SURGICAL ANATOMY OF THE HEART.

SURGERY FOR ISCHEMIC

HEART DISEASE. DISTURBANCES OF CARDIAC RHYTHM. HEART
TRANSPLANTATION.

HEART AND CORONARY ARTERIES.

The heart is an organ that is asymmetrically situated in the mediastinum. It is protected
by a mesodermal derived structure, the pericardial sac, consisting of two sheets: the external or
parietal, which is fibrous, and the internal or visceral, which is a thin serous membrane attached
to the heart muscle surface.
The heart is located in the middle portion of the inferior mediastinum bordered laterally
by the medial face of the lungs, anteriorly by the chest wall, and posteriorly by the dorsal spine.
In the majority of individuals, a large part of the heart lies in the left hemithorax and is partially
covered by the lingula of the left lung.
In humans, the heart is a double valvular pump that works physiologically in serial
sequence. The superior and the inferior venae cavae drain the systemic venous blood into the
right atrium, which is connected to the right ventricle through the tricuspid valve. The right
ventricle pumps the blood to the pulmonary artery across the pulmonary valve. The arterial blood
returning from the lungs drains into the left atrium through two left and two right pulmonary
veins. The atrioventricular ring, where the mitral valve is attached, separates the left atrium from
the left ventricle, which ejects the blood into the aorta across the aortic valve.
The longitudinal axis of the heart is most frequently oriented anteriorly, inferiorly, and
toward the left. If oriented toward the right, it characterizes the so-called dextrocardia, and if the
longitudinal axis is in the sagittal plane and the heart occupies the middle mediastinum, it is
called mesocardia.
When the heart is faced in frontal view, the right border is formed by the lateral wall of
the right atrium. The left margin is outlined cranially by the left atrium appendage and caudally
by the lateral wall of the left ventricle. The right atrium and the right ventricle are ventral to the
left atrium and the left ventricle is dorsal.
The heart has roughly the form of an inverted pyramid, with the base, formed by right
and left atria and the root of the great vessels, located at the upper mediastinum. The apex of the
pyramid corresponds to the apex of the left ventricle and is situated in the left hemithorax toward
the diaphragm. The anterior face of the heart or sternocostal face is related to the anterior wall of
the chest. The inferior face lies on the diaphragm and the lateral or pulmonary face is covered by
the lingula of the left lung. The junction of the sternocostal face with the inferior or
diaphragmatic face defines a sharp border called the acute margin. On the left side, the junction
of the left face with the diaphragmatic face is the obtuse margin with a rounded and ill-defined
border. The divisions of the four cardiac chambers are seen externally as sulci or grooves.
Between the atria and ventricles, there is the atrioventricular sulcus divided in right and left. The
ventricle's separation is marked externally by the interventricular sulcus, which is divided into
anterior and inferior. The point at which the atrioventricular sulcus meets the inferior
interventricular sulcus is termed the crux of the heart.
Although anatomic dissection has been the historical method for defining and
advancing our understanding of human anatomy, medical imaging now plays an invaluable role.
In the latter half of the twentieth century, angiography was the primary means of visualizing the
cardiac structures in a living person. Although this was and is an excellent technique, it has two
limitations. First, it is an invasive procedure requiring catheterization of the blood vessels with
placement of a catheter into the heart and coronary arteries. Second, only the column of contrast
material shows up on the radiographs, so it is the lumen of the arteries and cardiac chambers that
is imaged. Angiography gives no direct information about the solid cardiac structures such as
myocardium, pericardium, and valves. More recently echocardiography, magnetic resonance
imaging, and multislice computerized tomography have become advanced to the degree that they
provide a noninvasive means of evaluating cardiac anatomy. In addition to being noninvasive,
these techniques provide additional information about all cardiac structures. Computerized
tomography may ultimately prove to be the most useful, since it also visualizes the pulmonary
structures very well.

Cardiac Chambers
In angiography, the axial projections for identification of the cardiac structures are
used. These projections permit the visualization of the septum and the surrounding structures of
the heart in more detail than the classical frontal and lateral views.
The routine of the angiographic study of the heart consists of three projections:
Long axial view—30° craniocaudal image intensifier inclination and 60° left anterior
oblique patient inclination
Elongated right anterior oblique view—30° craniocaudal inclination of the image
intensifier and 30° right anterior oblique patient inclination
Four-chamber view—30° craniocaudal image intensifier inclination and 30° left
anterior oblique patient inclination
Additional views may be necessary in special situations. Frontal and lateral views may
be the elected projections for adequate visualization of the interventricular septum in some
complex cardiac defects. The pulmonary trunk and its bifurcation are better visualized in the
sitting up projection with the patient lying supine and the image intensifier rotating 30° cranially.
In CT, the initial images presented are in an axial plane. Subsequently this information
can be reformatted into any plane that is desired. Coronal and sagittal images are usually
reconstructed along with the long and short axis views that have been used historically in
echocardiography. In particular, the short axis left anterior oblique (LAO) view can be used to
evaluate the left ventricle through the cardiac cycle, thereby allowing for computation of an
ejection fraction. Threedimensional (3D) volume reconstructions are also generated, and as
spatial resolution improves these may ultimately be the most accurate and widely used method.
Right Atrium
Anatomic Aspects
The right atrium is a somewhat quadrangular chamber that forms the right surface of
the heart. It presents two main portions: the posterior smooth wall called sinus venarum and the
anterior with a trabeculated wall called atrium proper and auricle. The crista terminalis is a
smooth muscular ridge in the lateral wall of the right atrium separating the sinus venarum from
the proper atrium. The anterior trabeculated wall of the right atrium extends anteriorly with the
auricle or right atrium appendage, which is a conical pouch expanding in front of the root of the
ascending aorta. The left wall of the right atrium corresponds to the interatrial septum, which
separates this chamber from the left atrium. The right face of the interatrial septum presents a
central depression called fossa ovalis, which is encircled by a prominent margin: the limbus of
the fossa ovalis. The most inferior part of the interatrial septum, near the atrioventricular anulus,
is formed by the atrioventricular septum.
Angiographic Aspects
Long Axial View
 In this view, the left border of the right atrium corresponds to the anterior portion of the
interatrial septum, and the superior border is formed by the free superior wall of the right atrium.
The lateral border is represented by a continuous line between the superior and inferior caval
veins. The inferior border of the right atrium is the tricuspid valve and it overlaps the junction of
the inferior vena cava. The anterior wall and the right auricle are not seen in this projection.
Elongated Right Anterior Oblique View
The superior and inferior venae cavae are separated by a straight line that is the right
posterior wall of the right atrium. The tricuspid valve seen in profile is in the inferior and left
aspect of the atrial chamber. There is an inferior contour between the inferior vena cava and the
tricuspid anulus, wherein is located the entrance of the coronary sinus and is formed partially by
the atrioventricular septum. The left and superior aspect of the right atrium corresponds to the
right atrial appendage or right auricle.
Four-Chamber View
In this projection, the right atrium has a globular form, very similar to that seen in the
long axial view. The left border corresponds to the more posterior portion of the atrial septum and
the right border is related with the anterolateral atrial wall. The atrial appendage and the venae
cavae are overlapped by the right atrium contour. The tricuspid valve is not well defined in this
projection, although it forms the left inferior contour.
Right Ventricle
Anatomic Aspects
The right ventricle is a triangular-shaped chamber and is located at the ventral portion
of the heart. The base of the right ventricle is more cranial and to the right and the apex is caudal
and projected toward the left. The base is formed at the right by the atrioventricular anulus and
the leaflets of the tricuspid valve. At the left and more cranially is located the pulmonary valve.
These two valves are separated by a smooth and prominent muscular invagination of the right
ventricular wall called the ventriculoinfundibular fold. The rest of the right ventricle, including
the apex, has a coarse trabeculation. The right ventricular chamber is divided into three portions:
the inlet, the outlet, and the trabecular zones. The inlet zone includes the tricuspid valve and
extends until the implantation line of the papillary muscles. The outlet zone or infundibulum is a
tubular muscular formation with the pulmonary valve on its top. The trabeculated zone extends
from the papillary muscle's insertion until the apex. The right ventricle is limited by three walls:
the anterior or free wall, the inferior wall, and the septal wall, which corresponds to the
interventricular septum. The interventricular septum is formed by two components: the
membranous septum and the muscular septum. The membranous septum is a small fibrous
structure divided into two portions by the septal tricuspid leaflet attachment; the superior is the
atrioventricular portion and the inferior is the interventricular portion. The atrioventricular
portion is above the tricuspid anulus and separates the left ventricle from the right atrium. The
interventricular portion is related to both ventricles. The muscular component, the largest part of
the interventricular septum, is divided into three portions: the inlet portion, which divides the
inlet of the ventricles; the infundibular portion, which separates the outlet of the ventricles; and
the trabeculated portion, situated more apically. The outlet or infundibulum of the right ventricle
is limited anteriorly by the free anterior ventricular wall. The posterior wall is the
ventriculoinfundibular fold, the muscular formation that separates the tricuspid valve from the
pulmonary valve. The third wall of the infundibulum is the infundibular or outlet portion of the
interventricular septum. In normal hearts, the muscular structure, which separates the tricuspid
from the pulmonary valve, is called supraventricular crest and is formed in its greater part by the
ventriculoinfundibular fold and a small portion of the outlet septum. On the right side of the
muscular interventricular septum, there is a well-marked muscular band called the septomarginal
trabecula, which has two limbs embracing the body of the supraventricular crest. These three
structures, the ventriculoinfundibular fold, the outlet septum, and the septomarginal trabecula,
characterize the normal right ventricle.
The tricuspid valve consists of an atrioventricular orifice surrounded by a fibrous ring,
three somewhat triangular cusps or leaflets, various types of chordae tendineae, and papillary
muscles. The cusps are named anterior, septal, and posterior. The anterior cusp is the largest and
is interposed between the atrioventricular ring and the infundibulum. The septal cusp is attached
to the membranous portion of the interventricular septum. The posterior cusp is attached in the
inferior portion of the tricuspid annulus. The papillary muscles in the right ventricle are the
anterior with the base arising from the anterolateral ventricular wall and related to the
septomarginal trabecula, and the posterior, which is smaller than the anterior, arising from the
inferior portion of the septum. There are small, papillary muscles arising from the infundibular
septal wall.
The pulmonary valve is situated at the summit of the infundibulum. It consists of three
semilunar segments or cusps attached to a fibrous annulus. Two of the cusps are anterior (right
and left) and the third is posterior.

