and heart, and superior vena cava syndrome. 3,4 Airway management in these patients can prove challenging and demands proper planning and communication on the part of the anesthesia and surgical teams. This case describes the airway management of a high-risk patient with significant tracheal narrowing and a large retrosternal goiter undergoing combined resection of this mass with major cardiac surgery. CASE REPORT A 54-year-old woman presented with a 3-day history of shortness of breath, cough, and an inability to lie flat because of worsening dyspnea. Past medical history was significant for morbid obesity (weight 112 kg, height 162 cm), emphysema, angina, hypertension, non‐insulin-dependent diabetes mellitus, anxiety/depression, hyperlipidemia, osteoarthritis, gastroesophageal reflux, gastroparesis, and a more than 30 pack/year current smoking history. Two years earlier, she had undergone emergency tracheostomy for upper-airway obstruction after a dental infection. This was complicated by acute respiratory distress syndrome requiring mechanical ventilation for 2 weeks. Medications at the time of presentation included lasix, potassium chloride, prednisone, Nexium (AstraZeneca LP, Wilmington, DE), Lipitor (Pfizer Inc, New York, NY), Singulair (Merck, Whitehouse Station, NJ), Diovan (Novartis, Cambridge, MA), Lexapro (Forest Laboratories, New York, NY), reglan, Allegra (Sanofi Aventis, Bridgewater, NJ), Vioxx (Merck), Paxil (SmithKline Beecham, Philadelphia, PA), metoprolol, and albuterol. A computed tomography scan of the chest showed an enlarged thyroid gland extending down into the superior mediastinum and surrounding the upper trachea. The trachea was maximally narrowed to 5 mm at the level of the thyroid cartilage (Fig 1), with intrathoracic extension of airway narrowing. A transthoracic echocardiogram showed a left-ventricular ejection fraction of 55%, left-ventricular hypertrophy, mild mitral regurgitation, severe aortic insufficiency, and a small pericardial effusion. Cardiac catheterization revealed a 70% proximal left circumflex coronary artery stenosis. Pulmonary function tests showed the following: forced expiratory volume in 1 second of 1.3 L (61% predicted), forced vital capacity of 1.8 L (68% predicted), forced expiratory volume in 1 second/forced vital capacity of 72.3%, and FEF25-75 (forced expiratory flow from 25% to 75% of vital capacity) of 0.75 L/s (28% predicted). Spirometry showed flattening of the expiratory limb of the flow-volume loop (Fig 2). Laboratory data including complete blood count, electrolyte panel, coagulation profile, and thyroid function studies were all within normal limits. The patient was premedicated intravenously with midazolam, 1 mg, glycopyrollate, 0.2 mg, ranatidine, 50 mg, and metaclopromide, 10 mg. Preoperatively, her airway was anesthetized with 4 mL of nebulized 4% lidocaine. Intraoperative monitors included the standard American Society of Anesthesiologists monitors, a brachial arterial catheter, and a pulmonary artery catheter that was placed after intubation. Bilateral glossopharyngeal nerve blocks were performed by using 1% lidocaine. For anesthetic induction, she was maintained in 30 degrees of reverse Trendelenburg positioning and preoxygenated for 5 minutes. Eighty milligrams of propofol were administered, and a no. 4 laryngeal mask airway (LMA) was easily inserted. The patient maintained spontaneous respiration during this time, and sevoflurane was incrementally administered to 2.3% end-tidal concentration. With the patient breathing spontaneously, a fiberoptic bronchoscope loaded with an Aintree intubation catheter (Cook Critical Care, Bloomington, IN) was introduced into the trachea via the LMA by using a swivel adaptor to allow continued delivery of oxygen and sevoflurane. The Aintree intubation catheter is an airway-exchange catheter with a 4.8-mm internal diameter that can be loaded onto a 4.0-mm fiberoptic bronchoscope. The vocal cords were sprayed with 1% lidocaine through the suction port of the bronchoscope, the airway was examined for degree of patency, and the catheter was easily advanced across the narrowed portion of the trachea. The LMA was then removed, and a 7.0 armored endotracheal tube was gently advanced over the intubating catheter past the obstruction. After median sternotomy, the patient underwent total thyroidectomy, breathing spontaneously. End-tidal CO2 ranged between 40 and 50 mmHg, and PaCO2 measured during spontaneous ventilation was 47 mmHg. The surgeon confirmed by direct palpation that there was no tracheomalacia. Pancuronium was then administered, and the patient underwent uneventful aortic valve replacement and single-vessel coronary artery bypass grafting to the left circumflex coronary artery with cardiopulmonary bypass. She remained intubated overnight and was extubated the next morning after having met standard extubation criteria and the demonstration of a leak around the endotracheal tube with cuff deflation. Her postoperative course was uneventful, and she was discharged on postoperative day 6 with significant improvement in her respiratory complaints.

