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Eur J Cardiothorac Surg 2005;27:168-170
© 2005 Elsevier Science NL
Case report |
a Department of Cardiovascular Surgery-Padua University Medical School, Padova, Italy
b Department of Anaesthesiology and Pharmacology, Unit of Anaesthesia and Intensive Care-Padua University Medical School, Padova, Italy
c Department of Medical and Surgical Science, Division of Vascular Surgery-Padua University Medical School, Padova, Italy
Received 26 July 2004; received in revised form 5 October 2004; accepted 15 October 2004.
* Corresponding author. Address: Istituto di Chirurgia Cardiovascolare Centro V. Gallucci-Policlinico-Via Giustiniani 2, 35128 Padova, Italy. Tel.: +39 498 212 412;fax: +39 0498 212 409. (E-mail: gino.gerosa{at}unipd.it).
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Abstract |
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 Top Abstract 1. Introduction2. Clinical case3. DiscussionReferences |
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Key Words: Jehowa witness • Awake surgery • Coronary artery bypass • Carotid endarterectomy
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1. Introduction |
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TopAbstract1. Introduction2. Clinical case3. DiscussionReferences |
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Complex surgical procedures are associated with a major risk of peri-operative bleeding.
Jehova's witnesses (JWs), necessitate a tailored strategy warranting the optimal surgical management, in observance to their religion principles [2].
The application in cardiac surgery of epidural anaesthesia [3,4] represents an appealing alternative, in order to meet patients' requirements.
In this report, we present a JW female patient, who underwent coronary artery bypass grafting (CABG) and carotid endarterectomy (CEA), with neither endotracheal intubation nor general anaesthesia.
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2. Clinical case |
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TopAbstract1. Introduction2. Clinical case3. DiscussionReferences |
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Patient had previously undergone bilateral endarterectomy. Eco Duplex scanning evaluation showed a critical re-stenosis of the left internal carotid artery, requiring a re-operation on the left side. Brain magnetic resonance (MR) showed ischemic lesions on corona radiata and basal nuclei area.
Angiography documented a triple-vessel coronary artery disease, with moderate stenosis of the left main coronary artery and a critical stenosis of the right renal artery (80%). Left ventricle systolic function was slightly depressed (50% ejection fraction).
The patient, who referred a transient ischemic attack 6 months before, presented with angina at rest. Anti-platelet therapy was replaced by calciparine 10 days before surgery, because of persistent unstable angina. Hemoglobin (Hb) level at the admittance was 12.8g/dl.
After an extensive evaluation, we planned to perform CABG via a mid-line sternotomy followed by CEA, in the awake patient. The patient was affected by a triple-vessel disease. Because of the necessity to reduce as much as possible, the anemization related to the operation we decide to schedule the patient for an hybrid coronary procedure: a single CABG (left internal mammary artery on left anterior descending coronary artery), followed by percutaneous procedure on the left coronary vessels at a later date.
The evening before surgery, the epidural catheter was inserted at T2–T3 level and advanced 3cm inside the thoracic epidural space and the sensory and motor block was assessed by a lidocaine test dose (1.5%, 3ml).
On the day of surgery, the test dose was repeated. A light sedation and analgesia were achieved with infusion of remifentanyl (0.005mcg/kg per min).
The epidural anesthesia was administered as a slow bolus (ropivacaine 1%, 6ml+lidocaine 2%, 3ml and fentanyl 50mcg, 1ml; total volume 10ml). The somatosensory block level (T1–T8) was assessed by pin–prick test and temperature method at repeated intervals.
Neither analgesic nor other sedative medications have been administered during the whole procedure. Patient was conscious and co-operating. An O2 support by nasal prongs was maintained.
A complete median sternotomy was performed. A wide opening of the left pleura did not provoke any respiratory distress as reported by other authors [4]. Left internal mammary artery (LIMA) was dissected. Heparin (150 International Units IU/kg) was administered. The pericardium was opened and the left descending coronary artery (LAD) course identified. LAD was stabilized with Genzyme Immobilizer® (Genzyme Products, Fall River, MA) and incised. The anastomosis was performed on beating heart. At the end of the procedure, heparin was reversed with protamine. Sternotomy was closed. The whole procedure was optimally tolerated by the patient.