Angiographic Aspects
Long Axial View
In this view, the right ventricle has a triangular shape with the base at the top. The
tricuspid valve is at the right and the pulmonary valve is at the left and in an upper level. The
right contour corresponds to the free anterior wall. The upper left border is formed by the anterior
portion of the interventricular septum and the posterior portion is a straight line toward the apex.
The right ventricular outflow tract is limited by the supraventricular crest on the right side and by
part of the septomarginal trabecula on the left. It looks like as a wide channel with the pulmonary
valve on the top. The negative shadow of the tricuspid valve lies in the right and upper contour of
the right ventricle. The anterior leaflet can be visualized superiorly and to the right on the
tricuspid anulus. The septal leaflet is seen near and parallel to the interventricular septum. The
posterior or mural leaflet is not visualized.
Elongated Right Anterior Oblique View
The tricuspid valve seen in the lateral view is in the posterior border and to the right.
The outflow tract is superior and to the left and is limited posteriorly by the supraventricular crest
and anteriorly by the free wall of the right ventricle.
Four-Chamber View
The morphologic aspect of the right ventricle in this projection is similar to that of the
long axial view but the outflow tract is not visualized, and the tricuspid valve is localized more
medially.
Left Atrium
Anatomic Aspects
The arterial blood returns from the lungs to the left heart through two pulmonary veins
in each side of the left atrium. This is the most dorsal chamber and is localized in front of the
lumbar spine and esophagus. It communicates with the left ventricle through the mitral valve.
The left atrium has a quadrangular shape and a smooth posterior wall to which the four
pulmonary veins converge. To the right, there is the interatrial septum and to the left there is an
elongated pouch with a trabeculated wall that encircles the left aspect of the pulmonary artery;
that is the left auricle or left atrial appendage. The left appendage is a finger-like formation that
communicates with the left atrium through a narrow orifice. It is different from the right
appendage, where the communication with the right atrium is wide and has a triangular form. The
inferior wall of the left atrium corresponds to the mitral valve.
Angiographic Aspects
Long Axial View
The right contour of the left atrium is formed by the anterior portion of the atrial
septum. In the right upper corner, there is the entrance of the superior right pulmonary vein. The
left pulmonary veins and the left atrial appendage are not seen. At the floor of the left atrium
there is the mitral valve.
Elongated Right Anterior Oblique View
In this view, the most prominent structure is the left atrial appendage, which forms the
anterior and lateral borders of the left atrium. This is an irregular and elongated finger-shaped
structure that protrudes toward the left between the superior wall and the mitral valve. The
entrance of the right superior pulmonary vein is localized on the right in continuation with the
roof of the left atrium.
Four-Chamber View
This view shows an appearance similar to that described in the long axial view, but the
atrial septum is visualized in its posterior portion.
Computerized Tomographic (CT) Imaging
Computerized tomography is particularly useful for visualizing the left atrium and
pulmonary veins because of the 3D volume images that can be generated. This 360° visualization
of the pulmonary arteries can be used to rotate the image to quickly determine the number and
size of vein, for instance. The large size of the veins makes them easily identifiable.

Left Ventricle
Anatomic Aspects
The left ventricle has the thickest chamber wall of the heart and is located at the left and
posterior to the right ventricle. It has an elongated and triangular shape with the base upward
where the mitral and aortic valves are located. The apex is oriented inferiorly toward the left. The
left ventricle is divided into three portions: the inlet tract with the mitral valve complex, the
trabeculated zone with less coarse trabeculation than in the right ventricle, and the outlet tract that
supports the aortic valve. Unlike the right ventricle, in the left ventricle the inlet and the outlet
tracts are not separated by a well-developed infundibulum and the aortic and mitral annuli are in
continuity. The left ventricle has a lateral free wall, an inferior or diaphragmatic wall, and a septal
wall. This one is a nontrabeculated wall that extends from the aortic annulus to the apex.
The mitral valve is formed by two leaflets or cusps attached to a fibrous anulus, a
number of chordae tendineae, and two papillary muscles: the anterolateral and the posterior. The
cusps or leaflets are the anterior or septal and the posterior or parietal, separated, one from the
other, by two indentations: the anterolateral and the posteromedial commissures. The anterior
cusp is longer and narrower than the posterior, but both have about the same area.
At the top of the left ventricular outlet tract is located the aortic valve, which consists of
three cusps attached to the aortic anulus. Two cusps are posterior, right and left, and one is
anterior. The anterior cusp is related to the right coronary artery above and to the membranous
portion of the ventricular septum below, and is called the right coronary or septal cusp. The left
posterior cusp is related to the left main coronary artery and is called left coronary cusp. The right
posterior cusp is the noncoronary cusp.
Angiographic Aspects
Long Axial View
In this projection, the right contour of the left ventricle corresponds to the trabecular
portion of the interventricular septum. A small cranial portion of the septum is formed by the
outlet septum located just below the aortic valve. The outlet of the left ventricle is limited
anteriorly and at the right by the outlet portion of the ventricular septum and posteriorly by the
anterior leaflet of the mitral valve. The free wall of the left ventricle corresponds to the
posterolateral contour and extends from the mitral valve to the apex. The mitral valve is seen as a
negative shadow in the superior and lateral contour of the left ventricle. The papillary muscles are
seen as a negative shadow in the middle portion of the left ventricle.
Elongated Right Anterior View
In this view the outflow tract is limited anteriorly, and, to the left, by the infundibular
septum as a straight vertical line below the right coronary cusp, and posteriorly, to the right, by a
smooth contour extending from the noncoronary cusp to the crux cordis. It represents the
atrioventricular portion of the interventricular septum. The anterior free wall of the left ventricle
extends from the infundibular septum toward the apex, and the inferior wall corresponds to the
contour from the crux cordis to the apex. The mitral valve is not well visualized in this view. The
aortic valve is localized in the uppermost aspect of the outlet tract, and the coronary cusps cover
each other at the left. The noncoronary cusp is at the right.
Four-Chamber View
The left ventricle in this view has a semi-oval shape with a left rounded contour and a
right straight line. The apex is localized inferiorly towards the right. The left contour corresponds
to the free anterolateral wall, and the right limit is formed in the superior half by the
atrioventricular portion of the interventricular septum, which separates the left ventricle from the
right atrium. The mural leaflet of the mitral valve is localized laterally near this portion of the
septum (the crux cordis). The inferior half of the right contour is formed by the posterior portion
of the muscular septum. The aortic valve is visualized above the septal wall. The right coronary
and the noncoronary cusps are overlying each other on the right side. The left coronary cusp is on
the left side. The mitral orifice is fully exposed and the mural leaflet implantation is seen in all its
length. The septal leaflet is not visualized and the papillary muscles appear as two filling defects:
anterolateral and posteromedial. They are oriented toward the commissures of the mitral valve.
As a rule the left ventricle shows a smooth trabeculated contour at angiography and it differs
from the coarse trabeculation of the right ventricle.
CT Aspects
In the axial view, the relationships between the four chambers are well demonstrated.
Moving from a cephalad to caudal direction, the first chamber to come into view is the left atrium
at the level of the pulmonary valve. The right atrium begins to appear just above the level of the
aortic valve. Immediately below the aortic valve the right and left ventricles come into view.
Although the longitudinal axis of the heart usually is oriented inferiorly, this is variable and will
cause some variation in which structures can be seen at the level of the aortic valve. To get a true
“four chamber” view, an angled reconstruction is necessary. The base of the left atrium
corresponds to the midventricular level. Using computerized tomography it is also possible to do
“short axis” reconstructions, which allow one to cut the left and right ventricle in cross-section.
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3D volume images are similar to those seen on angiography. CT imaging better demonstrates the
atrial appendages, which often hang over the coronary artery origins. From the front, the left and
right ventricles, aortic and pulmonary outflow tracts, and a portion of the right atrium are seen.
Views from the inferior aspect of the heart show both ventricles with the inferior interventricular
groove. It should be noted that the heart at this level is actually more inferior than some
intraabdominal structures such as the dome of the liver and the lung bases. A posterior view
requires the thoracic spine to be cut away to allow better visualization of the descending aorta. If
the aorta is also removed, the left atrium is demonstrated to be the most posterior chamber.
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Coronary Arteries
The coronary arteries, the vascular network of the heart, provide arterial blood to the
myocardium. They are the left and right coronaries that originate from the left (posterior) and
right (anterior) coronary sinus of the aortic root .
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The left main coronary artery has a variable length and a diameter ranging from 5 to 10
mm. In about 1% of the hearts studied in a series, there was no left main coronary artery and two
orifices were found in the left coronary sinus, with the left anterior descending and circumflex
arteries originating separately from each one. The left main coronary artery bifurcates into two
vessels: the left anterior descending (LAD), running over the anterior interventricular sulcus and
the circumflex artery related to the left atrioventricular sulcus. The left main coronary artery in a
few cases may give rise to a third vessel: the intermediary artery, also called diagonalis artery,
which is located between the LAD and circumflex artery and supplies the free lateral wall of the
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The LAD extends down ending proximal, at or distal to the apex. In this last situation,
the LAD goes up into the posterior interventricular sulcus. The length of the LAD is thus
extremely variable. The main branches of the LAD are the diagonal and septal branches. The
diagonals vary in number and size. These vessels arise in an acute angle from the LAD and
supply the anterolateral wall of the left ventricle. Most frequently, there is a major artery, which
is identified as the first diagonal branch. The septal branches in number of four to six, or more,
originate from the LAD in right angle, coursing close to the endocardium on the right side of the
interventricular septum. They anastomose with the septal branches coming from the posterior
descending artery. In the majority of hearts, it is possible to identify a bigger septal branch called
the first septal artery, originating from the proximal portion of the LAD. In some hearts, the LAD
has an unusual configuration: it is short and divided into two parallel vessels called “dual” LAD.
One vessel running over the interventricular sulcus gives off the septal branches and the other,
lying in the anterior left ventricular wall, originates the diagonal branches.
The circumflex artery is the other principal vessel originating from the left main
coronary artery. It emerges in a right or acute angle and is covered by the left atrial appendage in
its proximal portion, and then takes position in the left atrioventricular sulcus. The circumflex
artery may terminate proximal to the obtuse margin of the left ventricle, before, at, or beyond the
crux cordis. The principal branches of the circumflex artery are the marginal arteries and the left
atrial branch. In 40% of hearts, the sinus node artery arises from the circumflex artery. The
marginal arteries are variable in number, but are usually three. The most prominent marginal
artery runs on the obtuse
margin of the heart and extends distally close to the apex. When the circumflex artery reaches the
crux cordis, it gives origin to the posterior descending and to the atrioventricular node arteries.
The right coronary artery has its origin at the right coronary aortic sinus. Often a small
branch may arise directly from the aortic sinus in an isolated ostium and supply the right ventricle
infundibulum. This branch is called the conus artery, which anastomoses with a left conus branch
coming from the left coronary artery to form the arterial anulus of Vieussens. Close to its origin,
the right coronary artery gives rise to the sinus node artery in 60% of hearts. The right coronary
artery goes into the right atrioventricular sulcus and has a variable form of termination. If it is a
short artery, it terminates between the acute margin of the right ventricle and the crux cordis as a
small branch (left dominance). When there is a dominant right coronary artery, it extends further
from the crux, supplying the posterolateral wall of the left ventricle with a variable number of
posterolateral branches. Near the acute margin of the heart, the right coronary artery gives origin
to the right marginal or acute marginal artery that supplies the free anterior wall of the right
ventricle. The shorter the left circumflex artery, the longer will be the terminal posterolateral
branches of the right coronary artery. At the crux cordis, the right coronary gives origin to the
posterior descending artery, which runs into the posterior interventricular sulcus and supplies the
inferior portion of the interventricular septum through a variable number of septal branches.
Several of these small septal branches anastomose with the septal branches coming from the
anterior descending artery. Just distal to the crux, the right coronary artery makes an inverted “U”
turn, giving origin to the atrioventricular node artery. The coronary arterial anatomy at this region
of the heart has a variable configuration. It is possible to find two parallel posterior descending
arteries, and the diaphragmatic surface of the heart may be irrigated by vessels coming from the
right coronary artery, from the circumflex or from both.
Angiographic Aspects
It is important to visualize all the segments of the main coronary arteries, their
branches, anatomic variations, and anastomoses that occasionally occur. All the details of the
lesions as well as their locations should be properly defined. To reach these goals, several
angiographic projections are used.
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Because the anatomic aspects of the coronary arteries are variable, a number of
appropriated projections with special angles of the x-ray beam are used for each different
individual. All the principal vessels must be visualized in at least two orthogonal projections.
The elongated or cranial left oblique view shows the left main coronary artery, the
LAD, and the diagonal branches. The caudal left oblique projection (spider view) shows the left
main coronary artery, its bifurcation, and the proximal circumflex artery. To visualize the LAD,
the septal and the diagonal branches, either the cranial or the caudal right oblique views are
indicated. The circumflex artery and its marginal branches are well defined in the elongated left
oblique and in the caudal right anterior oblique projections.
The anteroposterior view is a good projection to study the left main coronary artery and
its bifurcation. In some cases, the caudal anteroposterior or the true lateral views may help
visualize the proximal portion of the LAD and of the circumflex artery.
The right coronary artery is well visualized in the majority of the cases in the
conventional right and left oblique projections. The origin of the posterior descending and the
posterolateral branches are defined in the caudal left anterior oblique view.
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intravenous contrast material is given, the coronary arteries surrounded by fat clearly stand out
from the remainder of the heart. 3D volume images along with maximum intensity projection
images are used to evaluate the coronary arteries. This allows for visualization of the left main
coronary artery, right coronary artery, left anterior descending coronary artery, and the left
circumflex coronary artery. In addition, branches such as diagonals, obtuse marginals, and the
posterior descending coronary artery can be seen down to a diameter of 1 mm. Although many
different projections are used to visualize the coronary arteries in clinical practice, the fact that
the coronary arteries lie on the surface of the heart makes 3D volume reconstruction the most
useful way to study the anatomy.
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The origin of the coronary arteries can be well visualized on a cranial view with the more
superior structures removed In this projection both the right and left coronary origins are seen
clearly and any anomalies can easily be excluded. Rotating the image to a cranial left anterior
oblique defines the left main coronary artery and its bifurcation into the left anterior descending
and left circumflex coronary arteries. The LAD runs in the anterior interventricular groove with
its diagonal branches serving the anterior wall of the left ventricle. The circumflex coronary
artery runs in the atrioventricular groove with obtuse marginal branches serving the lateral wall
of the left ventricle.
The right coronary artery undergoes rapid complex motion during the cycle of the
beating heart. Until recently, this prevented imaging of this vessel because of excessive motion or
blurring artifact. Modern scanners are now quick enough to “stop” the motion of the right
coronary artery. Small branches less than 1 mm in diameter are difficult to visualize, but larger
branches such as the acute marginal artery can be well visualized. Computer workstations allow
these vessels to be displayed in a wide variety of formats, which can be used depending on
clinical necessity.
After removing the diaphragm, the inferior surface of the heart can be evaluated. About
80% of people have a so-called “right dominant” system, in which the right coronary artery
provides flow to the posterior descending coronary artery. The other 20% have either a left
dominant or co-dominant system.
CORONARY ARTERY BYPASS GRAFTS
 Although not a part of the original body, coronary artery bypass grafts have become so
common that knowledge of their location and appearance should now be part of any anatomic
field of study. Bypass grafts, as the name implies, are conduits that are used to bypass severely
diseased portions of the native coronary arteries. The material used is always autologous, since
manmade grafts have not been found to be effective. Veins or arteries may be used. If vein is
used, the greater saphenous vein in the leg is the donor site of choice. If this is unavailable or not
suitable, the lesser saphenous may be used. Less often, veins from other portions of the body may
be harvested. Recent data have shown that arterial conduits have a higher long-term patency, so
they are now preferred when possible. The left internal mammary artery (LIMA) is the most
common choice. It is left attached to the left subclavian artery at its origin, but its midportion is
freed up from the sternum and then attached to the vessel to be bypassed.
The usual nomenclature for coronary artery bypass grafting (CABG) is the number of
conduits; hence, a four-vessel bypass means there are four conduits providing flow to the
coronary arteries. It is important to note the proximal anastomosis and the distal anastomosis.
Commonly the LIMA is connected to the LAD or one of its branches, whereas venous grafts are
used for other locations. If a second surgery is needed, it is helpful to understand the relationship
of the sternum to the grafts. In the past surgeons commonly placed metallic rings around the
origin of vein grafts from the ascending aorta. This allowed for quicker and easier catheterization
if angiography was required. These are seen less commonly as more experience has been gained
with these grafts.
As greater experience has been obtained with these grafts, new problems and solutions
have arisen. For example a stenosis or narrowing in the proximal left subclavian artery will
inhibit flow to an otherwise good LIMA graft. In these cases the left subclavian artery can either
be treated with a stent or the LIMA can be reattached to the ascending aorta. Surgeons have also
begun to place more complex segmental grafts. This requires use of the original graft as the
origin site for the new segmental communication. With these grafts it is often helpful to use
different methods of display to better appreciate the entire course of the graft. Finally, in unusual
cases a surgeon may need to use a more remote site, such as the descending aorta, for the
proximal origin of the graft.

