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“LIMA Fissure” for a Tension-Free IMA Graft in Emphysema
HOW TO DO IT
“LIMA Fissure” for a Tension-Free IMA Graft in Emphysema Podila Sita Rama Rao, MCh, Krishna M. Natarajan, FRCA, and Graham Morritt, FRCS Departments of Cardiothoracic Surgery and Cardiothoracic Anaesthesia & Intensive Care, South Cleveland Hospital, Middlesbrough, United Kingdom
Tension on the mammary artery pedicle is a major concern during coronary artery bypass in asthmatic patients with emphysematous lungs. We are sharing here a simple and effective solution to this problem. (Ann Thorac Surg 1997;63:561–2) © 1997 by The Society of Thoracic Surgeons
S
everal techniques have been described to increase the length of the internal mammary artery (IMA) pedicle [1, 2]. These are used either singly or in combination to allow a tension-free distal left IMA–left anterior descending coronary artery anastomosis in asthmatic patients with grossly emphysematous lungs. The currently available techniques include skeletonization of the IMA [1– 4]; division of the internal mammary vein and extending dissection to the mammary artery’s origin from the subclavian artery, incising the pericardium in line with the pulmonary artery, and performing retrothymic tunneling of the mammary artery [3, 4]; and multiple incisions on the endothoracic fascia and the block of tissue around the IMA [2, 4]. Although some authors recommend taking down the mammary artery well beyond its bifurcation [3] to achieve additional length, it is desirable to anastomose the IMA just proximal to the bifurcation, where it has a maximum luminal diameter for anastomosis. The specific issue of overinflated lung was addressed earlier by suturing a pericardial flap to the chest wall [5]. There is some concern about this technique regarding reoperations and the possibility of pericardial flap tearing and compressing the mammary artery at a future date [4]. The present technique does not have these problems, whereas it further optimizes the length of mammary artery. It gives the shortest straight route to the left anterior descending artery across the apical segment of the upper lobe in emphysematous lung and also avoids stretching of the IMA by the overinflated lung during any future episodes of bronchospasm. We have employed this technique, with gratifying results, during redo coronary bypass grafting in an asthmatic patient with grossly emphysematous lung. This patient had a previous saphenous venous graft on the mid-left anterior descending artery, and the current
Accepted for publication Aug 15, 1996. Address reprint requests to Mr Morritt, Division of Cardiothoracic Surgery, South Cleveland Hospital, Marton Rd, Middlesbrough, United Kingdom TS4 3BW.
© 1997 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
anastomosis was possible only on the distal left anterior descending artery. When ventilation resumed at the end of bypass, it was obvious that the skeletonized full-length mammary artery was under tension because of the emphysematous lungs, and this was further aggravated by an episode of bronchospasm. The apical segment of the left upper lobe was then split with bovine pericardiumbuttressed staples (Peri-Strips; Bio-Vascular, Inc, St. Paul, MN) such that the left IMA ran comfortably through the resulting fissure (Fig 1) and was brought into the surgical field through an incision in the pericardium. The fissure was created to align with the path of the IMA. It was deep enough not to cause any stretch on the IMA even when the lung was fully inflated. Similar application of this technique on the right side may be useful when indicated. We believe this method is an effective addition to the cardiac surgeon’s armamentarium. It provides a simple solution to the long-standing dilemma in using IMA in asthmatic and emphysematous patients.
Fig 1. (1) Apical segment of left upper lobe split with bovine pericardium-buttressed staples. This “LIMA fissure” allows the shortest, straight, tension-free route for the left internal mammary artery (LIMA) to the left anterior descending artery (LAD). (2) Distended and emphysematous lung. 0003-4975/97/$17.00 PII S0003-4975(96)01233-7
562
HOW TO DO IT LIMA FISSURE
RAO ET AL
References 1. Nasef SAM, Angelini GD. Preparation of the internal mammary artery. Br J Hosp Med 1990;45:339– 42. 2. Cosgrove DM, Loop F. Techniques to maximize mammary artery length. Ann Thorac Surg 1985;40:78–9. 3. Brown AH, Dougenis D. Dissection of the two internal mammary arteries with maximal exposure and minimal adverse
Ann Thorac Surg 1997;63:561–2
sequel by means of an inexpensive, simple, atraumatic retractor. J Thorac Cardiovasc Surg 1991;102:753– 6. 4. Martinez MJ, Garcia-Rinaldi R, Traad EA. Minimizing internal mammary artery anastomotic tension [Letter]. Ann Thorac Surg 1988;46:712. 5. Todd EP, Earle GF, Jaggers R, Sekela M. Pericardial flap to minimize internal mammary artery anastomotic tension. Ann Thorac Surg 1987;44:665– 6.
