Ramachandra C. Reddy

Anomalous right coronary artery from the left sinus: a minimally invasive approach

OBJECTIVE Anomalous right coronary artery arising from the left sinus (ARCA) is a known cause of sudden cardiac death, particularly in young athletes. Surgery is recommended for all adult patients who are symptomatic or who have evidence of exercise-induced myocardial ischemia. Surgical options include coronary artery bypass grafting (CABG) and anatomic correction by unroofing the ostium or by reimplanting the ostium into the right sinus of Valsalva. We describe the rationale and technique of a minimally invasive right thoracotomy approach for correction of ARCA. METHODS We reviewed all patients with coronary artery disease operated upon at Mount Sinai Medical Center. Between March 2008 and September 2010, 17 patients underwent surgery for anomalous coronary origin from the opposite sinus of Valsalva. Nine of these patients had ARCA. We describe four adult patients with ARCA who were operated upon using a small right anterior thoracotomy incision to perform a right internal mammary artery (RIMA) to right coronary artery (RCA) bypass with ligation of the proximal RCA. This was performed under direct vision and without cardiopulmonary bypass. RESULTS There were two male and two female patients. Mean age was 55.3 ± 4.8 years (range 50-61 years). Three of the patients manifested chest pain and one each syncope, dyspnea, and palpitations. Two patients had preoperative stress testing that was positive for ischemia. Postoperative follow-up (mean 14 months and range 5-37 months) is complete. All patients are alive and asymptomatic. CONCLUSIONS ARCA can be managed with good early and midterm results using a minimally invasive right thoracotomy approach.

Minimally Invasive Direct Coronary Artery Bypass: Technical Considerations

Minimally invasive direct coronary artery bypass grafting (MIDCAB) uses a small anterior left thoracotomy incision and harvesting of the left internal mammary artery with an anastomosis performed to the left anterior descending artery without cardiopulmonary bypass. There is renewed interest in minimally invasive coronary surgery and hybrid revascularization. This article describes a standardized approach that has been consistently successful in our institution.

Anesthetic and technical considerations in redo coronary artery bypass surgery using sternal-sparing approaches.

REOPERATIVE CORONARY ARTERY bypass grafting (CABG) has decreased significantly in the previous 20 ears, likely because of the increased availability of percutaeous coronary intervention (PCI).1 Reoperative surgery using he classic trans-sternal approach is more technically challengng than primary surgery and is associated with an increased isk of major complications and death.2,3 There is an increased isk of injury to patent bypass grafts, the great vessels, and right entricle during sternal re-entry. Manipulation of the aorta or iseased bypass grafts can precipitate embolization and cause troke or myocardial infarction.2,4,5 Reoperative sternotomy also is associated with prolonged cardiopulmonary bypass (CPB) time, an increased risk of sternal wound infections, and postoperative mediastinitis.2,5 Patients undergoing reoperative sternotomy often have regional ischemia with patent grafts or native vessels to other territories. Although sternotomy provides the best exposure for global access to the myocardium, when only regional access is required, limited-access nonsternotomy approaches are an attractive option. Collectively, these are known as minimally invasive direct CABG (MIDCAB). In addition to the standard monitoring, there are specific anesthetic considerations for nonsternotomy approaches in reoperative coronary surgery. These include the possible use of lung separation techniques and the need for external defibrillator pads. In addition, it is imperative to be prepared for catastrophic events and longer surgical times. An avoidance of CPB affords the benefit of avoiding the coagulopathic derangements that occur on CPB, including platelet, fibrinogen, and coagulation factor dysfunction and dilution. Another common coagulopathic consequence of CPB is fibrinolysis. During off-pump CABG, the use of fibrinolytics usually is not needed. The authors present 3 patients who underwent nonsternotomy approaches to CABG. The surgical approach for each patient was chosen based on vessel involvement.

Intraoperative Imaging and Off-Pump Ligation of Coronary Artery Fistula

1. Delvi MB: Ultrasound-guided brachial plexus block in patient ith halo device. Saudi J Anaesth 4:20-22, 2010 2. Bhardwaj N, Yaddanapudi S, Makkar S: Retrograde tracheal ntubation in a patient with a halo traction device. Anesth Analg 103: 628-1629, 2006 3. Lorente L, Jiménez A, Martín MM, et al: Influence of tracheosomy on the incidence of central venous catheter-related bacteremia. ur J Clin Microbiol Infect Dis 28:1141-1145, 2009 4. Patrick SP, Tijunelis MA, Johnson S, et al: Supraclavicular sublavian vein catheterization: The forgotten central line. West J Emerg ed 10:110-114, 2009 5. Czarnik T, Gawda R, Perkowski T, et al: Supraclavicular aproach is an easy and safe method of subclavian vein catheterization ven in mechanically ventilated patients: Analysis of 370 attempts. nesthesiology 111:334-339, 2009 6. Troianos CA, Hartman GS, Glas KE, et al: Guidelines for perorming ultrasound guided vascular cannulation: Recommendations of he American Society of Echocardiography and the Society of Cardioascular Anesthesiologists. J Am Soc Echocardiogr 24:1291-1318, 011

Surgical Considerations in Off-Pump Coronary Artery Bypass Grafting

Off pump coronary artery bypass grafting remains an important technique particularly in the care of high-risk patients. Consistently successful adoption of this technique requires a cooperative team approach and standardization across all phases of patient care. This review describes our approach to off pump coronary surgery.

Video assistance for surgical pulmonary embolectomy

Surgical pulmonary embolectomy is one of the treatment options for massive pulmonary embolism. At our institute, we have recently adopted a strategy of video assistance for better visualization and clearance of distal pulmonary emboli. Here, we describe our experience.

Cardiac Surgery in a Patient With Pemphigus Vulgaris: Anesthetic and Surgical Considerations

Pemphigus vulgaris is an autoimmune disorder that causes blistering of the skin and mucous membranes. We present a patient with pemphigus vulgaris who required combined coronary artery bypass grafting and mitral valve repair. The challenges that we faced and modifications to the technique required in this situation are described and reviewed.

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

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