SURGERY FOR ISCHEMIC HEART DISEASE

 ISCHEMIC HEART DISEASE
Stenotic Arteriosclerotic Coronary Artery Disease
Definition
Stenotic atherosclerotic coronary artery disease (CAD) is narrowing of the coronary
arteries caused by thickening and loss of elasticity of their walls (arteriosclerosis) that, when
suficiently severe, limits blood low to the myocardium. Initially, the disease limits only coronary
low reserve (increase in low that normally accompanies increased myocardial oxygen demands),
but when suficiently advanced, CAD reduces blood low through the affected artery even at rest.
In its most severe form, atherosclerotic CAD occludes the coronary artery.

History and physical

Patients with stable angina commonly present with exertional chest pain symptoms.
The chest pain is usually gradual in onset and offset, reported as a diffuse chest discomfort that
may radiate to the neck, lower jaw and arms, and is typically provocable with exercise, anxiety,
cold, and after meals. Exertional dyspnea is a common associated symptom, reflecting pulmonary
congestion from ischemia-mediated systolic and diastolic dysfunction. Canadian Cardiovascular
Society Functional Class 3 (less than a block of walking) and 4 (mild activity) angina are
typically indications for intervention. Other associated symptoms may include nausea,
diaphoresis, fatigue, dizziness, and presyncope among others. Angina may present atypically, or
be clinically silent in certain individuals, most notably in diabetics, elderly, and women.
Comorbid conditions are sought out, particularly those that will impact outcomes and surgical
treatment decisions (cerebrovascular disease, smoking, COPD, cardiovascular risk factors, renal
disease, peripheral arterial and venous disease, peptic ulcers and gastrointestinal bleeding,
bleeding diathesis, active infections, and alcohol use). Physical exam findings in stable angina are
often nonspecific. Therefore, screening neurologic and head/neck exams (with attention to carotid
bruits) should be performed in addition to focused cardiac, respiratory, abdominal and peripheral
vascular exams. Evidence of previous chest, groin, and lower extremity surgery should be noted.
An assessment should be made of the availability and quality of peripheral conduits. Assess arm
dominance and plan to use the opposite hand for the radial artery if possible. Check an Allen’s
test in each hand and use a duplex-modified Allen’s test for any uncertain cases. The ideal hand
would be non-dominant, complete arch, good ulnar flow, and minimal artherosclerotic disease.
Check for varicosities which make it unfavorable to use the vein.
Clinical Features And Diagnostic Criteria
Routine MethodCAD is usually irst suspected with development of the symptom
complex of angina pectoris or an acute MI, occasionally because of electrocardiographic (ECG)
evidence of a silent acute MI, a positive ECG response to a graded exercise test, or sudden death
with resuscitation. Occasionally, CAD is irst suspected because of cardiomegaly and symptoms
of chronic heart failure without any other obvious cause. The precise nature, location, duration,
and severity of any chest pain are determined by carefully questioning the patient. Precipitating
causes and maneuvers that relieve the pain are noted, as are any recent changes in pain pattern.
Findings on physical examination are usually nonspecific. Many noninvasive tests, beginning
with a chest radiograph and ECG at rest and during exercise and then proceeding to more
complex studies, are currently used to identify and quantify CAD and its sequelae. Such tests
cannot yet deine extent or distribution of anatomic coronary disease with great accuracy. From a
surgical standpoint, therefore, properly performed coronary angiography remains the deinitive
diagnostic procedure. Contrast-enhanced computed tomographic coronary angiography (CTCA)
is emerging as a promising technique for detecting coronary artery disease and may, with
increased spatial and temporal resolution, be suitable as an accurate and noninvasive method to
select candidates for CABG. Methods of evaluating LV function are also necessary. These may
be based in part on historical data, physical indings, and chest radiography. Noninvasive and
invasive special study methods may be used. Even when complex study methods are employed,
results must be interpreted with knowledge of the simple but reliable clinical data. An ejection
fraction (EF) of 35% has a different implication when accompanied by minimal LV enlargement
seen on a chest radiograph than when enlargement is marked. An EF of 30% is much more
ominous when accompanied by important elevation of jugular and right atrial pressure with
hepatomegaly and luid retention than when these pressures are normal. Exercise capacity may be
variable in patients with similar EFs, and the variations are prognostically important. It should be
emphasized, however, that heart size can be deceptive because it can remain normal in the
presence of severe LV dysfunction. Important associated conditions such as hyperlipidemia,
arterial hypertension, and diabetes, and a history of MI, smoking, or a particularly stressful
occupation or lifestyle should be noted. Because arteriosclerosis is the cause of CAD, its presence
elsewhere in the circulatory system should be sought. A history suggesting transient cerebral
ischemic attacks or stroke, particularly when carotid bruits are present, must be carefully pursued.
A history of intermittent claudication and presence of diminished femoral, popliteal, or pedal
pulses are indicative of peripheral arterial occlusive disease. The thoracic and abdominal aorta
are examined for possible aneurysm or occlusive disease. Renal and pulmonary function should
also be evaluated.

