Beating heart coronary artery bypass via a small thoracotomy in a conscious patient has been described.1Anderson MB Kwong DF Rurst AJ Salerno TA Thoracic epidural anesthesia for coronary bypass via left anterior thoracotomy in the conscious patient.Euro J Cardiothorac Surg. 2001; 20: 415-417Crossref PubMed Scopus (32) Google Scholar, 2Karagoz HY Sonmez B Bakkaloglu B et al.Coronary artery bypass grafting in the conscious patient without endotracheal general anesthesia.Ann Thorac Surg. 2000; 70: 91-96Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar This surgical approach has the disadvantage of offering only one graft to the patient; hence, it may not be suitable for patients requiring multiple grafts. The authors describe an obese lady with an irritable bronchial tree, who underwent redo off-pump coronary artery bypass surgery through a repeat full midsternotomy, remaining awake, with high thoracic epidural anesthesia as the sole anesthetic. An obese, 69-year-old woman suffering from hypertension, diabetes, and chronic obstructive pulmonary disease with seasonal wheezing presented to the hospital with progressive worsening of breathlessness and chest pain on exertion. She weighed 72 kg, her height was150 cm, and her body mass index was 32. She was not a smoker and did not give a history suggestive of sleep apnea. She was admitted to the hospital with unstable angina (grade III, the Canadian Cardiovascular Society grading of angina of effort) and was started on medical therapy for the control of angina. The patient gave a history of seasonal bronchospasm and was being treated with nebulization with salbutamol and ipratropium. Her vital signs on admission were as follows: heart rate 90 beats/min, blood pressure 180/100 mmHg, respiratory rate 22/min, and transcutaneous oxygen saturation 95% on room air The pulmonary function tests showed moderate, reversible airflow obstruction with no restriction. Her forced vital capacity, forced expiratory volume in one second, forced expiratory volume and forced vital capacity ratio were 1.1 L, 0.72 L, and 63.9%, respectively, which increased 15% after 2 puffs of salbutamol inhalation. Her other medications consisted of amlodipine, 5 mg once daily; aspirin, 100 mg once daily; human insulin, thrice daily according to her blood sugar; and ranitidine, 150 mg thrice daily. The laboratory tests showed a hematocrit of 33%, white cell count of 9,000 CU/MM, and platelet count of 250,000 CU/MM. Blood urea nitrogen was 20 mg/dL and serum creatinine 1.0 mg/dL. The arterial blood gases were unremarkable except for PCO2 of 42 mmHg. The chest radiograph showed prominent bronchovesicular markings. The patient had undergone coronary artery bypass grafting 7 years ago, wherein the left internal mammary artery (LIMA) and radial artery were used to make a “T” anastomosis and grafts to the left anterior descending artery (LAD), ramus intermedius, and the posterior descending artery. All the grafts were perfused by the LIMA and radial aretery, which was proximally anastomosed to the LIMA; thus, there were no proximal anastomoses on the aorta. The repeat coronary angiogram showed low flow in the LIMA beyond the “T” junction, reducing the flow to the LAD. But the flow into the radial artery was normal, and thus the grafts perfused by the radial artery were patent and there was a new block of the obtuse marginal 2 (OM2). The patient had angina not withstanding full therapy including intravenous nitroglycerin, 50 μg/min; aspirin, 100 mg/d; enoxaparin, 40 mg twice daily in addition to her antihypertensive agents. The initial plan was to treat her conservatively, but the decision was revised in view of her worsening angina, which deteriorated from grade III to IV (the Canadian Cardiovascular Society grading of angina of effort). After the decision to operate on her was made, her enoxaparin was discontinued, and she was started on an infusion of heparin at the rate of 1,000 U/h. Strengthened by the experience of doing minimally invasive direct coronary artery bypass (MIDCAB) surgery with high thoracic epidural anesthesia (TEA) as the sole anesthetic, it was decided to perform the redo off-pump coronary artery bypass (OPCAB) via a standard midsternotomy with high TEA after obtaining an informed consent and approval of the hospital ethics committee. She was on the heparin infusion for 36 hours, and it was withheld for 6 hours