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Eur J Cardiothorac Surg 2001;20:415-417
© 2001 Elsevier Science NL

Case report

Thoracic epidural anesthesia for coronary bypass via left anterior thoracotomy in the conscious patient

Division of Cardiothoracic Surgery, University of Miami School of Medicine, Miami Veterans Affairs Hospital, Miami, Florida, FL, USA

Received 5 December 2000; received in revised form 6 January 2001; accepted 30 May 2001.

Corresponding author. Section of Cardiothoracic Surgery MEB-500B, UMDNJ/ Robert Wood Johnson School of Medicine, 1 Robert Wood Johnson Place, New Brunswick, NJ 08903, USA. Tel.: +1-732-235-8725; fax: +1-305-235-8727
e-mail: andersm2{at}umdnj.edu

	Abstract

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 
Cardiac surgery is perceived to be maximally invasive and fraught with complications. Secondary to this, cardiothoracic surgeons have been refining traditional techniques to minimize their invasive nature. Epidural anesthesia has been utilized safely and effectively for numerous surgical procedures to reduce the associated morbidity. In hopes of achieving a similar result, we utilized thoracic epidural anesthesia for a coronary artery bypass via a left anterior thoracotomy, in an awake, spontaneously breathing patient. To the best of our knowledge, this is the first reported case utilizing this approach. Herein we report the results and technique utilized.

Key Words: Coronary artery bypass grafting • Thoracic epidural anesthesia

	1. Introduction

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 
Cardiac surgery is perceived as a maximally invasive procedure. As a result and due to the availability of less invasive catheter-based interventions, surgeons have been refining traditional techniques to minimize their invasive nature and make them more appealing to patients. In this pursuit, extra-pleural coronary artery bypass was recently reported using thoracic epidural anesthesia [1]. With this as a background, we set out to determine the feasibility of a left anterior thoracotomy for a limited cardiac surgical procedure, utilizing this anesthetic approach.

	2. Materials and methods

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 
The patient was a 61-year-old male who had previously undergone stenting of his left anterior descending (LAD). When his angina recurred, repeat catheterization revealed re-stenosis of his LAD. There were no other lesions. The patient elected to pursue revascularization via minimally invasive direct coronary artery bypass grafting (MIDCAB).

Anticoagulants were discontinued 1 week prior to operation. He was admitted the evening before surgery for epidural placement as a safety measure. A high thoracic epidural anesthesia technique was utilized. A flexible catheter (Arrow International Inc., Reading, PA) was introduced at the fourth thoracic (T4) interspace. A dose of 2% lidocaine (with epinephrine 1:200,000) was given to test the efficacy of the block and to rule out intrathecal or intra-vascular catheter placement. Immediately prior to surgery, 0.75% bupivacaine was infused and titrated to achieve a motor and sensory block to the first thoracic (T1) level. Additional doses were given throughout the procedure to maintain the block. Intravenous sedation with dexmedetomidine was also administered to provide satisfactory patient comfort while preserving spontaneous respiration. Supplemental oxygen was given using a 100% non-re-breather mask. The patient was monitored in standard fashion including continuous end-tidal CO₂.

The MIDCAB was performed via a small left anterior thoracotomy. The chest was entered in the fourth intercostal space. With the pleura open, the left internal mammary artery (LIMA) was harvested to the first intercostal space. Subsequently, 10,000 U of heparin was administered. After pericardiotomy, the LAD was isolated, and using a surgical stabilizer (Genzyme Surgical, Fall River, MA) without a shunt, the anastomosis was performed. Upon completion, patency was assessed using a transit time flow meter (Medi-Stim A/S, Oslo, Norway). This demonstrated 47 ml/min of flow with a pulsatilty index of 2.7. Protamine was administered and the chest was closed in the routine fashion. The epidural catheter was left in place for postoperative pain control and was removed after 24 h.

	3. Results

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 
The procedure was completed without incident. Operative time was 170 min. At no point did the patient require assisted ventilation. Oxygen saturation was consistently maintained in excess of 90% and carbon dioxide levels did not exceed 50 mmHg. The patient was conscious throughout and responded to commands. Systemic hypotension, secondary to vasodilation from the sympathectomy, responded to intra-venous volume expansion. Post-operative pain relief was excellent. There were no complications and the patient was discharged home on post-operative day number three.

	4. Discussion

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 
Epidural anesthesia is used for a myriad of surgical procedures and is commonly employed for post-operative pain management following cardiothoracic surgery [2]. Although it is recognized that endotracheal anesthesia is safe and provides a stable operative environment, it is not exempt from complications. Further, there may be potential benefits from its avoidance. These include reducing the stress responses, preservation of the fibrinolytic system and the stimulation of coronary vasodilation [3–5]. In addition, patient satisfaction must be considered. Despite these potential benefits, we were concerned whether a thoracotomy would be tolerated from the physiologic and anesthetic point of view, as to date, the only reported experience with this technique utilized a limited extra-pleural approach without intrathoracic dissection. These concerns were unfounded, however several interesting observations were made.

