Aortic valve replacement after coronary artery bypass grafting with the in situ right gastroepiploic artery to the occluded right coronary artery using a temporary vein graft for cardioplegia
Fuke et al. Surgical Case Reports
Aortic valve replacement after coronary artery bypass grafting with the in situ right gastroepiploic artery to the occluded right coronary artery using a temporary vein graft for cardioplegia
Yoshifumi Fuke 0
Toru Yasutsune 0
Masato Sakamoto 0
0 Department of Cardiovascular Surgery, Kitakyushu Municipal Medical Center, Kyushu University , Sakemi 141-11, Okawa city, Fukuoka , Japan
Background: The operation of aortic valve replacement (AVR) after CABG is a technically challenging procedure in respect to dissection of living grafts from its surrounding tissue, myocardial protection, and so on, especially that procedure to patients with living in situ functional arterial grafts to occluded native coronary arteries has a special problem in regard to myocardial protection because myocardial blood supply originates from various arteries including the left internal thoracic artery (LITA), the right internal thoracic artery (RITA), and the right gastroepiploic artery (GEA); hence, adequate myocardial protection should be fastidiously considered. Case presentation: A 68-year-old woman, who underwent CABG comprised of the in situ LITA to the LAD, the in situ GEA to the RCA, and the saphenous vein graft (SVG) to the obtuse marginal branch of the left circumflex artery (LCX) to the triple vessel coronary disease 9 years before, was referred to our hospital due to the aortic valve stenosis. Conclusion: We successfully underwent an aortic valve operation to a patient with a functioning LITA to the occluded left anterior descending artery and a GEA to the right coronary artery (RCA) by using a temporary vein graft to the RCA for the infusion of cardioplegic solution in addition to the conventional antegrade and retrograde cardioplegic infusions with ice slush topical cooling.
Aortic valve surgery after previous coronary artery bypass grafting; In situ living grafts; Temporary bypass; Cargioplegia
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Background
Open-heart surgeries after CABG pose on cardiac surgeons
difficult problems of the re-sternotomy and dissection of
adhesion without injury, myocardial protection, and so on.
A functioning arterial graft to the right coronary artery
(RCA) is especially troublesome in terms of myocardial
protection to the right ventricular (RV) muscle, whereas
the conventional antegrade and retrograde cardioplegia
infusion might provide enough protection to the left ventricle
(LV). We report here a case of successful aortic valve
replacement (AVR) after the CABG operation with multiple
living arterial in situ grafts to the occluded left anterior
descending artery (LAD) and the occluded RCA, using
a temporary vein graft for myocardial protection in
addition of topical cooling and the conventional
antegrade and retrograde cardioplegia.
Case presentation
A 68-year-old woman with a long history of diabetes
mellitus and hypertension, who underwent CABG
comprised of the in situ left internal thoracic artery (LITA)
to the LAD, the in situ GEA to the RCA, and the
saphenous vein graft (SVG) to the obtuse marginal branch of the
left circumflex artery (LCX) to the triple vessel coronary
disease 9 years before, was referred to our hospital due to
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the aortic valve stenosis. She suffered a chest pain on
exertion 2 months before the presentation. A transthoracic
echocardiography showed severe aortic valve stenosis with
the aortic valve area (AVA) of 0.83 cm2 and the mean
transvalvular pressure gradient of 38 mmHg. Her
coronary angiography revealed severe triple vessel disease
with occlusions of the proximal parts of the LAD and
that of the RCA, and all of the bypass grafts were
patent (Fig. 1).
At the surgery, a standard re-sternotomy was
performed paying careful attention to avoid any injury to
mediastinal structures. The living grafts including
LITALAD, GEA-posterior descending artery, and SVG-LCX
were dissected completely freely from adhesion with
surrounding tissue, and the adhesion of the heart was
completely freed from the pericardium. A cardiopulmonary
bypass (CPB) was established by the cannulation to the
ascending aorta and to the superior and inferior vena
cava respectively, and the left ventricular venting tube
was inserted from the right upper pulmonary vein. First
and foremost, a new SVG was anastomosed to the
midportion of the RCA. The ascending aorta was
crossclamped, and the in situ grafts of LITA and GEA were
also clamped simultaneously. The initial cardioplegia
was infused antegradely from the aortic root and the SVG
anastomosed to the RCA, after which the retrograde
card (...truncated)