before the epidural catheterization was performed and restarted thereafter. Her activated partial thromboplastin time was normalized (after the withdrawal of heparin), and then the epidural catheterization was scheduled. On the eve of the surgery, venous access was secured, and an epidural catheter (17G) was placed at the C7-T1 interspace under local anesthesia with the patient in sitting position. Heart rate, noninvasive blood pressure, electrocardiogram, and transcutaneous oxygen saturation were monitored during the procedure. The epidural space was identified by the loss-of-resistance technique, and, on entering the space, 2 to 4 cm of the catheter was kept indwelling. The patency of the catheter was checked by a saline flush. No test dose was administered at this point of time. On the morning of surgery, 5-lead electrocardiogram (monitoring leads II and V5), ST-segment analysis, and transcutaneous oxygen saturation were established, and femoral arterial and pulmonary artery catheters were secured under local anesthesia and the patient connected to the hemodynamic monitor. Nasal and rectal temperatures were monitored. The operating room temperature was maintained above 20°C. A 9F sheath was placed in the right femoral vein to combat the eventuality of massive hemorrhage at the time of sternotomy or release of substernal adhesions. A hands-free defibrillation and pacing (Smart biphasic; Agilent Technologies, Andover, MA) electrode was placed to facilitate defibrillation/cardioversion/pacing if the need arose. As a test dose, 1 mL of lidocaine (2%) with epinephrine (1:200,000) was injected through the epidural catheter, and, after 5 minutes, noting absence of any untoward reactions, 5 mL of 0.5% bupivacaine and 25 μg of fentanyl were administered. Analgesia was noted up to the T5 level, and a further top up of 5 mL of 0.25% of bupivacaine and 10° Trendelenberg position resulted in analgesia at the T1 level. A nasopharyngeal airway was passed, and a nasogastric tube was passed through this. A stiff transparent oxygen mask with hooks for the harness was placed on the patient's face, connected to the oxygen source, and tested for the ability to assist ventilation after securing the harness. The nasogastric tube was rolled up, blocked, and placed inside the mask to prevent air leakage from under the mask when attempting to assist ventilation. The mask was connected to the circle absorber via a “Y” connection to ensure unidirectional flow of gases. The patient was sedated with midazolam, 2 mg intravenously, and was found to be asleep but arousable. The patient's limbs were taped and immobilized to prevent accidental movements during the surgery. The surgery commenced, allowing access to the airway, and a classical midsternotomy was made; the substernal adhesions were released. During the substernal dissection, the left pleura was opened inadvertently, which caused a pneumothorax, and the lung collapsed. The pleural hole was purse stringed, a 27F drainage tube was inserted through the pleural hole, connected to suction, and the purse string tightened as a matter of precaution, although the patient had no complaints. A brief period of manual positive-pressure ventilation was undertaken during this phase. The vein conduits could be harvested without any need for subcutaneous infiltration of local anesthetic. The patient was heparinized with 300 U/kg of heparin and the activated coagulation time was noted to be 350 seconds. Two vein grafts were put on the LAD and OM2 using the Octopus 2 and a tissue stabilizer. Reduction in pressure during the proximal anastomoses was achieved by tilting up the head end of the operating table and injecting100 to 150 μg of nitroglycerin. The hemodynamic changes during the surgery are shown in Figure 1.The patient required dopamine, 5 μg/kg/min, during the OM2 grafting. A total of 2 L of warm intravenous fluid was used, of which 500 mL was 5% dextrose in water and the rest was lactated Ringer's solution. During the procedure, epidural doses of 3 mL of 0.25% bupivacaine with 25 μg of fentanyl and 2 mg of midazolam intravenously, were administered after 1 and 2 hours from the time of incision. Protamine in a dose of 3mg/kg was used for the reversal of heparin, and homeostasis was secured. The surgery lasted about 180 minutes. The total blood loss was 650 mL, and the urine output was 350 mL; she was in a positive fluid balance