Coronary Angiography
Coronary angiograms provide important information. Their quality must be suficient to
permit detailed assessment from several angles of both coronary ostia and all major and minor
branches of the left and right coronary arterial systems. However, angiography remains an
imperfect method. Severity of a visualized stenotic lesion may be underestimated, and diameter
of vessels distal to a stenosis is often underestimated. Assessment of coronary arteries at
operation by external palpation or probing of the open vessel cannot substitute for coronary
angiography. When the arteries cannot be adequately illed by contrast media, however, or the
available study is incomplete and cannot be repeated (this should be uncommon), intraoperative
observations can be used to supplement angiographic indings. The surgeon should assess all
coronary arterial branches
carefully at the time of operation, rather than assume the coronary angiogram is a totally accurate
diagnostic tool.
Whatever the techniques used for coronary angiography, methods of recording and
analyzing the data are crucial. A 75% cross-sectional area loss (50% diameter) is considered an
important but moderate stenosis, and a 90% cross-sectional area loss (67% diameter) is
considered severe. Some groups consider only those lesions with 70% or more diameter loss
(90% or more cross sectional area loss) as important, but an appropriately documented basis for
this has not been established. Extent of important coronary artery stenoses has conventionally
been summarized as “single-vessel,” “double-vessel,” or “triple-vessel” disease, usually with left
main coronary artery disease as a separate category. This chapter uses the terms single-system,
two-system, and three- system disease, because each coronary system (LAD, Cx, and RCA)
consists of several vessels. Use of the term system is therefore more accurate than vessel. These
classiications have been criticized because they give no indication of the amount of LV
myocardium rendered ischemic by the lesions. For example, a stenosis in the LAD system has a
different signiicance when it lies at the origin of a large irst diagonal artery than when it involves
the middle third of the LAD beyond its major septal and diagonal branches, or only the irst
portion of a large first diagonal branch. A single stenosis in the proximal portion of the Cx artery
varies in signiicance depending on whether this artery is dominant. Single-system disease
involving the proximal RCA has a different implication from that involving only the posterior
descending branch of the RCA. Many other examples can be given of the inadequacies of these
classifications. A few classiication systems have been described to circumvent these limitations.
These include Gensini’s old and rather complex scheme that takes into account severity of the
stenoses, the various segments of the coronary artery tree involved, and the area of myocardium
usually perfused by them; a simple scheme from Massachusetts General HospitalJ7; and the
method of the Coronary Artery Surgery Study (CASS) of the U.S. National Heart, Lung, and
Blood Institute (NHLBI), dividing the coronary arteries into a total of 27 speciied segments.
Some myocardial jeopardy scores have attempted to provide similar information but are limited
by the assumption that akinetic areas cannot be revascularized. Whatever the recording and
reporting methods, they are not a substitute for the surgeon critically reviewing cineangiograms
before deciding for or against operation, and again immediately before operation.
 Computed Tomographic Angiography
Although conventional coronary angiography remains the gold standard to determine
extent and severity of CAD and indications for CABG, CTCA using 64-slice multidetector CT
scanners (MDCT) has been evaluated as an alternative method to select patients for CABG.
Initial studies suggest that this technique is a suitable alternative to conventional coronary
angiography in selected patients. However, concerns regarding exposure to excessive radiation
and the small but deined increased risk of cancer in later life associated with exposure to
radiation may limit its widespread application.

Coronary Intravascular Ultrasound

Intravascular ultrasound (IVUS) uses a high-frequency miniaturized ultrasound
transducer positioned on the tip of a coronary artery catheter to provide detailed cross-sectional
images of the coronary vessel wall. Unlike coronary angiography, which details only luminal
encroachment, IVUS provides images of the atherosclerotic plaque, characterizes its composition,
and assesses severity of stenosis. When compared with formalin-ixed and fresh histologic
specimens of coronary arteries, it correlates significantly with coronary artery cross-sectional
area (r = 0.94), residual lumen cross-sectional area (r = 0.85), and percent cross-sectional area (r
= 0.84). It is useful in determining the need for CABG in situations when the severity of coronary
artery stenosis cannot be precisely determined by angiography, particularly for left main and
LAD disease.
 Coronary Artery Pressure and Fractional Flow Reserve
Fractional low reserve (FFR) is a simple, reliable, and reproducible physiologic index
of lesion severity in patients with intermediate stenosis, and is another method to determine the
need for CABG and PCI in equivocal situations, particularly stenosis of the left main coronary
artery. Pressure measured distal to the stenotic coronary lesion during maximum hyperemia (Pd)
divided by mean aortic pressure (Pa) correlates with maximum myocardial blood low in the
presence of a stenosis QJS divided by the normal maximum myocardial blood low QJ N. FFR
0.75 to 0.80 or less is generally an indication for intervention.
 Normal. QN
Figure 7-4 Concept of fractional flow reserve (FFR). Key: Mean aortic press

Tests
• Laboratory investigations.
Routine preoperative blood work. Check cardiac

FFR-
O - — during maximum hyperemia enzymes for evidence of acute coronary
F
syndrome.
• EKG. Routinely performed to
establish a baseline assessment of rate/rhythm, axis, complex morphologies, the presence of
conduction system disease, left ventricular hypertrophy, and evidence of prior infarction. Note
that acute coronary syndromes including unstable angina, STEMI, and NSTEMI are covered in
Chapter 31, Acute myocardial infarction/unstable angina.
• CXR. Particular focus is on cardiac and pulmonary irregularities. Note should be
made of cardiac or great vessel enlargement, cardiac and great vessel calcifications, the presence
of pulmonary interstitial fluid and pericardial or pleural effusions.
• Echocardiogram. Routine preoperative echocardiogram to assess ventricular size and
function, and to rule out concomitant valvular and aortic disease is reasonable.
• Myocardial viability studies. Used in patients with multivessel disease, low EF (<
50%) or extensive areas of akinesis to ensure that the bypass is to viable and salvageable
myocardium.This is especially helpful in high risk patients if there is any question about the
utility of revascularization. PET scanning is the most common method used for this. Patients may
already have had a PET scan prior to their angiogram. If the PET shows decreased perfusion with
preserved F-fluorodeoxyglucose (FDG) uptake then this patient has viable myocardium that will
benefit from revascularization. If there is extensive scar tissue as evidenced by decreased
perfusion and decreased uptake then the benefits of revascularization are questionable. MRI is
another viability study that is sometimes used.
• Conduit studies. Venous mapping may be used to assess the suitability of saphenous
veins for bypass. The mammary can be assessed by either chest duplex or direct injection during
the angiogram.

Treatment/management
 The main class I and class Ila indications for CABG (from the 2011 ACC/AHA
guidelines for CABG) are as follows:
To improve survival
• Left main disease (> 50% stenosis) (I/B)
• Significant stenoses (> 70%) in 3 major coronary arteries, or in the proximal LAD
and 1 other major coronary artery (I/B)
• Survivors of sudden cardiac death with presumed ischemia-mediated ventricular
tachycardia (VT) caused by significant stenosis in a major coronary artery (I/B)
• Significant stenoses in 2 major coronary arteries with severe or extensive ischemia,
or target vessels supplying a large area of viable myocardium (IIa/B)
• Mild-moderate LV systolic dysfunction and significant multivessel CAD or proximal
LAD stenosis when viable myocardium is present in the region of intended revascularization
(IIa/B)
• CABG with left IMA (LIMA) in patients with significant stenosis of the proximal
LAD especially if supplying a large region of viable myocardium (IIa/B).
To improve
symptoms
• CABG or PCI for 1 or more significant stenoses and disabling angina despite guideline
directed medical therapy (GDMT)
)
(I/A
• CABG or PCI for 1 or more significant stenoses and disabling angina in cases where
GDMT cannot be implemented (IIa/C)
• CABG is preferred over PCI for complex 3 V Dz
In the United States, more than 80% of CABG cases are performed with the use of
CPB.
Offpump CABG may be preferred in certain settings, although its capacity to reduce
morbidity and mortality is controversial.
The patient in this scenario meets criteria for a CABG given the chronic symptoms and
extensive CAD. In addition, he meets anatomic criteria for deriving a survival benefit with
CABG over PCI. His low EF and diabetes also support this survival benefit. Given the low EF
and hypokinetic myocardium he may benefit from a viability study. Choice of conduits would
include a mammary and 2 vein grafts.

