Direct coronary artery surgery for coronary artery occlusive disease

Surgical revascularization of the myocardium for coronary artery occlusive disease has gained great impetus over the past five years with the advent of successful methods of direct surgical reconstruction of the coronary arteries. Seventy-five patients underwent direct coronary artery surgery for ischemic heart disease over the past two and a half years. The indication for coronary arterial revascularization was angina in forty-eight patients, congestive heart failure in twenty-four patients, and recurrent myocardial infarction in three patients. In this group of seventy-five patients there were 105 aortocoronary saphenous vein bypass grafts, five internal mammary-coronary artery bypass grafts, and thirty-five distal endarterectomies combined with aortocoronary vein bypass grafts. Direct coronary artery surgery was combined with resection of a left ventricular aneurysm in seven patients and with aortic valve replacement in three. A single coronary artery was reconstructed in twenty-seven cases and two of the three major coronary arteries were reconstructed in thirty-nine cases.     

Operation of coronary artery aneurysm after previous coronary artery bypass grafting

A 43-year-old male, who had undergone coronary artery bypass grafting 11 years ago, developed exertional chest pain. Selective coronary angiograms revealed severe stenosis and a large aneurysm in the obtuse marginal branch of the circumflex coronary artery. Previous grafts to the left anterior descending coronary artery and diagonal branch were patent. Ligation of the aneurysm and internal mammary artery grafting were performed through a left anterolateral thoracotomy. This approach made it easy to reach the aneurysm and to minimize bleeding during dissecting the adhesions. The patient had an uncomplicated postoperative course, and postoperative coronary angiograms revealed an obstructed aneurysm and a patient internal mammary artery graft. He has done well without recurrence of symptoms.     

Complete occlusion both left main coronary artery and right coronary artery

A 67-year-old man, who had complete occlusion both of left main coronary artery (LMCA) and right coronary artery (RCA), underwent coronary revascularization. He had been suffering from severe angina pectoris preoperatively. Exercise electrocardiogram (single Master) showed myocardial ischemia. On cardiac catheterization, he showed extensive collaterals from right main coronary artery, and well-preserved left ventricular function. At operation, coronary arteries revealed severe sclerosis, especially in RCA, but there was no evidence of old myocardial infarction. Three saphenous vein grafts were bypassed to LAD, LCX, and RCA. Postoperatively, he remained free of angina pectoris at 6 months after uneventful surgery.     

Current status of coronary artery bypass grafting for coronary artery atherosclerosis

Coronary artery bypass grafting has now undergone 18 years of proven benefit in the treatment of myocardial ischemic disease. The technique of CABG has been further extended to other situations in which myocardial blood supply is threatened, such as cardiac trauma, aneurysms of coronary arteries, and congenital lesions. The emphasis in choosing CABG over medical therapy in 1985 should be preservation of myocardium at jeopardy of infarction as well as relief of angina. Proximal stenoses in vessels subserving viable muscle that is ischemic at rest or with minimal exercise should be treated with reperfusion by angioplasty or CABG to prevent further injury. After infarction occurs and ventricular function is impaired, CABG is also necessary to preserve remaining myocardium at jeopardy. Such an aggressive approach seems warranted with today's excellent surgical results. Long-term results have also improved, as more attention has been paid to saphenous vein graft preparation, use of mammary artery grafts, complete revascularization, use of antiplatelet agents, control of spasm, and identification of hypercoagulable states that may require sodium warfarin (Coumadin). Angioplasty of vein grafts and distal anastomoses also appears promising to help extend the results of initial CABG. Figure 1 is our recommended approach for the treatment of coronary atherosclerosis.     

Anomalous right coronary artery originating from the left main coronary artery

A 54-year-old man with no cardiac history presented with exertional angina. Cardiac catheterization revealed an anomalous right coronary artery originating from the left main coronary artery with external compression during its course between the aorta and the pulmonary artery. He was successfully managed with surgical reimplantation of the right coronary artery into the aorta.     

Natural evolution of coronary artery ectasia after coronary artery bypass grafting

Coronary artery aneurysm and ectasia, unusual angiographic findings, are considered as variant of atherosclerotic coronary artery disease. A 49-year-old man whose right coronary artery ectasia had progressed to large aneurysm, accompanied by advanced obstructive coronary artery disease, 6 years after the initial coronary artery bypass grafting. It was treated with ligation of aneurysm and distal bypass grafting under cardiopulmonary bypass. Fragile fresh clot was formed within the aneurysm irrespective of coumadin therapy as a standard regimen for the coronary artery ectasias. We will discuss the surgical management for the dilated coronary artery with significant coronary stenosis.     