of 750 mL. At the end of the surgery, the patient had neither the memory nor any painful experiences of the surgery. The patient was transferred to the intensive care unit and was rendered pain free with intermittent epidural doses of fentanyl, 25 μg, once in 4 hours. She was discharged to the ward the next day. The rest of the hospital course was uneventful, and the patient was discharged from the hospital on the fifth postoperative day. Coronary artery surgery in patients with comorbid conditions is fraught with difficulties. Minimally invasive direct coronary artery bypass surgery and OPCAB have been performed in awake patients1Anderson MB Kwong DF Rurst AJ Salerno TA Thoracic epidural anesthesia for coronary bypass via left anterior thoracotomy in the conscious patient.Euro J Cardiothorac Surg. 2001; 20: 415-417Crossref PubMed Scopus (32) Google Scholar, 2Karagoz HY Sonmez B Bakkaloglu B et al.Coronary artery bypass grafting in the conscious patient without endotracheal general anesthesia.Ann Thorac Surg. 2000; 70: 91-96Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar, 3Vanek T Straka Z Brucek P Widimsky P Thoracic epidural anesthesia for off-pump coronary artery bypass without intubation.Eur J Cardiothorac Surg. 2001; 20: 858-860Crossref PubMed Scopus (36) Google Scholar with acceptable results. It is a well-known fact that a well-conducted general anesthetic provides good control of ventilation, hemodynamics, and allows for transesophageal echocardiography. General anesthesia is one of the main aspects of cardiac surgery, which was instrumental in widespread acceptance and popularity of cardiothoracic surgery. The advent of minimally invasive cardiac surgery inevitably affected the anesthetic approach as well. Newer strategies such as better analgesia, early extubation, improved respiratory function, earlier ambulation, and reduced narcotic requirement4Mehta Y Swaminathan M Mishra Y A comparative evaluation of intrapleural and thoracic epidural analgesia for postoperative pain relief after minimally invasive direct coronary artery bypass surgery.J Cardiothorac Vasc Anesth. 1988; 12: 162-165Abstract Full Text PDF Scopus (51) Google Scholar became regular features. Although general anesthesia is considered safe, it is not without complications. Further, avoidance of general anesthesia may potentially be beneficial to the patient.5Blomberg S Emanuelsson H Kvist H et al.Effects of thoracic epidural anesthesia on coronary arteries and arterioles in patients with coronary artery disease.Anesthesiology. 1990; 73: 840-847Crossref PubMed Scopus (298) Google Scholar, 6Paulissian R Salem MR Joseph NJ et al.Hemodynamic responses to endotracheal extubation after coronary artery bypass grafting.Anesth Analg. 1991; 73: 10-15Crossref PubMed Scopus (48) Google Scholar, 7Vandermeulen EP Aken HV Vermylen J Anticoagulants and spinal epidural anesthesia.Anesth Analg. 1994; 79: 1165-1177Crossref PubMed Scopus (816) Google Scholar Avoidance of endotracheal intubation in cardiac surgery, however, was never before deemed feasible.2Karagoz HY Sonmez B Bakkaloglu B et al.Coronary artery bypass grafting in the conscious patient without endotracheal general anesthesia.Ann Thorac Surg. 2000; 70: 91-96Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar Although general anesthesia has been used for a large number of patients without significant complications, documented hemodynamic responses to tracheal intubation, suction of the endotracheal tube, and extubation may lead to myocardial ischemia and pose a potential risk in patients with coronary artery disease.6Paulissian R Salem MR Joseph NJ et al.Hemodynamic responses to endotracheal extubation after coronary artery bypass grafting.Anesth Analg. 1991; 73: 10-15Crossref PubMed Scopus (48) Google Scholar, 8Mikawa K Nishina K Takao Y et al.Attenuation of cardiovascular responses to endotracheal extubation: comparison of verapamil, lidocaine and verapamil and lidocaine combination.Anesth Analg. 