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A Novel Cardiac Positioning Device for Left MainCoronary Artery StenosisSushil Kumar Singh, MCh, Ambrish Kumar, MCh, Nitin Rajput, MCh,Vijyant Devenraj, MS, Shailendra Kumar, MS, Tushar Goyal, MS, andJeevan Lal Sahni, MCh

Cardiothoracic and Vascular Surgery Department, Chhatrapati Shahuji Maharaj Medical University, Lucknow, India

Significant hemodynamic alterations often occur duringoff-pump coronary artery bypass operations. Historically,left main coronary artery stenosis has been excludedfrom off-pump coronary artery bypass operations be-cause of this concern. Many articles in recent times

support off-pump operations in left main coronary artery

IV/82, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raiba-reily Road, Lucknow, UP, India 226014; e-mail: doctorsushil@hotmail.com

© 2012 by The Society of Thoracic SurgeonsPublished by Elsevier Inc

(LMCA) stenosis. We describe here a safe and effectivemethod to reduce the incidence of hemodynamic changesduring beating heart surgery in patients with LMCAstenosis.

(Ann Thorac Surg 2012;93:682–3)

© 2012 by The Society of Thoracic Surgeons

Patients with left main coronary artery (LMCA) steno-sis are known to be at higher risk when treated with

medical therapy alone compared with surgical revascu-larization [1]. As techniques for performing off-pumpcoronary artery bypass procedures continue to improve,many surgeons are incorporating this approach into themajority of their elective coronary artery bypass opera-tions. Despite a high level of experience, hemodynamiccollapse sometimes occurs during off-pump coronaryartery bypass procedures. Because of this concern aboutthe ability of the patient to tolerate off-pump coronaryartery bypass procedures, patients with LMCA stenosishave been historically excluded from this procedure.However many surgeons in recent times are performingoff-pump coronary artery bypass procedures for left maincoronary artery stenosis with good results [2].

Here we describe a novel method to reduce the inci-dence of hemodynamic instability during off-pump cor-onary artery bypass operations in LMCA stenosis. It isour hope that this technique will lead to prevention ofsuch catastrophic events and make the operation safer.

Technique

This technique was used in the Department of VascularSurgery of Chatrapati Sahuji Maharaj Medical Univer-sity, Lucknow between January 2000 and December 2010in 92 consecutive patients with LMCA stenosis, in addi-tion to other patients without LMCA stenosis. The fol-lowing technique was used to lift the heart from thepericardial cradle for easy access to the target vesselswithout causing acute hemodynamic alterations.

Accepted for publication Sept 23, 2011.

Address correspondence to Dr Singh, Cardiothoracic Surgery Depart-ment, Chhatrapati Shahuji Maharaj Medical University, Lucknow, Type-

The patient was positioned supine, a median sternot-omy was carried out, and the pericardium was openedup. Suitable conduits were prepared. We took a No. 6surgical glove, an 8F suction catheter, a 3-way stopcock,and a 50-mL disposable syringe. A suction catheter wascut at both ends. A surgical glove was introduced andtied snuggly with 1–0 silk at 1 end of the suction catheter,and a 3-way stopcock was attached at the other end of thecatheter. A 50-mL syringe was attached to the 3-waystopcock (Fig 1).

The surgical glove was gently slipped between theheart and the pericardium and was then placed behindthe left ventricle. As air was injected with the syringe, theglove started inflating and anterior dislocation of theheart occurred as desired (Fig 2). Once the desireddislocation was achieved, the heart was stabilized withthe Octopus Tissue Stabilizer (Medtronic, Inc, Minneap-olis, MN) and target vessel anastomosis was performedwithout significant hemodynamic compromise. With thismaneuver we avoided the acute hemodynamic altera-tions, namely a significant fall in mean pulmonary arterypressure, mean arterial pressure, cardiac output, andmixed venous oxygen saturation and an increase incentral venous pressure. No patient had catastrophichemodynamic collapse during the operation, and none ofthese patients required cardiopulmonary bypass.

Comment

Introduction of cardiopulmonary bypass by Gibbon in1953 advanced cardiac operations as a specialty. Howevercardiopulmonary bypass has many known pathologiceffects like coagulopathy, hemodilution, systemic inflam-matory reactions, immune suppression, stroke, and pul-monary dysfunction among others.

