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Address for reprints: Hiromu Kehara, MD, PhD, Division of Cardiovascular Surgery, Lewis Katz School of Medicine at Temple University, 3401 N Broad St, Zone C, 3rd Floor, Suite 301, Philadelphia, PA 19140.
Concomitant off-pump CABG using an in situ RITA to the RCA with off-pump right SLT through a right anteroaxillary thoracotomy can be a valuable option in selected LTx recipients with significant coronary artery disease.
See Commentary on page XXX.
A 77-year-old man with progressive respiratory insufficiency due to pulmonary fibrosis was referred to our hospital for the consideration of lung transplantation (LTx). He was 70 inches tall with a body mass index of 24 kg/m2. Forced vital capacity, forced expiratory volume in 1 second, and diffusing capacity for carbon monoxide were 42%, 45%, and 26% of predicted, respectively. A lung perfusion scan showed right and left lungs is 38% and 62%, respectively. His medical history included coronary artery disease for which he underwent multiple percutaneous coronary interventions (PCIs). A preoperative coronary angiogram showed that previously placed stents were widely patent; however, the proximal right coronary artery (RCA) had an 80% to 90% stenosis (Figure 1 and Video 1). Given the lack of angina symptoms, the multidisciplinary team including cardiologists decided to list the patient for single lung transplantation (SLT) with concomitant coronary artery bypass grafting (CABG) rather than preoperative PCI, which requires 3 to 6 months of dual antiplatelet therapy. The patient’s lung allocation score was 44. This article includes no information that can identify the patient; thus, informed consent for publication and Institutional Review Board approval were not required.
Figure 1Coronary angiogram shows an 80% stenosis in the proximal RCA (black arrow).
was performed along the fourth intercostal space. The pericardium was opened, and using an Octopus stabilizer (Medtronic Inc), the mid-RCA was exposed. The right internal thoracic artery (RITA) was harvested in a semi-skeletonized fashion. Off-pump RITA-RCA anastomosis was performed using a 3-mm intracoronary shunt (Figure 2), followed by a right SLT without mechanical circulatory support. The total ischemic time was 193 minutes, and the warm ischemic time (the first anastomosis to reperfusion) was 34 minutes. The patient was extubated 38 hours after surgery and discharged home on postoperative day 21. Currently, the patient is doing well at home without any dyspnea and angina symptoms 8 months after LTx.
Figure 2Intraoperative illustration demonstrates RITA-RCA bypass through a right antero-axillary thoracotomy. In situ RITA was anastomosed to the mid-RCA using the Octopus stabilizer (Medtronic Inc).
Although equivalent outcomes after LTx with concomitant coronary revascularization compared with those without have been reported, the optimal timing (preoperative or intraoperative) and approach (PCI or CABG) still remain unknown.
When we consider concomitant CABG, there are a few options for the graft source. In left SLT through a left thoracotomy, left internal thoracic artery to left anterior descending artery bypass is an ideal option that produces excellent results. Based on recent favorable results of bilateral internal thoracic artery use, more RITAs have been used.
New technique “right anterior small thoracotomy (RAST operation)” for beating heart grafting of the right internal thoracic artery to the posterior descending artery to the posterior descending artery in a third redo CABG patient. A novel coronary technique.
New technique “right anterior small thoracotomy (RAST operation)” for beating heart grafting of the right internal thoracic artery to the posterior descending artery to the posterior descending artery in a third redo CABG patient. A novel coronary technique.
reported third-time redo CABG using the RITA through a right thoracotomy. However, the RITA needed to be extended with a saphenous vein graft to reach the posterior descending artery. In contrast, we anastomosed the in situ RITA directly to the mid-RCA.
Surgical approaches for SLT include posterolateral thoracotomy, median sternotomy, clamshell, anterolateral thoracotomy, and axillary incision, and we have developed an anteroaxillary approach providing excellent exposure of the hilum (Figure 3).
A median sternotomy is the best approach for CABG, but it has some disadvantages in performing LTx. First, the hilum is deeper, and access to the hilum is more difficult than the anteroaxillary approach. In addition, the posterior aspect of the hilum is even more difficult to access, especially after LTx. Second, we need to retract the pericardium and the heart to expose the hilum, and this might stress and damage the phrenic nerve and CABG grafts. Thus, the anteroaxillary approach would be the best if CABG is doable through the same approach.
Figure 3An antero-axillary skin incision was made beginning at the junction of the anterior axillary line and the infrathoracic crease, extending toward the axilla along the crease and lateral to the pectoralis major muscle. The incision was 8 to 12 cm in length.
There are a few technical points to be addressed. The pericardiotomy is along the RCA, enabling exposure of the target coronary artery and preventing the right lung from obstructing the exposure of the coronary target while ventilating both lungs with poor oxygenation. We chose an appropriate target and measured the length of the in situ RITA to the target accurately so that we could use the largest portion of the RITA. We used a suction stabilizer to pull the target superiorly to create a tension-free anastomosis. The largest intracoronary shunt for the lumen is used to maintain native right coronary blood flow to avoid regional ischemia, resulting in hemodynamic instability and bradycardia including complete atrioventricular block. An anastomosis was accurately and quickly performed. Thus, to perform successful concomitant LTx and CABG, especially both off-pump, the surgeons need to be experts in both components of the operation.
Conclusions
We report the first case of successful concomitant off-pump CABG using an in situ RITA to the RCA with off-pump right SLT through a right anteroaxillary thoracotomy. This procedure can be a valuable option in selected LTx recipients with significant coronary artery disease in the proximal RCA.
New technique “right anterior small thoracotomy (RAST operation)” for beating heart grafting of the right internal thoracic artery to the posterior descending artery to the posterior descending artery in a third redo CABG patient. A novel coronary technique.
Disclosures: The authors reported no conflicts of interest.
The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.
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