Eur J Cardiothorac Surg 2004;26:658-659
© 2004 Elsevier Science NL
Coronary artery bypass grafting in the awake patient: combined thoracic epidural and lumbar subarachnoid block
V. Lucchettia,
C. Moscarielloa,
D. Catapanoa,
G.D. Angelinib*
a Casa di Cura Montevergine, Avellino, Italy
b Bristol Heart Institute, University of Bristol, Bristol Royal Infirmary, Bristol, BS2 8HW, UK
Received 11 March 2004;
received in revised form 10 May 2004;
accepted 19 May 2004.
* Corresponding author. Tel.: +44-117-928-3145; fax: +44-117-929-9737
e-mail: g.d.angelini{at}bristol.ac.uk
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Abstract
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High thoracic epidural anaesthesia has recently been proposed to perform surgical revascularisation with arterial grafts in awake patients. However, in high-risk patients with associated co-morbidity it is not always possible to perform complete arterial revascularisation. A technique which combines thoracic epidural and selective lumbar subarachnoid block is described, allowing harvesting of saphenous vein and complete surgical revascularisation in awake patients.
Key Words: Off-pump • Thoracic epidural • Lumbar block
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1. Introduction
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Off-pump coronary artery bypass surgery is now a well established technique, known to decrease the adverse side-effects typically associated with cardiopulmonary bypass [1]. High thoracic epidural anaesthesia in awake patients has been shown to provide good conditions for coronary revascularisation on the beating heart using arterial grafts [2,3]. The addition of lumbar subarachnoid block to high thoracic epidural allows harvesting of saphenous vein also in the awake patient.
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2. Case report
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A 69-year-old male, obese, with diabetes, COPD and angina at rest was referred for coronary revascularisation following a coronary angiography which showed three-vessel coronary artery disease and a mildly impaired (40%) ejection fraction. Following informed consent and approval from the hospital Ethical Committee, the evening prior to the surgery an epidural 20G catheter (Becton Dickinson, USA) was inserted at T3/T4 level under local anaesthetic. On the day of surgery, the patient was premedicated with morphine 10 mg, midazolam 5 mg and atropine 0.5 mg intramuscular. In the operating theatre, blood pressure was monitored via the right radial artery and a three-lumen central venous line was inserted into the right subclavian vein. Under continuous ECG and pressure monitoring, the patient was positioned in a left lateral decupitus and using a 25G needle a selective lumbar block was performed at L4/L5 level using one single shot of bupivacaine 0.5% 6 mg, supplemented with clonidine 45 µg. The lateral decupitus position was maintained for 20 min until adequate analgesia was obtained at T12/S4 level.
The patient was then repositioned on his back and epidural anaesthesia started using ropivacaine 0.5%, clonidine 7.5 µg/ml, fentanyl 5 µg/ml, for a total of 12 ml (60 mg of ropivacaine), until the required level of anaesthesia was reached. The analgesic block extended from C5 to T10. A mild level of sedation was also maintained with 1 mg/kg/h of propofol. Following a median sternotomy, the left mammary artery was dissected, paying attention not to enter the pleural space. A segment of saphenous vein was also taken at the same time from the lower part of the left leg. The surgery was then conducted using our routine off-pump technique [1]. A half-folded swab 12 cm wide and 7 cm long was snared to the posterior pericardium using a single stitch 0 silk suture, half-way between the inferior vena cava and the left inferior pulmonary vein. Traction was applied on the two limbs of the swab and the snare and these were fixed to the surgical drapes to facilitate exposure of the target coronary vessels, which was then stabilised with a reusable stainless steel stabiliser. All anastomoses were performed with an intracoronary shunt, and visualisation was enhanced using a surgical blower humidifier. The left internal mammary was first anastomosed to the middle of the left anterior descending after which, using the segment of saphenous vein, a sequential graft was performed between the PDA and the OM of circumflex, and this was subsequently attached to the ascending aorta. Following verification of flow using a flowmeter (Transonic System, NY, USA), protamine was administered and the chest was closed in layers. Heart rate and mean arterial pressure remained stable during the entire procedure due to the thoracic epidural mediated sympatholysis. There was some minor alteration in central venous pressure (6±2 mmHg at baseline, 10±3 during construction of the anastomosis) attributable to the positioning and stabilisation of the heart. The total duration of the operation was 3 h and 40 min, during which two boluses of anaesthetic were infused through the thoracic epidural catheter to a total of 8 ml of solution. The patient was conscious throughout, responded to commands and we did not observe anxiety or lack of cooperation.
The procedure was completed without any complications and the epidural catheter was left for a further 24 h. There were no postoperative complications and the patient was discharged home on day 5 postoperatively.
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3. Comment
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The combination of high thoracic epidural and off-pump coronary artery bypass surgery has been proposed to extend the concept of minimally invasiveness. Whereas the off-pump coronary surgery reduces the morbidity associated with the extracorporeal circulation, the thoracic epidural should avoid the complication of general anaesthesia with intubation and mechanical ventilation. This, we believe, may be particularly relevant in patients with impaired pulmonary function like in our case. Based on our experience with thoracic epidural in awake patients, it is important to select individuals who are also compliant and mentally keen on the procedure, which needs to be explained in detail to them. To the best of our knowledge this is the first report in which a thoracic epidural was combined with a selective lumbar subarachnoid block, allowing harvesting of the saphenous vein. The case presented here shows the feasibility and safety of this technique to achieve complete surgical revascularisation with median sternotomy using arterial and venous grafts with the patient awake.
As with all new techniques many questions arise, such as the benefit for the patient, including improvement of ventilation-perfusion, decrease in peroperative stress and troponin release. Further studies are required to define the possible extent and limitations of this strategy.
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References
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- Angelini G.D., Taylor F.C., Reeves B.C., Ascione R. Early and midterm outcome after off-pump and on-pump surgery in Beating Heart Against Cardioplegic Arrest Studies (BHACAS 1 and 2): a pooled analysis of two randomised controlled trials. Lancet 2002;359:1194-1199.[CrossRef][Medline]
- Karagoz H.Y., Kurtoglu M., Bakkaloglu B., Sonmez B., Cetintas T., Bayazit K. Coronary artery bypass grafting in the awake patient: three years’ experience in 137 patients. J Thorac Cardiovasc Surg 2003;125:1401-1404.[Abstract/Free Full Text]
- Aybek T., Kessler P., Khan M.F., Dogan S., Neidhart G., Mortiz A., Wimmer-Greinecker G. Operative techniques in awake coronary artery bypass grafting. J Thorac Cardiovasc Surg 2003;125:1394-1400.[Abstract/Free Full Text]
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Abstract
1. Introduction
