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

Surgical Case Reports, Apr 2017

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.

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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 - 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 © The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. 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)


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Yoshifumi Fuke, Toru Yasutsune, Masato Sakamoto. 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, Surgical Case Reports, 2017, pp. 56, Volume 3, Issue 1, DOI: 10.1186/s40792-017-0331-1