First, upon entering the chest, the lung promptly collapsed and conveniently remained out of the surgical field throughout the procedure. Dissection of the LIMA was well-tolerated until the upper thorax was reached, when some discomfort ensued. This was managed with local lidocaine instillation. Also, upon opening the pericardium, significant left shoulder pain occurred. This was felt to be secondary to irritation of the pericardial branches of the phrenic nerve, which were not blocked by the epidural. The pleural space was subsequently bathed in lidocaine with marked relief. However, we now feel that local block of the intrathoracic phrenic nerve could ameliorate this problem. This would be tolerated since the lung on the blocked side is not contributing to respiratory function. Additionally, since the block would be short-lived, it would not interfere with postoperative respiratory mechanics. The mediastinal motion encountered was easily controlled with pericardial sutures and the surgical stabilizer. Having the epidural catheter in place for post-operative pain management was clearly beneficial and facilitated recovery.

It is obvious that this technique has several limitations. The potential patients must be cooperative and have favorable anatomy. In addition, they must be able to tolerate single lung spontaneous ventilation, which is solely dependent on diaphragmatic mechanics. Unstable patients, patients on anticoagulants and those requiring emergent procedures, will not be candidates. The possibility of developing an epidural hematoma must also be considered. However, it has been reported that epidural anesthesia in heparinized patients is a safe technique [6]. Procedures that require more exposure, such as provided by sternotomy, or that require extensive manipulation, will also be problematic. On the other hand, for limited interventions such as the MIDCAB or transmyocardial laser revascularization, this technique may be eminently appropriate. The current literature suggests that the results with MIDCAB surgery are comparable to conventional techniques and the reported outcomes with TMR have been satisfying [7,8]. In addition, many surgeons are beginning to favor less invasive and targeted approaches for more complicated cases. The end result should be an increasing frequency of these types of cases. The degree of patient satisfaction we encountered was gratifying. It is not uncommon for our patient's primary concern to be the experience of endotracheal intubation. As such, in each of these cases the patients overwhelmingly accepted this anesthetic approach. Finally, the technique offered no real technical hurdles and should afford results comparable to conventional methods. In pursuing this approach, we hope to better define candidacy criteria, procedure applicability, as well as operative results and long term outcomes.

	Acknowledgments

 
The authors would like to acknowledge the technical advice of Dr Marco A. Zenati in pursuing this endeavor.

	References

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 

1. Karagoz H.Y., Sonmez B., Bakkaloglu B., Kurtoglu M., Erdine M., Turkeli A., Bayazit K. Coronary artery bypass grafting in the conscious patient without endotracheal general anesthesia. Ann Thorac Surg 2000;70:91-96.[Abstract/Free Full Text]
2. Liem T.H., Williams J.P., Hensens A.G., Singh S.K. Minimally invasive direct coronary artery bypass using a high thoracic epidural plus general anesthetic technique. J Cardiothorac Vasc Anesth 1998;12:668-672.[Medline]
3. Blomberg S., Emanuelsson H., Kvist H., Lamm C., Ponten J., Waagstein F., Ricksten S.E. Effects of thoracic epidural anesthesia on coronary arteries and arterioles in patients with coronary artery disease. Anesthesiology 1990;73:840-847.[Medline]
4. Rosenfeld B.A., Beattie C., Christopherson R., Norris E.J., Frank S.M., Breslow M.J., Rock P., Parker S.D., Gottlieb S.O., Perler B.A. The effects of different anesthetic regimens on fibrinolysis and the development of postoperative arterial thrombosis. Anesthesiology 1993;79:435-443.[Medline]
5. Paulissian R., Salem M.R., Joseph N.J., Braverman B., Cohen H.C., Crystal G.J., Heyman H.J. Hemodynamic responses to endotracheal extubation after coronary artery bypass grafting. Anesth Analg 1991;73:10-15.[Abstract/Free Full Text]
6. Vandermeulen E.P., Aken H.V., Vermylen J. Anticoagulants and spinal-epidural anesthesia. Anesth Analg 1994;79:1165-1177.[Free Full Text]
7. Lansing A.M. Transmyocardial revascularization – late results and mechanisms of action. J Ky Med Assoc 2000;98:406-412.[Medline]
8. Mehran R., Dangas G., Stamou S.C., Pfister A.J., Dullum M.K., Leon M.B., Corso P.J. One-year clinical outcome after minimally invasive direct coronary artery bypass. Circulation 2000;102:2799-2802.[Abstract/Free Full Text]

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