REVIEW OF RECENT BOOKS Perioperative Management of the Patient With Congenital Heart Disease Edited by William J. Greeley, MD Baltimore, Williams & Wilkins, 1996 242 pp, illustrated, $67.00 ISBN 0-683-18302-8 Reviewed by Jonah N. K. Odim, MD, PhD Perioperative Management of the Patient With Congenital Heart Disease is the ninth in a series of monographs from the Society of Cardiovascular Anesthesiologists addressing topical issues. The Editor and 17 contributors have assembled eight “state-of-theart” chapters highlighting the recent developments in managing individuals with congenital heart disease that have made a positive impact on patient outcome. Although this book, written predominantly by nonsurgical experts, does not emphasize operative technique per se, an underlying preeminent theme is the coordinated, multidisciplinary team approach to patient care that optimizes postoperative recovery. The first chapter presents a succinct pathophysiologic conceptual approach to the neonate and infant with congenital heart disease. Emphasis is placed on the recognition and treatment of abnormal postoperative convalescence and the goals of optimal single-ventricle physiology. Transesophageal echocardiography has emerged as the standard of care for intraoperative and early postoperative evaluation of patients undergoing operations for congenital heart disease. Chapter 2 reviews the indications, contraindications, technique, and utility of this modality in patients with congenital heart disease. Expertise in transesophageal echocardiography is no longer confined to cardiologists, but other members of the multidisciplinary team of surgeons, anesthesiologists, intensivists, and specialized nurses are increasingly gaining experience with this tool. Chapters 3 and 4 review unique aspects of pediatric cardiopulmonary bypass, hypothermia, CO2 regulation, cerebral cooling strategies, and the rapidly gaining practice of hemoultrafiltration to attenuate the deleterious effects of hemodilution and systemic inflammation from cardiopulmonary bypass. Chapter 5 is an erudite and superb account of the neurodevelopmental consequences of cardiac operation for congenital heart disease. The exquisite sensitivity of the brain to ischemia and the short-term and long-term sequelae of neurologic injury during cardiac repair is an area of intense basic and clinical investigation. In a thorough but concise manner this section reviews the mechanisms of neurologic injury, the variables
© 1997 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
related to differing perfusion modes, deep hypothermic circulatory arrest, and glucose management. The roles of the excitatory amino acids such as glutamate and their associated synthetic receptor agonists such as N-methyl-d-aspartate and a-amino-3hydroxy-5-methyl-4-isoxazole in neural injury are described. The roles of inflammatory cells and their mediators, free radical injury, and nitric oxide-mediated neuronal toxicity are examined. In a departure from basic science of the brain, the sixth chapter is a brief and complete review of the evolution and rationale for staging the management of the univentricular heart. The next to last chapter deals with the emergence of interventional techniques in the treatment of congenital heart disease spurring increasing collaboration between cardiac surgeons, interventional cardiologists, and cardiac anesthetists in mapping the therapeutic strategy for children with complex and critical heart disease. The final chapter of this book deals with managing the ever-increasing population of adult patients with congenital heart disease that require noncardiac operations. There are 500,000 adults in the United States with congenital heart disease. There are approximately 20,000 intracardiac operations for congenital heart disease performed annually. About 85% of the 25,000 children born in the United States with congenital heart disease are now expected to reach adulthood given the advances of the last decade. The author addresses the medical management of this group of patients from the point of view of the anesthesiologist who is called to put these patients to sleep or administer sedation and analgesia. The physiologic implications of the underlying cardiac defect(s), the cardiac and noncardiac residua and sequelae of previous operations, and the acquired cardiac and noncardiac diseases that accrue with normal aging make for a diverse and challenging group of patients who may undergo a full spectrum of noncardiac procedures during their life span. Except for the occasional typographic error this neatly bound volume is a collection of uniformly well-written and pithy chapters addressing the recent advances in managing patients with congenital heart disease. The chapters are for the most part well illustrated and referenced. A predominant authorship of pediatric cardiac anesthesiologists should not deter cardiothoracic surgeons and others involved in the perioperative management of patients with congenital heart disease from reading this superb monograph. Atlanta, Georgia
