POSTOPERATIVE DIAGNOSIS: Severe coronary artery disease.

TITLE OF OPERATION: Coronary artery bypass grafting surgery.

ANESTHESIA: General.

DESCRIPTION OF OPERATIVE PROCEDURE: Under general anesthesia, the patient was prepped and draped in the usual sterile fashion. A midline sternotomy incision was made through the skin, the fascia was divided, and the sternum was divided with the use of the sternal saw.

The left internal mammary artery was harvested simultaneously with the video endoscopic harvesting of the right greater saphenous vein. Clips were placed on the branches.

The pericardium was opened. The patient was heparinized. Pericardial stays were used for retraction. The aortic pursestring was inserted. The atrial pursestring was inserted. The aortic line was inserted. The atrial line was inserted. The patient was placed on cardiopulmonary bypass. Cardioplegia was administered in an antegrade fashion via the aortic root. Crossclamp was applied. A good diastolic arrest was achieved and the clamp was placed on the surface of the right ventricle.

Attention was turned to the distal right coronary artery and origin of the acute marginal branch of the right coronary artery. An arteriotomy incision was made in the acute marginal branch. The saphenous vein was anastomosed to this in a running fashion using 7-0 Prolene. Attention was turned to the obtuse marginal of the circumflex artery. An arteriotomy incision was made and saphenous vein was anastomosed to this in a running fashion using 7-0 Prolene. Cardioplegia was administered at the end of each distal graft down through the graft and down through the aortic root to 250 cc. Attention was then turned to the left anterior descending artery. The left anterior descending artery was buried in the fat. The left internal mammary artery was anastomosed to the left anterior descending artery in a running fashion using 7-0 Prolene. A good flush was noted.

The flow was turned down. The crossclamp was removed. The side biter was applied to the aorta and the two proximals were anastomosed to the aorta, one from the obtuse marginal and one from the acute marginal. Prolene 6-0 was used to perform these anastomoses. Marking rings were placed on each of these. The flow was turned down. The side biter was removed. All grafts were deaired.

Flow was resumed to all grafts. The heart began in a normal spontaneous rhythm. The left chest was aspirated. The lungs were inflated. The patient was weaned from cardiopulmonary without difficulty. Pacing wires were placed on the right ventricle and brought out on the left lateral aspect of the incision. All lines were removed. Protamine was administered. Hemostasis was secured from all sites, including the skin fat, the mammary bed, and all cannulations, all proximal and distal anastomotic sites.

The incision was then closed in layers with #5 stainless steel wires used to approximate the sternum, 0-Vicryl suture used to approximate the muscle, 2-0 Vicryl to approximate the subcutaneous tissue, and 4-0 Vicryl subcuticular closure used to approximate the skin.

The patient tolerated the procedure well and returned to the recovery room in stable condition. All lap, instrument, and needle counts were correct.

DESCRIPTION OF OPERATION: The patient was delivered to the operating room and was placed upon the operating room table supine. Swan Ganz catheter and radial artery line were inserted. General endotracheal anesthesia was administered. The patient was prepared with Betadine and draped in a sterile fashion.

The saphenous vein was harvested from the lower extremity, sufficient for three bypass grafts. The tributaries of the vein were controlled with silk clips and silk ligatures. The venous bed was irrigated with antibiotic-containing saline and closed in layers.

The chest was opened through a median sternotomy incision. The left pleural cavity was opened and the left internal mammary artery was fully mobilized. The patient was heparinized systemically after which, the internal mammary was transected distally and prepared for anastomosis. The pericardium was opened. Arterial cannulation was achieved. The distal ascending aorta and venous were placed with a dual-stage venous cannula. Via the right atrial appendage, cardiopulmonary bypass was initiated.

The patient was cooled systemically to approximately 32 degrees C. With application of the aortic crossclamp, the cold blood cardioplegia solution was administered to effect a good cardiac arrest. Cardioplegia was administered in 15-20 minute intervals throughout the period of the aortic occlusion. After hypothermia was achieved, iced saline slush and phrenic nerve protector was employed. The distal anastomoses were accomplished first. Individual segments of reverse saphenous vein were sewn to the obtuse marginal, to the posterolateral branch of the circumflex artery, and to the distal right coronary artery respectively. Each of these anastomoses were carried out with running sutures of 7-0 Prolene. The left internal mammary artery was then brought through a window in the pericardium and was sewn to the left anterior descending vessel with a running suture of 8-0 Prolene. At the termination of this, warm blood cardioplegia was administered and the aortic crossclamp was then released. A partial occluding clamp was placed on the aorta. Three buttons of aortic tissue were excised and used as three proximal anastomoses for the saphenous grafts which were carried out with running sutures of 6-0 Prolene. Temporary pacing wires were placed on the surface of the right atrium and right ventricle.

With the patient fully re-warmed, the heart resumed a good contractility and resumed a normal sinus rhythm. The patient was weaned from cardiopulmonary bypass. This was tolerated without difficulty or need for inotropic support. Excellent Doppler signals were appreciated over all grafts. Protamine was administered to reverse the heparin effect. Decannulation was accomplished. All cannulation sites were reinforced. The patient's hemodynamics remained stable. The entire wound was inspected for hemostasis and was felt to be adequate. One mediastinal tube and one left pleural tube were placed.

The chest was closed in layers in the usual fashion and dry sterile dressing was applied. The patient tolerated the procedure well.

DESCRIPTION OF PROCEDURE: After induction of general anesthesia, the patient was prepped and draped in the usual sterile fashion. A median sternotomy incision was made and hemostasis was acquired with the electrocautery. The left internal mammary artery was harvested and prepared with papaverine and concurrent saphenous vein was harvested endoscopically.

After heparinization, deep pericardial retraction sutures were placed. A partial clamp was then placed on the ascending aorta and the saphenous vein graft was sewn end-to-side with a running 6-0 Prolene. It was then allowed to distend under arterial pressure.

The heart was elevated out of the pericardial cavity and the diagonal was isolated with the octopus stabilizer. The anastomosis was then performed utilizing a side-to-side 8-0 running technique with the left internal mammary artery. The continuation of the left internal mammary artery was then placed end-to-side to the left anterior descending artery with a running 8-0 Prolene technique.

The heart was strongly elevated out of the pericardial cavity and the anastomosis of the saphenous vein graft to the obtuse marginal one was completed end-to-side with a running 7-0 Prolene. The heart was then allowed to return to the pericardial cavity and preparations for wound closure were made.

The pericardium was loosely approximated with interrupted silk sutures. The mediastinum was drained with a single Silastic tube. The sternum was approximated with interrupted heavy wire and the presternal fascia was closed with a running 0-PDS. The skin was closed with a subcuticular 3-0 Monocryl.

Sponge and needle counts were correct. The technical aspects of the procedure were satisfactory and it is hoped that the patient will have a good operative result.

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Rosemarie