Coronary artery spasm following coronary artery surgery

Coronary artery spasm during the early postoperative period following cardiopulmonary bypass for coronary artery surgery can be an unrecognized cause of sudden, severe cardiopulmonary collapse. The literature regarding perioperative coronary artery spasm is reviewed, and methods of prevention, diagnosis, and treatment are suggested. Preoperative angina at rest appears to be an important identifying factor in patients who experience postoperative coronary spasm. Anatomically, the presence of a relatively normal, dominant right coronary may also indicate increased risk for early post-coronary bypass spasm. Acute hypotension is often the first sign of coronary artery spasm, and conventional treatment methods may only worsen the vasospastic reaction. Peripheral intravenous nitroglycerin infusion has often been unsuccessful treatment while intragraft or intracoronary nitroglycerin injection or administration of calcium channel-blocking drugs, or both, has proven to be effective in reversing the coronary artery spasm and ventricular dysfunction. Reluctance to use vasodilating agents must be overcome, even in the face of hypotension, when evidence of spasm is present.     

Refractory coronary artery spasm after minimally invasive direct coronary artery bypass grafting

Postoperative coronary arterial spasm is a rare but potentially fatal complication. A 51-year-old male patient with a history of a reactive ergonovine stress test coronary angiogram developed refractory coronary artery spasm after undergoing minimally invasive direct coronary artery bypass grafting of the left anterior descending coronary artery. The patient was successfully managed with rapid implementation of intra-aortic balloon-pump counter pulsation and extracorporeal membrane oxygenation.     

Excision of coronary artery fistula and coronary artery reconstruction without cardiopulmonary bypass

In three patients, coronary artery fistulas originating from a conal branch of the mid-segment of the left anterior descending coronary artery (n = 2) and right coronary artery (n = 1) with drainage into the right atrium (n = 2) and right ventricle (n = 1) were successfully closed without the use of cardiopulmonary bypass. The use of a coronary artery stabilizer greatly facilitated the operation by immobilization of the fistula, its supplying coronary artery, and the regional myocardium. In selected patients, this technique allows secure closure of the fistula and meticulous reconstruction of the coronary artery without the use of cardiopulmonary bypass.     

Off-pump coronary artery surgery

Cardiopulmonary bypass has several associated deleterious effects that include a systemic inflammatory response, coagulopathy, central nervous system complications and a variable degree of end-organ damage. The recent upsurge in interest in "beating-heart" surgery attempts to avoid these deleterious effects. Advances in surgical technique, such as the use of intracoronary shunts and the Octopus retractor, have made beating-heart surgery a reality. The challenges for the anaesthetist are greater than for coronary artery surgery using cardiopulmonary bypass, and whilst some advantages are proven, such as the lack of the inflammatory response and the decreased need for blood or blood products, others have yet to be proved and there is a need for further research. The advantages and disadvantages need to be evaluated in randomised studies in order to confirm the safety and efficacy of these new techniques in terms of long-term graft patency and decreased morbidity.     

The saccular coronary aneurysm associated with coronary artery to pulmonary artery fistulae

Coronary artery fistulae are relatively rare congenital anomalies. Those associated with saccular coronary artery aneurysms are even rarer. Including the current case, only 65 such cases have been reported in Japan. A 62-year-old female was admitted to our hospital for evaluation of abnormal shadow on the chest X-ray. The enhanced chest computed tomography (CT) scan demonstrated a giant saccular coronary aneurysm on the left side of the pulmonary artery. Multi-detector row CT (MDCT) scan demonstrated the coronary artery aneurysm was connected to the left anterior descending artery. Coronary angiography revealed 2 aneurysms with bilateral coronary artery to pulmonary artery fistulae. The patient underwent aneurysmectomy and ligation of fistulae under cardiopulomonary bypass. The postoperative course was uneventful and postoperative coronary angiography revealed complete resection of the aneurysms and only slight blood flow through the fistulae. She was discharged on the 10th postoperative day.     

Stabilizing technique of intra-fat coronary artery in off-pump coronary artery bypass grafting

Suction type stabilizers are popular for off-pump coronary artery bypass. However, arteries running deeply underneath fatty tissue are not stabilized well because the soft tissues act as cushions between the coronary artery and the stabilizer. We propose a simple method to stabilize and visualize intra fat coronary arteries. After dissection of target arteries, 5-0 polypropylene continuous over-and-over sutures are placed on the fat tissues along both sides of the coronary artery. These sutures are pulled laterally, and a suction stabilizer is placed so that the sutures lie under the legs of the stabilizer. Sutures fixed to the stabilizer legs with suction force reduce motion of the target vessel. Visualization of the coronary arteries is also improved because the banks of fat tissue become flat by pulling the sutures laterally.     

Coronary artery spasm following coronary artery revascularization

Coronary artery spasm is a well-documented phenomenon in patients undergoing medial treatment. We describe coronary artery spasm occurring in the immediate postoperative period following coronary artery bypass operation. The spasm occurred in a vessel that was not operated on and that had no apparent lesion. The diagnosis of spasm was made by coronary angiography immediately after operation. Complications associated with this spasm are discussed. Emphasis is placed on early postoperative angiography for patients whose condition is inexplicably unstable after operation.