With the evolution of cardiac operations, coronaryartery bypass grafting without cardiopulmonary bypass

became a viable alternative to standard techniques of

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683Ann Thorac Surg HOW TO DO IT SINGH ET AL2012;93:682–3 POSITIONING DEVICE FOR LEFT MAIN DISEASE

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revascularization. Reports from institutions performinglarge numbers of coronary artery revascularization pro-cedures without cardiopulmonary bypass have con-firmed the safety and durability of this procedure [3].

Significant LMCA stenosis is a standard indication forcoronary artery bypass grafting, regardless of the pre-senting complaint of the patient [4]. Surgical revascular-ization in a patient with LMCA stenosis has been shownto prolong survival [1]. Because of some concern abouthe ability of the patient to tolerate off-pump grafting,atients with LMCA stenosis have been excluded histor-

cally from off-pump revascularization.Despite a high level of experience and comfort with

ff-pump coronary artery bypass operations, significantemodynamic derangements continued to occur on nu-erous occasions, and patients required cardiopulmo-

ary bypass [5]. Rotation and dislocation of the heart,ven with the apex out of the pericardial cavity, does notbstruct coronary circulation during off-pump coronaryrtery bypass grafting, but it induces a reduction inardiac output that is primarily caused by impairediastolic expansion of the right ventricle, which getsqueezed between the left ventricle and the right peri-ardium [6]. Hemodynamic alterations occur mainly fromhe act of displacing the heart rather than the displace-

ent itself [7] and hemodynamic changes normalizence the heart is stabilized, using any stabilizing device.ostly the treatment consists of elevation of the right

entricular preload and/or inotropic support. These al-erations in hemodynamics are sometimes catastrophicn patients with left main coronary artery disease.

In our technique, the act of displacing the heart wasinimized by passing the device behind the left ventricleithout lifting the heart; by injecting the air through thether end of the catheter the heart was lifted out of theericardial cavity without any hemodynamic compro-ise. Once the left internal mammary artery to left

nterior descending artery anastomosis was performedfter applying the Octopus Tissue Stabilizer (Medtronic,nc), hemodynamic stability was achieved, and the rest of

Fig 1. Assembly of equipment.

the coronary artery bypass grafting procedure could beperformed. The heart was lifted further to accomplish thecircumflex territory revascularization by injecting moreair into the glove through the catheter.

In conclusion, this technique is safe, reproducible, andcost-effective, which can make off-pump coronary arterybypass operations a routine possibility, even in patientswith LMCA disease.

References

1. Takaro T, Hultgren HN, Lipton MJ, Detre KM. The VAcooperative randomized study of surgery for coronary arterialocclusive disease II. Subgroup with significant left mainlesions. Circulation 1976;54(6 suppl):III:107–17.

2. Dewey TM, Magee MJ, Edgerton JR, Mathison M, TennisonD, Mack MJ. Off-pump bypass grafting is safe in patients withleft main coronary disease. Ann Thorac Surg 2001;72:788–92.

3. Tasdemir O, Vural KM, Karagoz H, Bayazit K. Coronaryartery bypass grafting on the beating heart without the use ofextracorporeal circulation: review of 2052 cases. J ThoracCardiovasc Surg 1998;116:68–73.

4. Kouchoukos NT, Oberman A, Kirklin JW, et al. Coronarybypass surgery: analysis of factors affecting hospital mortality.Circulation 1980;62(2 Pt 2):184–9.

5. Calafiore AM, Mauro DM, Contini M. Myocardial revascular-ization with and without cardiopulmonary bypass in multi-vessel disease: impact of strategy on early outcome. AnnThorac Surg 2001;72:456–63.

6. Mathison M, Edgerton JR, Horswell JL, Akin JJ, Mack MJ.Analysis of hemodynamic changes during beating heart sur-gical procedures. Ann Thorac Surg 2000;70:1355–60.

7. Nierich AP, Diephuis J, Jansen EWL, Borst C, Knape JTA.

Fig 2. Lifting of the heart from the pericardial cradle after injectionof air into the glove.

Heart displacement during off-pump CABG: how well is ittolerated? Ann Thorac Surg 2000;70:466–72.