Operative steps
 Goals - complete myocardial revascularization, while protecting head, heart, and body,
and minimizing cardiopulmonary bypass (CPB) time.
• General anesthesia with endotracheal intubation, invasive arterial monitoring, central
venous access, Swan-Ganz catheter.
• It is reasonable to routinely use trans-esophageal echocardiography (TEE) for pre and
postCPB cardiac assessment.
• Standard skin prep; draping of chest with groins and both legs exposed; arm(s)
prepped and draped if radial arterial harvest is necessary.
• Median sternotomy, harvest of internal mammary artery (IMA) (left +/- right),
harvest of other conduits concomitantly.
• Administration of heparin, with a goal activated clotting time (ACT) of greater than
480
seconds.
• “Inverse T” pericardiotomy, pericardial stay sutures, palpation of aorta.
• Aortic cannulation, right atrial (RA) cannulation with a two-stage venous cannula,
and root cannulation for antegrade cardioplegia/aortic root vent +/- retrograde via coronary sinus.
• Initiation of CPB when target ACT achieved.
• Cross-clamp with antegrade cardioplegic arrest; consider retrograde as well if severe
proximal disease. Intermittent maintenance doses of antegrade or retrograde cardioplegia
throughout the cross-clamp period often augmented with cardioplegia down the vein grafts.
• Final preparation and review of conduits.
• Identification of epicardial coronary targets, assessment of quality and feasibility for
grafting.
• Begin with the distal right. Deair and size the graft to the proximal aorta with the
heart engorged. Hook up a caridoplegia line to the graft if desired. Move onto the circumflex then
the L-LAD. The order may be institution specific.
• Performance of distal and proximal anastomoses -pay attention to anastomotic
quality, lie of conduits, and adequacy of territorial perfusion via new grafts.
• For the proximals use running prolene suture, full thickness bites on the aorta, deair
after the last proximal.
• Removal of cross-clamp, reperfusion.
 CORONARY ARTERY BYPASS GRAFT
Coronary artery bypass graft operations are effective in the treatment of ischemic heart
disease. Although these operations have become quite standard, there seems to be an ininite
variety of presentations of atherosclerotic disease and combinations of operations to revascularize
the ischemic myocardium.
PREOPERATIVE ASSESSMENT AND PREPARATION
All patients who are referred to a surgeon for consideration of CABG will have had a
coronary angiogram performed. Often, however, the patient who is referred for CABG should
have one or more additional studies. Assessment of global left ventricular function with
calculation of the ejection fraction as well as assessment of regional ventricular function, using a
perfusion study or two-dimensional echocardiogram, may be helpful. Regional wall motion
assessment may be especially important in situations in which coronary arterial branches are
completely occluded and not visualized on coronary angiography. The presence of retained
regional contractile.
Conventional coronary artery bypass grafting function, as well as other signs of
viability, should prompt an attempt at coronary artery identification and grafting in these areas.
The surgeon should assess these studies and discuss his or her plans for bypass grafting with the
patient before the procedure. Requests by cardiologists for consideration of bypass grafting
should be seen as actual consultations for assessment of suitability for surgery, not prescriptions
to perform specific operations according to the judgments made exclusively by the cardiologists
or other physicians. Another important component of preoperative assessment that requires the
input of the surgeon is the availability of suitable conduits. Few CABG candidates have such
severe peripheral vascular disease that the IMA is not suitable for use as a bypass conduit. A
complete occlusion of the proximal left subclavian artery, however, such that a subclavian ‘steal’
might occur, can be determined by the absence or marked reduction of blood pressure in the left
arm. The diagnostic cardiologist should be expected to visualize the LIMA during coronary
artery studies in patients with severe brachiocephalic arterial obstructive disease. A commoner
problem that causes unsuitability of the LIMA for grafting is seen in patients who have had prior
anterior thoracic irradiation, especially those who have been radiated for mediastinal lymphoma.
In some instances, the LIMA is encased in dense fibrous scarring from postirradiation
inflammation. This situation may also occur in some female patients after mastectomy with
postresection chest wall irradiation. The commonest problem that is overlooked by cardiologists
when referring patients for multi-vessel coronary artery grafting, however, is the absence of
saphenous veins in those who have had saphenous vein stripping because of severe varicosities.
In addition, varicosed saphenous veins may pose problems. In either situation, physical
examination and ultrasonic venous mapping, especially if lesser saphenous veins might be used,
should be undertaken preoperatively.
The surgeon must also assess the patient for comorbid conditions that can be expected
to increase operative risk or the degree of difficulty with the operation. The presence of common
coexisting states, such as chronic obstructive pulmonary disease, diabetes mellitus, severe
peripheral vascular disease, renal insufficiency, bleeding and coagulation disorders, liver disease,
autoimmune conditions, and any condition that results in the possible compromise of the patient’s
immune status, such as HIV-AIDS, should be noted. The presence of concurrent infection, be it
cutaneous, respiratory, upper airway, or urinary tract, also should be noted. Not only is such
assessment essential for ensuring appropriate comprehensive care of the patient during the
surgery, but it also is necessary to provide the patient with a risk-benefit assessment for the
proposed surgery. Furthermore, the patient should be expected to understand and participate in
the treatment plan to the extent that he or she is committed to postoperative risk modification and
secondary prevention measures, as well as immediate postoperative rehabilitation.
Preoperative evaluation
Many complications encountered during on-pump CABG may be avoided by careful
preoperative assessment and planning. This assessment is extremely important, not only in
planning the procedure, but also in communicating operative risk and possible alternatives to the
patient.
The preoperative assessment begins with a complete history and physical
examination.With the increasing use of electronic medical records, a complete summary of
previous hospitalizations and significant medical issues may be reviewed. Nonetheless, the best
history and physical exam is usually obtained directly from the patient with little reliance on data
obtained (sometimes incorrect and repeatedly copied) in the patient’s chart. Table 16.1 [2-6]
highlights key historical and physical findings that may alert one to the possibility of future
complications. These findings may prompt additional testing or evaluation to aid in the planning
of the operative procedure.
 Several preoperative assessment tools are available to determine a numerical and
objective evaluation of operative risk. These tools include the EuroSCORE and the STS Risk
Model Score [7, 8]. Both methods utilize measurable factors to stratify risk. The EuroSCORE
derives risk by totaling points for each risk factor, whereas the STS algorithm derives risk via a
patented software calculation after risk factors are entered [7, 9]. Risk factors for each
stratification system as they apply to on-pump CABG are noted in Table 16.1. An accurate
preoperative risk assessment will aid in preoperative planning and may also indicate that the risks
of an operative approach may outweigh the benefits in some cases.
Table 16.1 Pertinent findings on history and physical exam guide preoperative
planning.
 Key findings Potential importance
Preoperative state5-*; unstable angina0; CHF6:
shock3: NYHA class3: preop IABP3j5
Previous cath, recent Ml3-*; stents: PCI; ejection
fraction3'6; left fmain disease3
Pericarditis
TIA or CVA, any current symptoms5
DM5, control of DM3 Hypertension3
Renal failure3; recent cath; baseline creatinine3-*
COPD; emphysema: significant lung disease5-6:
use of home oxygen: pulmonary hypertension5 J
Liver disease; bleeding problems: coagulation
profile
PVD (including carotid) ■ ; claudication: DVT
3 D
Neurologic dysfunction6 Malignancy with chest
wall XRT Previous sternotomy5-6
Previous tracheostomy Varicose vein stripping
Allergy to heparin, protamine
Immunosuppression or steroid use3
Recent use of Plavix; antiplatelet agents; Mb—Ilia
inhibitors
Exercise tolerance Social support
Tobacco abuse3; ethanol abuse; elicit drug use
Age3jJ; gender3-*: race3 Abnormal (low or high)
BMI3 Carotid bruits
Timing of procedure
Carefully plan complete revascularization, target
location, consider viability study
Anticipate difficult dissection
t Risk of CVA. consider carotid Doppler, consider
combined procedure
t Risk wound infection [2], t mortality [3] t Risk of
CVA t Risk of renal failure [4]
Consider PFTs, t risk of prolonged ventilation
Anticipate excessive bleeding, consider
hematology or hepatology consult
Consider vein mapping, bilateral lower extremity
arterial
Doppler, dictate site of conduit harvest, t risk
cerebrovascular accident
Difficult rehabilitation, f risk pulmonary
complications
Anticipate difficult dissection and friable tissues
Obtain previous operative note, anticipate difficult
dissection, plan for possible femoral access
May indicate f risk for ventilator dependence
Consider vein mapping
Consider hematology consult, plan alternate
agents
f Risk of poor wound healing, fragile tissues t Risk
of bleeding, timing of surgery
Good indicator of outcome Difficult rehabilitation if
poor support: mechanisms f Risk pulmonary
complications, risk of substance withdrawal *-Age:
f risk CVA. prolonged ventilation [5]; female: t
mortality f Risk of sternal infection or nonunion, t
mortality [6]
Hot necessarily correlated with stenosis.
consider carotid
Doppler
3F
«
 Key findings Potential importance

Loud heart murmur Identify source

Diffuse crackles on lung exam Timing of surgery
Pulsatile abdominal mass Consider abdominal ultrasound
Varicose veins; non healing ulcers; poor distal Guide decisions regarding location of conduit
pulses; Allen test harvest

Combinations for Saphenous Vein Bypass Grafts

Sequential grafts conserve the amount of saphenous vein required for complete
revascularization. A number of combinations and sequences can be used. One common sequence
is that used in the left anterior descending coronary artery system. The graft is anastomosed side-
to- side to the diagonal branch and end-to-side to the left anterior descending coronary artery.
Another common sequence is anastomosis to the marginal branches of the circumlex coronary
artery. The vein graft is anastomosed to the proximal marginal branches in a side-to-side fashion
and to the most distal marginal branch in an end-to-side fashion. Posterior sequential grafts to the
circumlex marginal branches can be continued to include branches of the right coronary artery,
such as its posterior lateral or posterior descending branch. The right posterior descending
coronary artery and a left ventricular branch of the distal right coronary artery can be used in
sequence. Posterior sequential grafts that include both the right coronary artery and branches of
the circumlex coronary artery eliminate the requirement for one proximal anastomosis. The
direction is chosen based on the premise that placing the largest coronary artery branch at the end
of the sequence will provide runoff that is greatest to the end of the graft.

Combinations for Internal Mammary Artery Bypass Grafts

The left internal mammary artery is commonly used for bypass to the left anterior
descending artery. Sequential graft techniques may include the diagonal branch of the left
anterior descending artery. The right internal mammary artery can be used for bypass to the right
coronary artery. The left internal mammary artery can be anastomosed to the obtuse marginal
branch of the circumlex coronary artery. The right internal mammary artery can be brought
across the midline to the left anterior descending coronary artery; however, most surgeons avoid
this coniguration because the right internal mammary artery is placed in proximity to the
sternotomy increasing the hazard of re-entry. When extensive revascularization of the posterior
surface of the heart is required, a posterior sequential vein graft in combination with a left
internal mammary artery graft to the left anterior descending coronary artery is usually
performed. The radial artery can be used to sequentially bypass arteries on the posterior surface
of the heart. The radial artery is anastomosed to the left internal mammary artery, which is used
to revascularize the anterior circulation. Visceral arteries, such as the right gastroepiploic artery
or the splenic artery, can be used for posterior revascularization. Combined with a left internal
mammary artery bypass graft for anterior revascularization, this achieves total artery
revascularization.

Preparation of Saphenous Vein Graft

While the midsternal incision is made and preparations for cardiopulmonary bypass are
under way, a simultaneous incision is made in the left leg over the course of the greater
saphenous vein. The leg is abducted and rotated laterally by placing a roll under the knee. The
foot is draped so that the ankle is exposed. With the leg in the dependent position, the vein
becomes distended, allowing its course to be easily marked on the skin with a ine needle or
marking pen before making the incision. The skin is opened sharply down to the level of the
saphenous vein. Beginning at the ankle—to ensure a constant location anterior to the medial
malleolus and easy identiication of the vein—the connective tissue overlying the vein is removed.
Curved Mayo scissors are ideal for this dissection. These scissors can be placed easily and safely
into the plane between the connective tissue and adventitia of the saphenous vein, allowing the
plane to be opened without injuring the vein. The scissors are opened perpendicular to the vein to
lift the connective tissue from the top of the vein. Lateral blunt dissection should be avoided to
prevent tearing of the side branches. The dissection must be limited to tissues directly over the
vein. The scissors are then used to divide the connective tissue and expose the vein. Most of the
side branches of the vein come into view without any lateral dissection. The entire length of the
vein should be exposed before attempting to remove any of it. For a single segment of vein graft,
the incision extends from the ankle to the midportion of the leg below the knee. For two grafts,
the vein from the ankle to just below the knee is suficient; for three or more grafts, the vein
should be exposed to the midportion of the leg above the knee.
The saphenous vein is ligated at the ankle over the medial malleolus. The vein is
divided, and an angled peripheral vascular clamp is applied to the end to serve as a handle for
retraction. For ease of dissection, irm upward retraction is applied to expose the posterior
connective tissue and the side branches of the vein as they are encountered. Connective tissue
must be cleanly removed from each branch’s junction with the main vein so that the branch can
be accurately ligated. A ligature of 4/0 silk is passed on a curved hemostat around the branch.
The branch is tied precisely on the side of the saphenous vein. A small hemoclip is applied to the
branch at the tissue level, and the vein branch is divided. Ligatures placed too close to the
saphenous vein or that include any connective tissue not completely removed from the junction
will distort and narrow the saphenous vein as its adventitia is drawn into the ligature. If the
ligatures are placed away from the side of the vein, thereby leaving a length of branch between
the vein and the ligatures, there is the potential for thrombus formation where stasis occurs. These
errors in technique should be avoided.
The desired length of saphenous vein is removed and prepared for bypass grafting by
gentle distension using heparinized isotonic electrolyte solution. Some surgeons prefer to use the
patient’s blood to distend the vein. The addition of papaverine to the solution is optional. A
Dietrich vascular clamp is placed on the distal end of the saphenous vein as a matter of routine to
ensure proper orientation of the valves. As the vein is distended, side branches that have not been
ligated are identiied. A small hemostat can be applied, and the branch can simply be ligated with
4/0 silk suture or a hemoclip. When the branch consists of a hole in the vein, the site is closed by
a doubleloop stitch of 7/0 polypropylene. This technique provides the most accurate and secure
closure of the vein perforation and results in the least chance of vein distortion by the pulling in
of adventitial connective tissue. The right coronary system, anterior descending coronary system,
and circumlex coronary system can be bypassed using individual grafts for each system. When
more than one anastomosis is required in any of the three systems, sequential graft techniques are
used. Alternatively, various combinations of graft sequences can be employed to conserve the
length of vein required to accomplish complete revascularization of the coronary arteries.

