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Emergency Off-Pump Coronary ArteryBypass (OPCAB) for Left MainCoronary Occlusion Using RapidAorto-Coronary PerfusionPaul Kerr, D.O., and Reginald Abraham, M.D.

Department of Cardiothoracic Surgery, SUNY at Buffalo, Buffalo, New York

ABSTRACT 64 year old female with occluded left main after first injection brought to the operating

room in extremis on IABP and maximum inotropes. LAD grafted with sapenous vein and imme-

diate aorto-coronary perfusion. Circumflex grafted and patient taken to ICU. Patient discharged

on POD #6 after echo shows normal ventricular with no wall motion abnormality. (J Card Surg2002;17:495-497)

INTRODUCTION

Coronary artery bypass grafting (CABG) foracute coronary occlusion and impending acutemyocardial infarction (AMI) is associated withhigh mortality and morbidity. Avoidance of cardio-pulmonary bypass (CPB) for CABG has recentlybeen proposed as an alternative to traditionalmethods of myocardial revascularization.1,2 Mod-ern techniques of CPB and myocardial protectionare remarkably safe in many routine procedures.However, patients with significant preoperativecomorbidities, such as peripheral and cerebrovas-cular disease, renal insufficiency, chronic obstruc-tive pulmonary disease (COPD), and AMI, may nottolerate the well-known side effects of CPB. AsOPCAB experience and technology improves, ex-tending the indications to emergency cases maybe appropriate.

CASE REPORT

A.M. is a 64-year-old female with well-knowndouble vessel coronary disease and normal ejec-

Address reprints and correspondence to: Dr. Paul C. Kerr, Di-vision of Cardiothoracic Surgery Millard Fillmore Gates-CircleHospital 3 Gates Circle, Buffalo, NY 14209. Tel: (716) 884 3734Fax: (716) 884 3235 e-mail: paulckerr@msn.com

tion fraction was scheduled for percutaneouscoronary intervention. The first time the catheterwas introduced into the left main ostia, the arterydissected with no flow distally. The right coronaryartery was normal. Despite multiple attempts toopen the left main the patient became progres-sively unstable. The patient was intubated andan intraaortic balloon pump (IABP) was inserted.The patient was brought to the operating room onhigh doses of epinephrine, Levophed, and nitro-glycerin. The chest was quickly opened while twopieces of saphenous vein were harvested. The pa-tient remained in sinus rhythm with a blood pres-sure of 85/60 mmHg augmenting to 110. We de-cided at that point we could graft the left anteriordescending artery (LAD) in less time than it wouldtake to cannulate, clamp, and adequately delivermyocardial protection. Therefore, the LAD wasgrafted and was immediately perfused from theaorta with a 14-gauge angiocatheter (Fig. 1). Theblood pressure increased dramatically to 120 sys-tolic and the epinephrine and Levophed could beweaned off. While the LAD was being perfused,a partial-occluding clamp was placed on the aortaand the proximal graft to the circumflex coro-nary artery was constructed. Then the LAD per-fusion was stopped for a brief period to construct

496 KERR AND ABRAHAM J CARD SURGEMERGENCY OPCAB FOR LEFT MAIN CORONARY OCCLUSION 2002;17:495-497

Figure 1.

the proximal anastomosis. Once the clamp wasremoved and the LAD perfused again, the circum-flex could be grafted without difficulty. Flow wasmeasured in both grafts and was found to be inthe 40 to 50 cc/min range with good diastolic pat-terns. The IABP was removed the next morningand the patient was extubated. The postopera-tive echocardiogram showed an ejection fractionof 55% with no wall motion abnormalities. The pa-tient was discharged on postoperative day six.

DISCUSSION

Despite advances in CPB and myocardial pro-tection, CABG in the face of acute coronary oc-

clusion with impending infarction carries a highmortality.3,4 Mortality rates in patients operatedon early after recent AMI varies from 3.2% to16%.5-8 The STS national database from 1995to 1996 reported a risk-adjusted mortality rang-ing from 3.88% to 3.94%. Avoidance of CPBhas been shown to reduce perioperative mortal-ity in patients operated on early after AMI.9,10

The obvious question that cannot be answered bythis case is whether the time spent grafting theLAD contributed to ongoing myocardial ischemiaany more than the time spent cannulating, goingon CPB, and adequately delivering optimal my-ocardial protection. Although we are not advo-cating this as the standard procedure for acute

J CARD SURG KERR AND ABRAHAM 4972002;17:495-497 EMERGENCY OPCAB FOR LEFT MAIN CORONARY OCCLUSION

coronary occlusion, we think it does point outthat the application of OPCAB is still in its in-fancy. We feel that avoiding the well-documentedside effects of CPB in these critically ill patients,without compromising revascularization OPCAB,may well become another tool in the treatmentof acute coronary occlusion.

EDITOR’S NOTE

“Emergency OPCAB for left main coronary

occlusion using rapid aortocoronary

perfusion”

Is this interesting surgical technique reallynew? Most surgeons established rapid coronaryperfusion by a vein graft in earlier times, but car-diopulmonary bypass circuits can now be assem-bled so rapidly and cannulation accomplished soquickly that the times are similar to vein harvest-ing and creation of a distal anastomosis. Further-more, institution of cardiopulmonary bypass andcardioplegic arrest prevents ongoing ischemiawhile maintaining peripheral perfusion. Indeedmost surgeons would now take down the internalmammary artery on cardiopulmonary bypass forthe LAD in such a patient 60-years-old, perhapsgrafting a diagonal coronary first and perfusing thevein graft from the cardioplegic circuit.

The deleterious effects of cardiopulmonary by-pass are mentioned a few times in this casereport without mentioning the deleterious ef-fects of an unstable patient with low cardiac out-put on massive inotropes with ongoing myocar-dial ischemia. While emergency performance ofOPCAB is increasingly performed by more sur-geons, my own practice still relies on circulatorysupport by extracorporeal perfusion and possiblyintraaortic balloon pump assist with cardioplegicarrest and creation of a mammary-LAD bypassfor circumstances described in the above casereport.

Bernard S. Goldman, M.D.

REFERENCES

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10. Locker CH, Moshkovitch Y, Gurevitch J, et al.Myocardial revascularization with and withoutcardiopulmonary bypass in patients with acutemyocardial infarction. Paper presented at: thir-teenth meeting of the EACTS; September 1999,Glasgow, Scotland.