1997; 85: 1005-1010PubMed Google Scholar Furthermore, in an era of patient satisfaction, eliminating endotracheal intubation, and hence tube suctioning and the extubation experience in a cardiac surgical patient, may be considered a less invasive approach.2Karagoz HY Sonmez B Bakkaloglu B et al.Coronary artery bypass grafting in the conscious patient without endotracheal general anesthesia.Ann Thorac Surg. 2000; 70: 91-96Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar If surgery can be performed without technical problems and patient satisfaction can be assured, high TEA can be used for selected cases for OPCAB through midsternotomy. Avoiding general anesthesia with endotracheal intubation is said to offer little advantage9David A Invited commentary.Ann Thorac Surg. 2000; 70: 96Abstract Full Text Full Text PDF Google Scholar while exposing the patient to risks, which he would not otherwise be incurring (eg, epidural hematoma, pneumothorax in a spontaneously breathing patient), and, therefore, the issue of coronary artery surgery without endotracheal anesthesia remains controversial. O'Connor and Tuman10O'Connor CJ Tuman KJ Epidural anesthesia and analgesia for coronary artery bypass graft surgery: Still forbidden territory?.Anesth Analg. 2001; 93: 523-525Crossref PubMed Scopus (31) Google Scholar in their recent editorial state that epidural anesthesia and analgesia have several advantages, and they commend the evaluation of epidural anesthesia and analgesia in an area once considered forbidden territory. Administration of high blocks such as the one in this case may theoretically lead to bronchospasm because of the sympathetic blockade.11Kritzinger M Jantsch U Gruber E et al.Thoracic epidural analgesia with 0.25% bupivacaine does not alter airway resistance in patients suffering from severe chronic obstructive pulmonary disease.Br J Anesth. 1999; 82: 18Google Scholar The authors did not encounter any bronchospasm in the patient, and others also have made similar observations.2Karagoz HY Sonmez B Bakkaloglu B et al.Coronary artery bypass grafting in the conscious patient without endotracheal general anesthesia.Ann Thorac Surg. 2000; 70: 91-96Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar It was also observed that patients with chronic obstructive pulmonary disease do not develop bronchospasm when high TEA is used as a sole anesthetic or as an adjunct to general anesthesia. High TEA has been used for relief of postoperative pain12Liem TH Williams JP Hensens AG Singh SK Minimally invasive direct coronary artery bypass using a high thoracic epidural plus general anesthetic technique.J Cardiothorac Vasc Anesth. 1998; 12: 668-672Abstract Full Text PDF PubMed Scopus (26) Google Scholar in cardiac surgery as an adjunct to general anesthesia; therefore, use of high TEA is accepted as a safe adjunct in patients undergoing cardiac surgery. The fear of pneumothorax during MIDCAB has been alleviated to a large extent, and, if the patient tolerates the pneumothorax without hypoxia or hypercarbia, it can be left alone1Anderson MB Kwong DF Rurst AJ Salerno TA Thoracic epidural anesthesia for coronary bypass via left anterior thoracotomy in the conscious patient.Euro J Cardiothorac Surg. 2001; 20: 415-417Crossref PubMed Scopus (32) Google Scholar and treated at the end of the surgery. The authors' experience of MIDCAB under high TEA with the patient awake has strengthened this knowledge. The occurrence of epidural hematoma remains a fear that has not (yet) been documented in the literature,7Vandermeulen EP Aken HV Vermylen J Anticoagulants and spinal epidural anesthesia.Anesth Analg. 1994; 79: 1165-1177Crossref PubMed Scopus (816) Google Scholar, 13Ho AMH Chang DC Joynt GM Neuraxial blockade and hematoma in cardiac surgery.Chest. 2000; 117: 551-555Crossref PubMed Scopus (211) Google Scholar and in unpublished data of more than 1,200 high TEAs, this complication has not occurred. Based on the assertion that in almost 4,600 reported cases up to 1999, there has not been a single reported case of clinically significant spinal hematoma, Ho et al13Ho AMH Chang DC Joynt GM Neuraxial blockade and hematoma in cardiac surgery.Chest. 2000; 117: 551-555Crossref PubMed Scopus (211) Google Scholar estimated the risk of spinal injury from an epidural blockade–induced hematoma during conventional cardiac surgery to range from 1:150,000 to 1:1,500 (95% confidence interval). It is to avoid such a potential complication that the epidural catheter is inserted the day before surgery after withdrawing heparin for at least 6 hours and normalizing the activated partial thromboplastin time. In summary, it is possible to perform OPCAB surgery through a midsternotomy in awake patients under high TEA. There are no added technical difficulties, and the patient acceptance is good.