A closed blood cell-salvage circuit uninterruptedly connected to the patient (complying with GW patients necessary formalities) was precautionary at disposal in order to face up possible blood losses. Nevertheless both the intra-operative and post-operative blood losses were trivial.
During the CABG performance, the epidural anaesthesia was administered with repeated bolus of ropivacaine 0.25% (total 5ml). The patient appeared comfortable and symptom-free. Neither hemodynamic instability nor neurologic impairment were recorded.
After completion of the cardiac surgery procedure, epidural anaesthesia was continued by elastomeric infusion (ropivacaine 0.1%, 250mg with morfine 7mg and saline solution 250ml, at 5ml/h infusion rate). Left deep cervical plexus block was achieved with 20ml of ropivacaine 0.5%. Superficial plexus block was achieved with a solution of bupivacaine 0.25% and lidocaine 0.5%, by multiple subcutaneous infiltrations, in the convergence area between external jugular vein and posterior border of sternocleidomastoideal muscle. After carotideal tripod exposure and isolation, systemic heparinization was re-established (5000IU). The internal carotid artery was clamped and longitudinally incised at the level of the patch of the previous operation. Re-endarterectomy was performed, upon positioning of an endoluminal shunt, and arteriotomy was closed with a Gore-Tex patch. The carotid artery was declamped (carotid clamp time was 24min) and cervicotomy closed, upon suction drainage placement.
There were no intra-operative complications. The patient left the operative room in stable hemodynamic conditions, calm and spontaneously breathing. Respiratory function was unimpaired during the whole procedure.
The post-operative course was uneventful. Protrombin time (PT) and PTT were assessed daily. Neurologic monitoring was repeated every 4–6h. The epidural catheter was removed on the fourth post-operative day. Patient was discharged home on the VI post-operative day.
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3. Discussion |
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TopAbstract1. Introduction2. Clinical case3. DiscussionReferences |
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Patients who do not necessitate urgent revascularization are scheduled for a multidisciplinary staged approach, possibly with prior percutaneous angioplasty and stenting of the carotid lesion. This is not applicable to unstable patients because of the necessity of a 1 month interval of anti-platelet therapy between the two procedures.
In patients with critical carotid stenoses, isolated CABG is associated with an increased risk of peri-operative cerebral adverse events. [5] In simultaneous coronary and carotid surgery, the conventional timing is justified by the potential protective effect of a prior CEA.
When feasible, coronary artery bypass surgery is performed on beating heart. Bleeding risk is reduced and a lower rate of post-operative stroke due to the avoidance of cardiopulmonary bypass (CPB) has also been reported [6].
In this report, we present a high risk surgical candidate with peculiar issues:
For these reasons, the traditional surgical timing was modified. In order to abolish the bleeding risk at the CEA site related to heparin administration, and to take advantage of the reduced neurological risk associated to beating heart technique, we decided to postpone the carotid procedure after off-pump CABG completion and heparin neutralization.
Conventional anaesthetic management was also abandoned. The reversal of the traditional timing required a strict neurological monitoring. The patient had already experienced an awake carotid surgery and felt comfortable with the procedure. In order to carefully monitor neurological status during CABG, we decided to perform the whole surgery without general anaesthesia and intubation. This approach allowed a constant neurologic monitoring both before and during CEA [7].
In adjunct, high thoracic epidural anaesthesia protects the heart by sympatholysis. Beneficial effects on peri-operative stress response (reduced post-operative heart rate and lower plasma epinephrine levels), as well as on myocardial ischemia, have already been shown. Moreover neither cardiac output nor perfusion pressure are jeopardized [8].
As a result, patient anaemization, secondary to either intrathoracic and neck bleeding, was minimized. Hb levels, which were constantly monitored by repeated blood gases controls, maintained above 10g/dl during the whole procedure.
The operative strategy adopted in this patient was innovative both for the surgical timing and the anaesthesiologic management. High thoracic epidural anaesthesia has been recently introduced at our institution in association to general anaesthesia in selected coronary artery surgery. In this patient, for the first time, a high risk CABG procedure and a high risk CEA were carried out simultaneously, in the awake setting.
This approach represented a meeting point between surgical requirements and specific patient's needs. We believe it could be a safe alternative management applicable to high risk candidates, presenting with bleeding-related issues.
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References |
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TopAbstract1. Introduction2. Clinical case3. DiscussionReferences |
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