On-Pump Beating Heart Complete Arterial Coronary Revascularization in a Patient with Porcelain Aorta

Procedure description

We decided to undertake total arterial myocardial revascularization with both internal thoracic arteries. After a median sternotomy, the pericardial cavity was entered. Intraoperative examination revealed that the entire wall of the ascending aorta was severely calcified, thus, unsuitable neither for arterial cannulation nor for side clamping. Both internal thoracic arteries (ITAs) were dissected along their entire length in a skeletonized fashion with opening of both pleuras and using low intensity electrocauterization. The left side of the opened pericardial sac was incised down vertically just opposite the pulmonary artery until 2 cm above the phrenic nerve. The left ITA (LITA) was divided proximal the distal bifurcation. LITA flow was over 100 ml per minute. Afterward, its distal end was occluded with a soft bulldog clamp and covered with a papaverine solution impregnated gauze pad. Then, the right ITA (RITA) was transected at its origin from the subclavian artery and distally at the level of its bifurcation. It was anastomosed in a T fashion to LITA (Fig. 2 a) at the level of the pulmonary valve. Both internal thoracic arteries were preserved in papaverine impregnated gauze. Three deep traction pericardial sutures in the left pericardial sac were placed using 3-0 Prolene (Ethicon, Somerville, NJ) to accomplish adequate exposure of the coronary vessels. Off-pump beating coronary artery bypass grafting was intended, but deterioration of the patient’s hemodynamic status (non-sustained ventricular tachycardia and hypotension during cardiac repositioning) demanded cardiopulmonary circulatory support. Timely insertion of cannulas thru the right femoral artery and the right atrial appendage for arterial perfusion and venous drainage respectively were performed. Peripheral arterial cannulation was considered mandatory given the overwhelming risk of aortic manipulation in cases of PA. Furthermore, preoperative ultrasonographic evaluation of limbs and carotid arteries in our patient revealed only mild atheromatous affection of the femoral arteries. Subclavian arterial cannulation is an alternative approach which, despite its proximity to the surgical field, requires further time to anastomose an interposition graft for the cannula. Partial cardiopulmonary bypass was started. Then we evaluated if the right AMI was long enough to reach the posterior descending coronary artery (PDA) before emptying the heart. Full flow cardiopulmonary bypass at 36°C was established. The heart remained beating to avoid any clamping procedure involving the friable aorta, either external or endoluminal, necessary for successful cardioplegia. Pledgeted stiches with 3/0 prolene surrounding epicardial coronary arteries placed on tourniquets were used to occlude the target vessels proximal to the anastomotic sites. Octopus 4 cardiac suction stabilizer was employed. For better exposure of the lateral and inferior left ventricular wall we used a Starfish stabilizer.