Avoid these ligature errors

Vein Harvest
Endoscopic dissection and excision of the saphenous vein have the advantages of
requiring smaller skin incisions, which heal better; produce less postoperative pain and patient
discomfort; and reduce the incidence of infection of the leg incision. Minimally invasive harvest
of the greater saphenous vein also improves cosmesis. Nearly the entire saphenous vein can be
removed with this technique, using just a few small incisions.
A small incision is made on the medial aspect of the knee. Direct or endoscopic
visualization is used to locate the greater saphenous vein, which can be encircled with a vascular
snare if necessary. Prior to inserting the endoscopic system, intravenous heparin is administered
to prevent intraluminal clot. The endoscopic port is inserted into the incision. The balloon on the
port is inlated to maintain the seal if necessary. Continuous carbon dioxide insuflation is used to
expand
the tunnel and subcutaneous tissues for better visualization. A tunnel is created along the course
of the saphenous vein in the thigh by gradually advancing the cone of the dissector under
videoscopic guidance. The vein and side branches are freed from the subcutaneous tissue
anteriorly, posteriorly, and bilaterally. The side branches are then cauterized and divided to free
the vein within the tunnel in the thigh. A similar tunnel is created along the course of the
saphenous vein in the calf by reversing the direction of the endoscopic system within the primary
incision. The vein and side branches are freed from the subcutaneous tissue, and the side
branches are divided to free the vein within the tunnel in the lower leg. Using videoscopic
guidance, a small stab wound is made through the skin and into the tunnel above the vein at both
the proximal and distal ends of the tunnel. The vein is gently retrieved through the stab incision
and divided under direct vision. Alternatively, an endoloop can be used to ligate the proximal and
distal ends; the vein is then divided with electrocautery. The entire saphenous vein is removed
through the knee incision. The remnants of the side branches are reinforced with ine silk
ligatures. A pressure dressing is applied to the leg.
 Saphenous Vein-Coronary Artery (Distal) Anastomosis
Cardiopulmonary bypass is established using a single cannula (two stage) for venous
drainage, with oxygenated blood returned to the ascending aorta through a cannula placed just
below the pericardial relection. The left ventricle is decompressed by a right-angled vent catheter
or a pediatric vent catheter passed via the right superior pulmonary vein to the left atrium and left
ventricle. The aorta is occluded by a vascular clamp high on the ascending aorta.
Revascularization is accomplished during a single aortic occlusion period. Cold cardioplegic
solution (blood-based) is injected into the ascending aorta, retrograde through the coronary sinus;
alternatively, a combination of antegrade and retrograde perfusion can be used. The myocardium
is perfused intermittently during the procedure. Exposure of the coronary arteries for the distal
anastomosis of the saphenous vein to the coronary arteries can be accomplished by a number of
techniques. The common practice of having an assistant retract the heart under a gauze sponge or
with a cotton glove may cause unwanted cardiac trauma. The quality of the exposure depends on
the attention of the assistant. Static exposure of the distal right coronary artery and its posterior
descending branch can be obtained by placing three or four traction stitches on the acute margin
of the heart. One of the stitches should be near the atrioventricular groove. These stitches are held
with a hemostat, which is retracted cephalad either by an assistant or by attaching it to a rubber
band secured to the drapes.
Exposure of the left coronary branches is accomplished by a net device tied to umbilical
tape. The ends of the tape are drawn through the transverse sinus and through an opening below
the right inferior pulmonary vein behind the inferior vena cava. The net is placed behind the heart
and drawn tight to the atrioventricular groove by right lateral retraction and by securing the tape
to hemostats on the right anterior chest wall. Elevating the net and securing the end of it to the
left anterior chest wall expose the left anterior descending coronary artery.
By retracting the net to the right and securing it to the right anterior chest wall, the
cardiac apex is tipped up, exposing the posterior surface of the left ventricle and providing access
to the left circumlex coronary artery. Sections of the net can be removed for improved access to
the surface coronary arteries.
Incision of the Coronary Artery
The coronary artery is exposed and incised directly through the epicardium, without
mobilization. Lateral traction with forceps ixes the coronary artery in place. A No. 15 scalpel is
gently stroked on the coronary artery until the lumen is entered. The part of the scalpel blade near
the tip is used so that neither the scoring nor the subsequent arteriotomy is too long. Entry of the
coronary artery is conirmed by observing cardioplegic solution exiting the artery. Optical
magniication (2.5 to 3.53) is essential for precise and accurate visualization of the coronary
artery.
The arteriotomy is extended at each apex using Dietrich coronary artery scissors. The
20- or 45-degree scissors are used to open the artery at the proximal end. The scissors should be
placed carefully into the lumen of the artery so that the tips do not damage the intima. The tips of
the scissors should never be used to probe the lumen of the coronary artery. The cut should be to
the tips of the scissors so that the length of the incision is precisely controlled. Should there be
any question about the identiication of the actual coronary artery lumen, calibrated coronary
probes should be employed judiciously.
 The distal end of the arteriotomy is completed in a similar fashion using 130-degree
Dietrich scissors. The length of the coronary artery incision should approximate the diameter of
the saphenous vein, measuring about 4 to 5 mm. Care should be taken to ensure that the
completed arteriotomy extends for the full length of the scoring to avoid potential weakness at the
ends of the arteriotomy.

End-to-Side Anastomosis: Left-Side Grafts

The distal end of the saphenous vein segment is beveled at a 30- to 45-degree angle,
and an adequate length is ensured for its course over the surface of the heart. A 10-stitch
anastomosis is constructed using 7/0 polypropylene. Performing the anastomosis in precisely the
same fashion in every case ensures a standardized technique and reproducible patency results.
Five stitches are taken around the “heel” of the graft: two stitches to the side of the apex of the
vein graft and coronary artery, one stitch through the apex, and two stitches on the opposite side
of the apex. The graft is held apart from the coronary artery while these stitches are taken.
Tension on the suture and retraction of the vein graft to the side provide exposure of the
subsequent stitch. The vein graft is held by ine forceps at the side so that the intima at the tip is
not injured. Suturing for left-side grafts is performed clockwise on the vein and counterclockwise
on the artery.
The suture loops are drawn up, and the suture is pulled straight through to prevent a
pursestring effect. The ends of the suture provide lateral traction on the coronary artery for
exposure of the distal apex of the coronary arteriotomy.
Five stitches are taken around the “toe” of the graft, with the third stitch placed
precisely at the apex of the coronary arteriotomy. Loops of the ive suture are left lax for exposure
of the distal portion of the anastomosis. For the proper wagon-wheel effect, the needle direction
is changed after the apex stitch is placed. Retraction of the vein graft and opposing traction on the
epicardium expose the intima of the coronary artery. The ends of the sutures are tied precisely
with tension to approximate the tissue without causing a purse-string effect.
End-to-Side Anastomosis: Right-Side Grafts
The arteriotomy in the right coronary artery is generally made in the distal portion near
the takeoff of the posterior descending coronary artery or in the posterior descending coronary
artery itself as it courses along the posterior aspect of the ventricular septum. With right coronary
artery grafts, it is usually easier to place the initial ive stitches around the toe of the graft. Careful
orientation of the graft prevents confusion. Stitches are placed around the toe of the graft in a
counterclockwise fashion and around the distal end of the coronary arteriotomy in a clockwise
fashion. The graft is held by ine forceps at the side. Retraction of the graft and suture tension help
achieve exposure of the apex of the coronary arteriotomy. Suture loops are drawn up to
approximate the graft to the artery and to provide lateral traction on the coronary arteriotomy.
The vein graft is retracted inferiorly with forceps to expose the proximal end of the
coronary arteriotomy. Five stitches are placed at the heel in a clockwise fashion to complete the
anastomosis. As the apex of the arteriotomy is passed with a suture placed directly in line with
the coronary artery, the suture is passed beneath the vein graft.
The inal two stitches are placed accurately by retracting the graft laterally and applying
opposing traction on the epicardium medially. The suture ends are joined to complete the
anastomosis.
 Lelt-side
grafts