Ann Thorac Surg 1997;63:562
• 0003-4975/97/$17.00 PII S0003-4975(96)01240-4
“LIMA Fissure” for a Tension-Free IMA Graft in Emphysema Podila Sita Rama Rao, MCh, Krishna M. Natarajan, FRCA, and Graham Morritt, FRCS Departments of Cardiothoracic Surgery and Cardiothoracic Anaesthesia & Intensive Care, South Cleveland Hospital, Middlesbrough, United Kingdom
Tension on the mammary artery pedicle is a major concern during coronary artery bypass in asthmatic patients with emphysematous lungs. We are sharing here a simple and effective solution to this problem. (Ann Thorac Surg 1997;63:561–2) © 1997 by The Society of Thoracic Surgeons
S
everal techniques have been described to increase the length of the internal mammary artery (IMA) pedicle [1, 2]. These are used either singly or in combination to allow a tension-free distal left IMA–left anterior descending coronary artery anastomosis in asthmatic patients with grossly emphysematous lungs. The currently available techniques include skeletonization of the IMA [1– 4]; division of the internal mammary vein and extending dissection to the mammary artery’s origin from the subclavian artery, incising the pericardium in line with the pulmonary artery, and performing retrothymic tunneling of the mammary artery [3, 4]; and multiple incisions on the endothoracic fascia and the block of tissue around the IMA [2, 4]. Although some authors recommend taking down the mammary artery well beyond its bifurcation [3] to achieve additional length, it is desirable to anastomose the IMA just proximal to the bifurcation, where it has a maximum luminal diameter for anastomosis. The specific issue of overinflated lung was addressed earlier by suturing a pericardial flap to the chest wall [5]. There is some concern about this technique regarding reoperations and the possibility of pericardial flap tearing and compressing the mammary artery at a future date [4]. The present technique does not have these problems, whereas it further optimizes the length of mammary artery. It gives the shortest straight route to the left anterior descending artery across the apical segment of the upper lobe in emphysematous lung and also avoids stretching of the IMA by the overinflated lung during any future episodes of bronchospasm. We have employed this technique, with gratifying results, during redo coronary bypass grafting in an asthmatic patient with grossly emphysematous lung. This patient had a previous saphenous venous graft on the mid-left anterior descending artery, and the current
Accepted for publication Aug 15, 1996. Address reprint requests to Mr Morritt, Division of Cardiothoracic Surgery, South Cleveland Hospital, Marton Rd, Middlesbrough, United Kingdom TS4 3BW.
© 1997 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
anastomosis was possible only on the distal left anterior descending artery. When ventilation resumed at the end of bypass, it was obvious that the skeletonized full-length mammary artery was under tension because of the emphysematous lungs, and this was further aggravated by an episode of bronchospasm. The apical segment of the left upper lobe was then split with bovine pericardiumbuttressed staples (Peri-Strips; Bio-Vascular, Inc, St. Paul, MN) such that the left IMA ran comfortably through the resulting fissure (Fig 1) and was brought into the surgical field through an incision in the pericardium. The fissure was created to align with the path of the IMA. It was deep enough not to cause any stretch on the IMA even when the lung was fully inflated. Similar application of this technique on the right side may be useful when indicated. We believe this method is an effective addition to the cardiac surgeon’s armamentarium. It provides a simple solution to the long-standing dilemma in using IMA in asthmatic and emphysematous patients.
Fig 1. (1) Apical segment of left upper lobe split with bovine pericardium-buttressed staples. This “LIMA fissure” allows the shortest, straight, tension-free route for the left internal mammary artery (LIMA) to the left anterior descending artery (LAD). (2) Distended and emphysematous lung. 0003-4975/97/$17.00 PII S0003-4975(96)01233-7
562
HOW TO DO IT LIMA FISSURE
RAO ET AL
References 1. Nasef SAM, Angelini GD. Preparation of the internal mammary artery. Br J Hosp Med 1990;45:339– 42. 2. Cosgrove DM, Loop F. Techniques to maximize mammary artery length. Ann Thorac Surg 1985;40:78–9. 3. Brown AH, Dougenis D. Dissection of the two internal mammary arteries with maximal exposure and minimal adverse
Ann Thorac Surg 1997;63:561–2
sequel by means of an inexpensive, simple, atraumatic retractor. J Thorac Cardiovasc Surg 1991;102:753– 6. 4. Martinez MJ, Garcia-Rinaldi R, Traad EA. Minimizing internal mammary artery anastomotic tension [Letter]. Ann Thorac Surg 1988;46:712. 5. Todd EP, Earle GF, Jaggers R, Sekela M. Pericardial flap to minimize internal mammary artery anastomotic tension. Ann Thorac Surg 1987;44:665– 6.
