Eur J Cardiothorac Surg 1998;14:536-537
© 1998 Elsevier Science NL
Right ventricular rupture in minimally invasive direct coronary artery bypass grafting
Minoru Ono,
Shinichi Takamoto,
Toshiya Ohtsuka
Department of Cardiothoracic Surgery, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo Bunkyo-ku, Tokyo, 113-8655, Japan
Received 10 June 1998;
received in revised form 5 August 1998;
accepted 11 August 1998.
Corresponding author. Tel.: +81 3 58008654; fax: +81 3 56843989.
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Abstract
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We report a rare case of the rupture of the right ventricle which occurred in a minimally invasive direct coronary artery bypass grafting (MIDCABG) for a redo bypass surgery. A 52-year-old male patient underwent a left internal thoracic artery (LITA) to the left anterior descending artery (LAD) bypass. Rupture of the right ventricle occurred abruptly during dissection to find the LAD. Too much dissection of the interventricular groove under undue traction of the pericardium may cause a rupture of the heart.
Key Words: Minimally invasive direct coronary artery bypass grafting • Rupture of the right ventricle
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Introduction
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Minimally invasive direct coronary artery bypass grafting (MIDCABG) is a good alternative for the treatment of strictly selected subgroup of patients. This procedure is, however, still in development, and some technical modifications or improvements are reported in many papers. We describe a case of redo left internal thoracic artery (LITA) to left anterior descending coronary artery (LAD) bypass by MIDCABG, which was complicated with the rupture of the right ventricle.
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Case report
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A 52-year-old male patient was admitted to our hospital for a redo coronary artery bypass grafting (CABG). He had underwent the initial double CABG to the LAD and the right coronary artery (RCA) using saphenous veins in 1986. He had his left lung resected for lung cancer in 1993. The patient developed the return of angina, and coronary artery angiography revealed the occlusion of the vein graft to the LAD with severe stenosis of the proximal LAD. The vein graft to the RCA was patent without any sign of graft disease. We planned to treat the patient by the minimally invasive approach. An ultrafast computed tomography (
Fig. 1
) was employed to detect the spatial relationship of the LAD and the LITA, by which we decided the final incision. At the operation a small incision (5 cm in length) was made in the fourth intercostal space, through which the LITA was harvested under direct vision. The pericardium was opened and dissected just around the area which was supposed to be necessary for anastomosis. Its cut edges were tightly secured to the skin. The previous distal anastomosis to the LAD was so proximal that it was impossible to find it. While dissecting the fat tissue of the anterior interventricular groove to find an optimal anastomotic site, massive bleeding suddenly began. Blood was flooding out of the right ventricle through a 2-cm long tear along the ventricular septum. As it was quite difficult to obtain a good whole view of the ruptured site, the femoro-femoral bypass was initiated quickly. The ruptured right ventricle was successfully repaired using a strip of equine pericardium. Subsequently, LITA to LAD bypass was completed on a beating heart via the mini-thoracotomy without transfusion. Postoperative course of the patient was uneventful, and the coronary angiography revealed the patency of the graft.
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Fig. 1. A preoperative ultrafast computed tomographic scan. This modality facilitated preoperative spacial imaging of LITA (white arrow) and LAD (white arrowhead). Note that the free wall of right ventricle is very thin (black arrowhead).
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Discussion
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MIDCABG is still evolving and has not been standardized yet. However it proved to be a vital choice of treatment for the carefully selected patients. Several surgical indications have been proposed by some surgeons
[1]
[2]. The best candidates are maybe those patients who require reoperative CABG
[2]. Off-pump reoperative CABC has some advantages in terms of avoidance of non-physiological extracorporeal circulation, preservation of normal interventricular septal movement and less requirement for transfusion
[3]
[4]. In addition MIDCABG in a redo case eliminates the necessity to access the diseased aorta and avoids injury to patent vein grafts by minimizing dissection of the heart.
However this approach requires the surgeon to identify a target vessel in a limited dissection, which has a possible risk of damaging the heart, particularly the thin wall of the right ventricle. In this case, the LAD could be identified, but we had some difficulties to find an optimal site for anastomosis. During subsequent dissection on the anterior interventricular groove, the right ventricle was torn abruptly along the ventricular septum. Excessive suspension of the pericardium, which tightly adhered to the epicardium, may have put undue tension on the dissected interventricular groove. The free wall of right ventricle was found to be very thin at its junction with the ventricular septum on careful retrospective observation of the computed tomography (
Fig. 1).
In MIDCABG for reoperative CABG with pericardial adhesion, suspending the pericardium is an efficacious technique for immobilization of the heart, which often eliminates the need for mechanical stabilization within a limited surgical field. We learned a lesson from this case, that too much tension on the suspended pericardium for gaining a better immobilization could injure the heart in a redo case which requires probing dissection to find a target coronary artery.
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References
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- Calafiore A.M., Di Giammarco G., Teodori G., Bosco G., D'Annunzio E., Barsotti A., Maddestra N., Paloscia L., Vitolla G., Sciarra A., Fino C., Contini M. Left anterior descending coronary artery grafting via left anterior small thoracotomy without cardiopulmonary bypass. Ann Thorac Surg 1996;61:1658-1665.[Abstract/Free Full Text]
- Subramanian V.A. Less invasive arterial CABG on a beating heart. Ann Thorac Surg 1997;63:S68-S71.
- Akins C.W., Boucher C.A., Pohost G.M. Preservation of interventricular septal function in patients having coronary artery bypass grafts without cardiopulmonary bypass. Am Heart J 1984;107:304-309.[Medline]
- Moshkovitz Y., Lusky A., Mohr R. Coronary artery bypass without cardiopulmonary bypass: analysis of short-term and mid-term outcome in 220 patients. J Thorac Cardiovasc Surg 1995;110:979-987.[Abstract/Free Full Text]
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Abstract
Introduction