«gnt-slde

Completed anastomosis

Aorta-Saphenous Vein (Proximal) Anastomosis

Traction on both the suture and the vein graft helps expose the edge of the aortic
opening for accurate needle placement. Stitches include about 3 to 5 mm of the aortic wall to
ensure adequate strength of the anastomosis. Anastomosis of the saphenous vein to the aorta is
usually performed after construction of the distal anastomosis to the coronary artery. We favor
this technique and use a single period of aortic occlusion and intermittent retrograde perfusion of
the myocardium via the coronary sinus for both distal and proximal anastomoses. Alternatively,
some surgeons prefer to perform the proximal anastomosis as the initial step to ensure aortic
input to the graft and to allow antegrade perfusion of cardioplegia solution through the graft via
the aorta as the revascularization proceeds. The pericardial layer covering the aorta is removed
over its anterior wall. Small openings (4 to 5 mm in diameter) are made into the ascending aorta
using an aortic
punch. The opening for the right coronary artery graft is directly anterior to or to the right lateral
side of the aorta, whereas openings for left-side grafts are made on the left lateral side. The end of
the saphenous vein is cut back longitudinally for a distance of approximately 1 cm. A Cooley
infant vascular clamp is placed across the tip of the saphenous vein to latten it for exposure of the
vein’s shorter, beveled end. Five suture loops of 5/0 polypropylene are then placed around the
heel of the graft and passed through the aortic wall. Two stitches are placed to the side of the
apex, the third stitch is placed precisely through the apex of the incision in the saphenous vein,
and the inal two stitches are placed on the opposite side of the apex.
Anastomosis of the saphenous vein to the aorta is usually performed after construction
of the distal anastomosis to the coronary artery. We favor this technique and use a single period
of aortic occlusion and intermittent retrograde perfusion of the myocardium via the coronary
sinus for both distal and proximal anastomoses. Alternatively, some surgeons prefer to perform
the proximal anastomosis as the initial step to ensure aortic input to the graft and to allow
antegrade perfusion of cardioplegia solution through the graft via the aorta as the
revascularization proceeds.
The pericardial layer covering the aorta is removed over its anterior wall. Small
openings (4 to 5 mm in diameter) are made into the ascending aorta using an aortic punch. The
opening for the right coronary artery graft is directly anterior to or to the right lateral side of the
aorta, whereas openings for left-side grafts are made on the left lateral side. The end of the
saphenous vein is cut back longitudinally for a distance of approximately 1 cm. A Cooley infant
vascular clamp is placed across the tip of the saphenous vein to latten it for exposure of the vein’s
shorter, beveled end. Five suture loops of 5/0 polypropylene are then placed around the heel of
the graft and passed through the aortic wall. Two stitches are placed to the side of the apex, the
third stitch is placed precisely through the apex of the incision in the saphenous vein, and the inal
two stitches are placed on the opposite side of the apex.
The suture loops are pulled up to approximate the vein graft to the aorta. The
anastomosis is completed by placing stitches in a wagon-wheel fashion around the opening in the
aorta. The placement of each stitch should be accurately visualized by observing the edge of the
vein graft and the intima of the aorta. Retraction of the vein graft with forceps and slight
relaxation of suture tension as the needle passes from the graft to the aorta provide exposure.
Wide stitches are taken along the lateral edge of the saphenous vein as it is
approximated with narrow stitches to the aorta to ensure that the maximal length of saphenous
vein is positioned laterally. The completed anastomosis should bulge anteriorly above the aortic
wall, achieving a “cobra head” appearance.
Left-side grafts are oriented so that the shorter, beveled end of the saphenous vein graft
(the heel) directly faces the left side. The stitches are placed in a clockwise fashion around the
heel of the graft and in a counterclockwise fashion around the aortic opening. The right coronary
graft is placed so that the heel is oriented caudally; the stitches are placed in a counterclockwise
fashion around the heel of the graft and in a clockwise fashion around the aorta.
Preparation of the Internal Mammary Artery Pedicle
Coronary artery bypass using the internal mammary artery for the bypass conduit has
become established practice. Long-term outcome data show favorable results and excellent
patency.
A midsternal incision is made, and the pleura is swept back from the sternal edge with a
gauze sponge. The posterior surface of the sternum and ribs are exposed using specially modiied
self-retaining rake retractors to elevate the anterior chest wall. The internal mammary artery is
dissected from the anterior chest wall by electrocautery. An incision is made at the edge of the
sternum for its entire length using electrocautery. The dissection of the artery is started inferiorly,
just above the diaphragm. The artery is mobilized from the ribs by blunt dissection where there
are no arterial branches.
Strong tension is exerted posteriorly on the vascular pedicle to expose the branches
located in the rib interspaces. The blade of the electrocautery is angled so that the tissue can be
cut deep in the interspace, allowing a considerable length of arterial branch to be retained with
the internal mammary artery when it is divided. The internal mammary artery, along with the
venae comitantes and the chest wall fat, muscle, and fascia, is mobilized as a pedicle.
The internal mammary artery is mobilized for its entire length. The dissection should
be continued until the artery is completely freed from the parasternal tissues to the level of the
diaphragm. Electrocautery is used to complete the pedicle dissection by incising the chest wall
tissues and pleura for the length of the dissection.
Heparin is administered for systemic anticoagulation, and cardiopulmonary bypass is
established.
The internal mammary artery pedicle is divided, and the distal end of the pedicle is
ligated. Division of the internal mammary artery should result in forceful blood low from the
proximal end, but on cardiopulmonary bypass, the low may be minimal. A Dietrich vascular
clamp is applied to the pedicle to control blood low. The pedicle is soaked with 5% dextrose
containing sodium nitroprusside to obtain vasodilation of the internal mammary artery.
The aorta is occluded, and the heart is arrested by administering cold cardioplegic
solution in the aortic root. The coronary artery is incised as described for a saphenous vein bypass
graft, with special care taken to make a short, controlled arteriotomy. An appropriate length of
the internal mammary artery is dissected free of the pedicle to approximate the coronary
arteriotomy. Dissecting scissors are used to separate the veins and other tissues from the artery.
The pedicle is cut just short of the proposed location of the anastomosis. Venae
comitantes and arterial branches are ligated with small hemoclips. During the dissection and
subsequent anastomosis, the internal mammary artery is handled only at the tip, which will be
discarded later.

Radial Artery Bypass Grafts

The radial artery can be used in combination with the left internal mammary artery to
achieve complete revascularization of the heart with an all-arterial conduit. Using the artery as a
pedicle with its venae comitantes and employing calcium channel blockers for vasodilation have
proved to be very satisfactory, with late patency rates approaching those of internal mammary
artery grafts.
Open Radial Artery Harvest
An Allen test is performed on the nondominant hand (usually the left). The radial and
ulnar arteries are compressed while the hand is opened and closed vigorously to produce
blanching of the skin on the palm. The ulnar artery is released while maintaining compression
over the radial artery. The skin on the palm of the hand should immediately become red as blood
low is restored through the ulnar artery to the palmar arch. This hyperemic response is taken as
evidence that the radial artery can be removed without risk to the blood supply to the hand.
The arm is positioned on an arm board at the patient’s side. As a practical matter, the
left radial artery is used so that it can be removed simultaneously as a median sternotomy is
performed and the left internal mammary artery is mobilized. An incision is made in the forearm.
The incision takes a gentle curve, following the brachioradialis muscle belly. The lateral
antebrachial cutaneous nerve is lateral to the incision and is carried laterally as the incision is
deepened. Some surgeons recommend continuous intravenous infusion of diltiazem to prevent
vasoconstriction in the radial artery, but we have not found this to be particularly helpful.
The deep fascia of the forearm is opened, exposin the radial vascular pedicle. The
lateral antebrachial cutaneous nerve is now far lateral to the dissection; the supericial radial nerve
is also lateral to the vascular pedicle. As dissection proceeds along the anterior surface of the
vascular pedicle and the incision is deepened, the muscles of the forearm are displayed. This is a
deep forearm dissection, not to be equated with the supericial dissection required for removal of
the saphenous vein. The anatomy of the forearm should be clearly understood, and the dissection
plane should be limited to the vascular pedicle to avoid injury to deep forearm structures.
The radial vascular pedicle is mobilized at its midpoint, which is the easiest location for
gaining control of the pedicle. A Silastic vessel loop is used to retract the pedicle. The dissection
proceeds proximally to the recurrent radial artery branch.
Further dissection to the brachial artery bifurcation is possible, but this adds
considerable dificulty and is seldom required to obtain suficient length of radial vascular pedicle
for posterior heart surface revascularization. The dissection proceeds distally to the fascia
enclosing the tendons at the wrist. Again, greater length can be acquired by crossing the wrist, but
this is usually not necessary. The side branches of the radial artery are controlled with hemoclips.
There are many side branches, so hemoclips are used liberally. The surface of the radial artery is
marked with ink or dye to ensure its later correct orientation against the surface of the heart; the
side with all the branches is exposed after the artery is attached to the heart as a bypass graft.
The arterial graft is gently dilated with blood via an olive-tip needle. The external
surface of the graft is irrigated thoroughly with nitroprusside in dextrose and water over a gauze
sponge in which the graft is stored.