REVIEW OF RECENT BOOKS Perioperative Management of the Patient With Congenital Heart Disease Edited by William J. Greeley, MD Baltimore, Williams & Wilkins, 1996 242 pp, illustrated, $67.00 ISBN 0-683-18302-8 Reviewed by Jonah N. K. Odim, MD, PhD Perioperative Management of the Patient With Congenital Heart Disease is the ninth in a series of monographs from the Society of Cardiovascular Anesthesiologists addressing topical issues. The Editor and 17 contributors have assembled eight “state-of-theart” chapters highlighting the recent developments in managing individuals with congenital heart disease that have made a positive impact on patient outcome. Although this book, written predominantly by nonsurgical experts, does not emphasize operative technique per se, an underlying preeminent theme is the coordinated, multidisciplinary team approach to patient care that optimizes postoperative recovery. The first chapter presents a succinct pathophysiologic conceptual approach to the neonate and infant with congenital heart disease. Emphasis is placed on the recognition and treatment of abnormal postoperative convalescence and the goals of optimal single-ventricle physiology. Transesophageal echocardiography has emerged as the standard of care for intraoperative and early postoperative evaluation of patients undergoing operations for congenital heart disease. Chapter 2 reviews the indications, contraindications, technique, and utility of this modality in patients with congenital heart disease. Expertise in transesophageal echocardiography is no longer confined to cardiologists, but other members of the multidisciplinary team of surgeons, anesthesiologists, intensivists, and specialized nurses are increasingly gaining experience with this tool. Chapters 3 and 4 review unique aspects of pediatric cardiopulmonary bypass, hypothermia, CO2 regulation, cerebral cooling strategies, and the rapidly gaining practice of hemoultrafiltration to attenuate the deleterious effects of hemodilution and systemic inflammation from cardiopulmonary bypass. Chapter 5 is an erudite and superb account of the neurodevelopmental consequences of cardiac operation for congenital heart disease. The exquisite sensitivity of the brain to ischemia and the short-term and long-term sequelae of neurologic injury during cardiac repair is an area of intense basic and clinical investigation. In a thorough but concise manner this section reviews the mechanisms of neurologic injury, the variables
© 1997 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
related to differing perfusion modes, deep hypothermic circulatory arrest, and glucose management. The roles of the excitatory amino acids such as glutamate and their associated synthetic receptor agonists such as N-methyl-d-aspartate and a-amino-3hydroxy-5-methyl-4-isoxazole in neural injury are described. The roles of inflammatory cells and their mediators, free radical injury, and nitric oxide-mediated neuronal toxicity are examined. In a departure from basic science of the brain, the sixth chapter is a brief and complete review of the evolution and rationale for staging the management of the univentricular heart. The next to last chapter deals with the emergence of interventional techniques in the treatment of congenital heart disease spurring increasing collaboration between cardiac surgeons, interventional cardiologists, and cardiac anesthetists in mapping the therapeutic strategy for children with complex and critical heart disease. The final chapter of this book deals with managing the ever-increasing population of adult patients with congenital heart disease that require noncardiac operations. There are 500,000 adults in the United States with congenital heart disease. There are approximately 20,000 intracardiac operations for congenital heart disease performed annually. About 85% of the 25,000 children born in the United States with congenital heart disease are now expected to reach adulthood given the advances of the last decade. The author addresses the medical management of this group of patients from the point of view of the anesthesiologist who is called to put these patients to sleep or administer sedation and analgesia. The physiologic implications of the underlying cardiac defect(s), the cardiac and noncardiac residua and sequelae of previous operations, and the acquired cardiac and noncardiac diseases that accrue with normal aging make for a diverse and challenging group of patients who may undergo a full spectrum of noncardiac procedures during their life span. Except for the occasional typographic error this neatly bound volume is a collection of uniformly well-written and pithy chapters addressing the recent advances in managing patients with congenital heart disease. The chapters are for the most part well illustrated and referenced. A predominant authorship of pediatric cardiac anesthesiologists should not deter cardiothoracic surgeons and others involved in the perioperative management of patients with congenital heart disease from reading this superb monograph. Atlanta, Georgia
Ann Thorac Surg 1997;63:562
• 0003-4975/97/$17.00 PII S0003-4975(96)01240-4