DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Acute coronary artery syndrome with severe 90% left main stenosis.
POSTOPERATIVE DIAGNOSIS: Acute coronary artery syndrome with severe 90% left main stenosis.
OPERATION PERFORMED:
1. Coronary artery bypass grafting x4 using the left internal mammary artery and segments of the left greater saphenous vein.
2. Endoscopic saphenous vein harvesting.
SURGEON: John Doe, MD
ANESTHESIA: General.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old female with diagnosis of acute coronary artery syndrome. She has a history of a prior PTCA, diabetes and hypertension. Cardiac catheterization here showed a 90% stenosis of the left main coronary artery. Ejection fraction was 80%. In addition, the patient did have some stenosis involving the distal bifurcation of the right coronary artery.
DESCRIPTION OF OPERATION: The patient was brought to the operative room and placed supine, then induced under suitable general anesthesia. The patient was then prepped and draped in the usual sterile fashion. A sternotomy incision was made and the sternum divided with use of the sternal saw. Using a self-retraining retractor, the left internal mammary artery was mobilized on the pedicle, which included a slip of the endothoracic fascia as well as the accompanied vein. The length of the left greater saphenous vein was harvested endoscopically by first making a small 1 inch transverse incision over the medial aspect of the left knee joint. The vein was identified and harvested endoscopically.
Systemic EPO was administered. The pericardium opened in the midline and the distal ascending thoracic aorta cannulated. A two-stage venous cannula was placed in the atrium and a pulmonary vent placed for cardiac decompression. The patient was then placed on cardiopulmonary bypass and cooling down to 32 degrees centigrade was carried out. Successful cardiac arrest of the heart was achieved by cross-clamping the aorta and by inserting cold blood cardioplegia into the aortic root at approximately 4 degree centigrade. About 400 mL was given antegrade and an additional 500 mL given through a retrograde coronary sinus catheter. Satisfactory cooling was achieved below 10 degree centigrade.
The first distal anastomosis was completed to the circumflex branch, where a 4 mm arteriotomy was made using the saphenous vein graft, a distal end-to-side anastomosis was completed with running suture of 6-0 Prolene. The second sequential side-to-side anastomosis was completed to the marginal branch. Again, a 3 to 4 mm arteriotomy was made. A corresponding venotomy was made on the vein graft and the second sequential side-to-side anastomosis completed with running suture of 6-0 Prolene. Additional cardioplegia was infused at this point through the retrograde coronary sinus catheter. Using a second segment of the saphenous vein, a third bypass was completed to the proximal portion of the posterolateral branch. Again a 4 mm arteriotomy made and the end-to-side anastomosis completed using the saphenous vein graft with a running suture of 6-0 Prolene.
The internal mammary artery was then transected distally; the proximal end was appropriately beveled. A 4 mm arteriotomy was made in the proximal half of the anterior descending, and the internal mammary artery to LAD anastomosis completed with running suture of 7-0 Prolene. Warming was initiated. The two proximal anastomoses were completed with the use of a partial occluding aortic clamp. A 5 mm aortic punch was used to remove two buttons of the aortic wall. The two proximal anastomoses were completed with a running suture of 6-0 Prolene.
Warming was continued until a venous temperature of 37 degree centigrade, at which time, the patient was weaned from cardiopulmonary bypass. All of the cannulas were removed and protamine sulfate administered. The pericardium was closed with interrupted sutures of 3-0 silk. A single #28 chest tube was used for drainage. The sternum was reapproximated with monofilament #5 wire along the sternum in the appropriate end spaces and the fascia overlying the sternum closed with a running suture of 3-0 Vicryl. The skin incision was closed with a running subcuticular stitch of 4-0 Monocryl. The patient tolerated the procedure well and was returned to the ICU in satisfactory condition. Cross clamp time 62 minutes. Pump time 94 minutes.