Surgical treatment for coronary artery aneurysm

Two successful cases of the surgical treatment for coronary artery aneurysm (non-Kawasaki disease) were reported. The first case had a saccular aneurysm on the left circumflex coronary artery (LCx) #14. Resection of the LCx aneurysm was performed subsequent to single vessel coronary artery bypass grafting (CABG) to the distal portion of LCx#14 under the cardioplegic cardiac arrest. The second case had aneurysms on both the left anterior descending artery (LAD) #7 (fusiform) and the LCx#11 (saccular). After double vessel CABG to LAD#7 and LCx#11, ligation or resection of two aneurysms was performed successfully. Postoperative courses have been uneventful with good angiographic results achieved. Since these surgical procedures demonstrated safety, the patients are expected to achieve a good long-term prognosis.

Improved Recovery after the Endoscopic Atraumatic Coronary Artery Bypass Procedure Compared with Sternotomy for Off-Pump Bypass of the Left Internal Thoracic Artery to the Left Anterior Descending Coronary Artery: A Case-Matched Study

The endoscopic atraumatic coronary artery bypass (endo-ACAB) procedure allows single-vessel coronary artery bypass grafting (CABG), avoiding sternotomy or thoracotomy. We set out to define the effect of this surgical approach on postoperative recovery, blood loss, and return to work. We performed a case-control comparison of our first 29 endo-ACAB procedures for left anterior descending coronary artery (LAD) disease against 29 control patients, who underwent off-pump beating heart CABG via sternotomy for isolated LAD disease in the same institution. Control pairs were matched for age, sex, and ventricular function. In a matched population, endo-ACAB is associated with shorter postoperative ventilation times (6.2 hours versus 9.0 hours, P = .034) and hospital stays (5.3 nights versus 6.4 nights, P = .04), less blood loss (363.9 mL versus 570.3 mL, P = .017), and lower transfusion requirements. Endo-ACAB patients were more likely to return to employment and did so at a mean of 6.6 weeks earlier than sternotomy patients (P = .019). Endo-ACAB for grafting of the left internal mammary artery to the LAD is associated with reduced blood loss and faster postoperative recovery. Avoiding sternotomy appears to be a significant factor in recovery after beating heart single-vessel CABG surgery.

Minimally invasive single-vessel coronary artery bypass with the internal thoracic artery and early postoperative angiography: midterm results of a prospective study in 120 consecutive patients

Background. This prospective study was undertaken to determine the role of the minimally invasive direct coronary artery bypass with early postoperative angiography and midterm follow-up in 120 consecutive patients with single-vessel coronary artery disease. Methods. Minimal access (6 to 10 cm), without complete sternotomy and no cardiopulmonary bypass, was used. The lesions were located at the proximal left anterior descending coronary artery in 95% of the patients. Routine coronary angiography was performed before discharge. Results. Postoperative angiography was performed in 104 (90.4%) of those 115 patients who had coronary revascularization concluded by the mini-access method. The internal thoracic artery patency rate was 98.1% (95.2% grade A). Two (1.7%) patients presented with perioperative myocardial infarction, which led to the single in-hospital death (0.8%). Of the remaining 119 patients, 113 (95.0%) were asymptomatic. The event-free probability was 94.9% and the actuarial survival was 98.3% with 42 months of follow-up. Conclusions. For selected patients with single-vessel coronary artery disease and no major myocardial dysfunction, minimally invasive direct coronary artery bypass is a safe operation and a less invasive alternative to conventional coronary artery bypass grafting.