Endoscopic Radial Artery Harvest

Minimally invasive harvest of the radial artery reduces patient discomfort and improves
the appearance of the arm after operation. The artery can be removed through a single incision at
the wrist. Adequate perfusion of the hand through the ulnar artery must be veriied with an Allen
test and ultrasound evaluation before removing the radial artery.
A small vertical incision is made directly over the distal aspect of the radial artery
proximal to the wrist crease. Direct vision is used to locate the artery and encircle it with a
vascular snare. The forearm is exsanguinated via circumferential compression and inlation of a
tourniquet placed above the antecubital fossa. This provides a bloodless field for endoscopic
harvesting.
The endoscopic port is inserted into the incision. Continuous carbon dioxide is
insuflated to expand the subcutaneous tissue as careful blunt dissection along the anterior and
posterior radial artery progresses.
 A tunnel is created proximally along the course of the radial artery by gradually
advancing the cone of the dissector anterior and posterior to the artery. The fascia is cut
superiorly along the tunnel to provide visualization and to enlarge the tunnel. The arterial side
branches are cauterized and divided using bipolar cautery.
After the entire length of the radial artery is free within the tunnel, an endoloop of 2/0
polypropylene suture is placed around the distal radial artery pedicle. The endoloop is then
advanced through the tunnel to the proximal aspect, below the origin of the ulnar artery. The
dissector arm of the endoscopic system is used for guidance and countertraction as the knot is
gently tightened to occlude the artery. Bipolar cautery is used to divide the artery distal to the
knot.
The tourniquet is released, and the radial artery stump is carefully inspected for
hemostasis. The artery is divided distally at the wrist and removed through the incision. The
wound is closed with absorbable suture, and a gentle pressure dressing is applied around the
entire forearm.
All-Arterial Revascularization
The left internal mammary artery is used in conjunction with the radial artery to achieve
an all-arterial revascularization of the myocardium. The left internal mammary artery is
mobilized as a pedicle in the usual fashion. It is used to revascularize the anterior surface of the
heart, whereas the radial artery is used to revascularize the posterior surface. The left internal
mammary artery is used as the sole conduit for input to the bypass grafts. The radial artery input
is based on the left internal mammary artery.
Alternatively, the radial artery can be based on the aorta, but it will not reach the distal
marginal branches of the circumlex coronary artery or the posterior descending coronary artery.
The mammary artery must be thoroughly mobilized to that it can drop posteriorly to enter the
pericardial sac through an incision in the pericardium near the left atrial appendage. This is the
point at which the radial artery will be anastomosed to the left internal mammary artery.
A longitudinal incision is made through the pleura and endothoracic fascia into the left
internal mammary artery. The incision is extended appropriately to match the diameter of the
radial artery.
An end-to-side anastomosis of the radial artery to the mammary artery is performed.
Attention must be paid to the proper orientation of the grafts. The anastomosis to the mammary
artery is usually made on the pleural surface, so it may be necessary to rotate the artery to achieve
the correct exposure.
The toe end of the radial artery is directed toward the proximal end of the arteriotomy
in the left internal mammary artery. This orientation allows the anastomosis to direct the radial
artery posteriorly and inferiorly toward the atrioventricular groove near the left atrial appendage.
The anastomosis is constructed using continuous stitches of 7/0 polypropylene.
The wall of the radial artery is thick and may be tough and therefore iner suture
material and delicate needles are not useful. The anastomosis is completed as the suture line is
carried around the heel of the radial artery to the opposite side of the arteriotomy.
The radial artery pedicle is used to revascularize the posterior circulation. There is
suficient length to reach the posterior descending coronary artery. The radial artery is brought
onto the posterior surface of the heart by passing it over the pulmonary artery (PA) near the left
atrial appendage (LA).
Marginal branches of the left circumlex coronary artery are anastomosed to the radial
artery in a side-to-side fashion. It is preferable to make each anastomosis in line with both arteries
rather than in a crossing fashion.
This construction requires a gentle curving of the radial pedicle on the surface of the
heart to prevent kinking. If the radial artery is large, crossing or diamond-shaped anastomoses
may be used.
The sequential radial artery bypass graft is completed by constructing an end-to-side
anastomosis to the posterior descending coronary artery in the usual fashion. Continuous stitches
of 7/0 polypropylene are used for all anastomoses. The left internal mammary artery is used to
revascularize the anterior surface of the heart. An end-to-side anastomosis of the left internal
mammary artery to the left anterior descending coronary artery is constructed in the usual fashion
using continuous stitches of 7/0 polypropylene. Side-to-side anastomoses to the diagonal
branches can be employed for complete revascularization.
 Coronary Thromboendarterectomy
Coronary obstructive disease may be treated by coronary thromboendarterectomy in
certain circumstances, such as occlusion of a dominant right coronary artery in which there are
small but signiicant distal branches to the posterior wall of the left ventricle that cannot be treated
effectively using bypass grafts.
Thromboendarterectomy involves an increased risk of intraoperative myocardial
infarction compared with bypass graft operations. Removal of the thrombotic core also removes
the arterial intima, which has likely been irreversibly injured by the atherosclerotic process.
Thromboendarterectomy is best performed in the right coronary artery and should be used
sparingly in the left coronary artery.
A longitudinal arteriotomy is made in the distal right coronary artery close to the origin
of the posterior descending artery. The arteriotomy should be kept short because it will lengthen
during removal of the atherosclerotic core.
Dissection of the core starts in the plane between the adventitia and media of the artery.
An ophthalmologic spatula (Wheeler cyclodialysis spatula) is the most versatile instrument to use
because of its shape, blade length, and malleability. The core is carefully separated from the ends
of the arteriotomy to minimize stretching of the incision during manipulation.
A small clamp is passed around the core, which is then divided.
The distal portion of the atherosclerotic core is dissected with the endarterectomy
spatula by gently passing the instrument into the plane between the core and the adventitia and
advancing it past all points of resistance while gently retracting the core with vascular forceps.
The spatula should be used to cut through the core’s points of attachment at branches rather than
pulling on the core, which could break it off prematurely.
Once all points of attachment have been severed, the atherosclerotic core can be
removed from the coronary artery with ease. The spatula naturally inds its way into the coronary
artery lumen and tapers the end of the core once it extends beyond the plaque. The inclination to
forcefully pull out the plaque must be avoided, lest it break off and leave a lap of residual disease
or intima. Should this happen inadvertently, a Jacobsen forceps can be used to grasp the
remaining plaque and complete the dissection.
Alternatively, a second arteriotomy may be required if the entire plaque cannot be
extracted to a tapered end point. The end points should always be carefully checked to ensure that
the plaque has been fully removed and tapered. It is easier to divide the plaque and remove the
posterior descending artery plaque separately from the distal right coronary artery plaque.
An eversion endarterectomy is performed to remove the atherosclerotic core proximal
to the arteriotomy. The core is grasped irmly with forceps, and the proximal right coronary artery
is pushed back from the core with a second pair of forceps. The core usually breaks off
spontaneously at the location of the worst proximal disease, or it can simply be cut off once
enough has been extracted to free it from the proximal end of the arteriotomy.
The arteriotomy is closed by placing a saphenous vein bypass graft into it. The lumen
of the coronary artery is irrigated, and any residual debris is removed. The tissue of the right
coronary artery is remarkably strong after thromboendarterectomy, so no special suture
techniques are required. In fact, because the lumen is usually very large at the arteriotomy site,
substantial bites of the arterial wall can be taken as the vein bypass graft is being attached.
 Minimally Invasive Direct Coronary Artery Bypass (MIDCAB)
Isolated bypass of the left anterior descending artery can be performed through a
minimally invasive approach using the left internal mammary artery as the bypass graft.
Sternotomy is not required, and cardiopulmonary bypass is not employed.
A small anterior thoracotomy is made in the left fourth intercostal space. The left
internal mammary artery is identiied at the medial aspect of this incision.
The left internal mammary artery is dissected off the chest wall in a pedicle fashion. A
retractor is used to elevate the fourth rib for improved visualization. It is important to mobilize
the artery as high as possible superiorly to ensure an adequate length to reach the anterior wall of
the heart without tension and to conform to its contour. The internal mammary artery pedicle is
divided, and the proximal end is occluded with a small vascular clamp.
The pericardium is opened over the anterior wall of the heart and suspended on the
chest wall. A stabilizing device is positioned to expose the left anterior descending artery. Soft
Silastic snares are placed proximally and distally around the left anterior descending coronary
artery to isolate the intended site for vascular anastomosis.
 The internal mammary artery is prepared for grafting by making an angled cut to create
a tip and making a short cut back at the heel. A longitudinal incision is made in the coronary
artery.
Excessive bleeding is controlled with combined carbon dioxide and saline mist irrigation or by
placement of an intracoronary shunt (inset). Continuous stitches of 7/0 polypropylene are used to
construct an end-to-side anastomosis of the left internal mammary artery to the left anterior
descending coronary artery.
The coronary artery snares are released, and the temporary occlusion clamp is removed
from the internal mammary artery. The internal mammary artery pedicle is tacked to the
epicardium, and the wound is drained and closed in standard fashion.

Cocnptolad anistynosts tftri tactr-g sacras

HYBRID CORONARY REVASCULARIZATION

While conventional revascularization is routine in patients with triple-vessel CAD,
hybrid coronary revascularization (HCR) has evolved to combine (a) surgical revascularization to
the LAD coronary artery with the LIMA through a minimally invasive approach and (b)
percutaneous coronary revascularization (PCI) to the circumflex and right coronary artery (RCA)
territories. HCR is an alternative revascularization strategy for patients with triple-vessel CAD.
HCR achieves complete revascularization and combines the advantages of bypass surgery and
PCI (Fig. 51.4).
 Fig. 51.1 Hybrid coronary revascularization in a patient with tnple-vessel coronary artery disease (A)
Completion angiogram of the left internal mammary artery to left anterior descending. (Bl l Right
coronary artery (RCA) lesions that were treated by percutaneous coronary intervention (PCI). (B2) RC
A alter PCI. lesions in the arcumllex coronary artery before (Cl)and alter (C2) PQ.

Although traditional CABG is highly effective in improving symptoms and increasing

survival, it is associated with morbidity and mortality mostly related to the invasiveness of the
procedure. Revascularization of the L AD coronary artery with the LIMA provides the major
clinical advantage of CABG and provides the majority of the survival advantage provided by
CABG with the best long-term patency rate. Compared with PCI, LIMA bypass for isolated
lesions of the LAD results in better angina relief, and lower incidence of major adverse
cardiovascular and cerebrovascular events and need for repeat revascularization.
Long-term patency of saphenous vein bypass grafts (SV G) is inferior to that of arterial
grafts. It is unknown how the patency of SV G compares to the patency of DES in the same
position.
PCI CABG Müiiiïj-aLh- HCR (pote vû LaJ bmefits)
tanuin CABG
bvulVHM 4 44444 44 44
Procedural mi hdditv 4 444 4 4 4
Pnocedura 1 mortal ity 4 44 4 4

[/irçç-term patency D/I 444 44 444 44 4 44 4 4

artariaJ graft
Repeated
444 4 4 4
revascularization rate
444 444 44 4 4 4444
Completeness
revascularization
lullll’ fll. t
Comparison of Fotaitiai Bairits of Pcicutancous Ccraiarv intervention (R!i), Convaitional Camay Artery Bypass Grafting
(CABG l Minimally Invasve CABG and Hybrid Ccraiaiy RevasciïajËariMi (HŒ)
Table 51.3 summarizes the potential advantages of HCR and compares them with PCI
and CABG. HCR achieves complete revascularization potentially combining the advantages of
both revascularization strategies: low procedural morbidity and mortality, low restenosis rate, and
low repeated revascularization rates.HCR builds on the concept of "heart team'' approach for the

management of coronary revascularization. The heart team, integrated by cardiac surgeons,

interventional cardiologists, clinical cardiologists, and primary physicians, evaluate the patient's
clinical and angiographic characteristics and offer the patients a revascularization strategy based
on best evidence and clinical guidelines.
For HCR, interventional cardiologist and surgeons should agree that the patients are
candidates for both (a) PCI to the non-LAD territories and (b) minimally invasive bypass to the
LAD using the LIMA.
Theoretically, all patients with triple-vessel CAD can be considered for HCR. However,
until the results of randomized prospective trials exploring the safety and efficacy of HCR
compared with conventional CABG are available, HCR should be reserved for:
(a) Patients with proximal LAD stenosis or chronic total occlusion of the LAD and
focal lesions in the RCA or circumflex artery amenable to PCI. Patients with multisegment and
diffuse disease of the RCA or circumflex artery, which would require complex PCI with multiple
stents, are better candidates for conventional CABG. The SYNTAX score is helpful to select
these patients. Patients with a high SYNTAX score because of complex lesions in the RCA and
circumflex territory may benefit from conventional CABG rather than PCI to those targets. The
LAD target should be adequate for bypass.
(b) Patients with limited or absent venous conduits.
(c) Patients with severe calcification of the ascending aorta.
(d) Patients at high risk for conventional surgery secondary to multiple comorbidities
or who would tolerate a median sternotomy poorly (elderly, disabled or deconditioned patients,
immunosuppressed). Patients with double-vessel CAD may also benefit from HCR. These
indications are reflected in the European Society of Cardiology and AC CF-AHA guidelines
(Table 51.4).
HCR is contraindicated in patients who are hemodynamically unstable or in cardiogenic
shock, or who have malignant arrhythmias. Patency of the LIMA should be evaluated
preoperatively either by conventional angiogram or by CT angiography.
Patients unable to tolerate single-lung ventilation due to underlying poor pulmonary
function (severe COPD with FEV < 50% predicted, baseline hypercarbia or hypoxia on ABG,
severe pulmonary hypertension) are not candidates for HCR.
Patients with contraindications to PCI are also not candidates for HCR. Those include
patients with:
(a) In stent stenosis in a non-LAD territory.
(b) Intolerance to clopidogrel or inability to take double antiplatelet therapy for more
than
a year.
(c) Nonresponders to antiplatelet therapy.
(d) Severe renal dysfunction.
(e) Severe PVD that preclude angiographic access.
(f) Lesion at high risk of restenosis (bifurcation, trifurcation lesions}.
Relative contraindications include:
(a) Previous left-sided thoracic surgery or adhesions on left pleural space.
(b) Previous cardiac surgery.
(c) Morbid obesity (BMI > 40).
(d) Small left chest cavity with large cardiac silhouette and a thick chest wall due to
obesity. This combination makes the trocar placement dangerous. It also compromised the
movements of the robotics arms and requires a larger thoracotomy to perform the anastomosis.
(e) EF < 20%.
(f) Inability to tolerate CO 2 insufflation.
(g) Intramyocardial LAD.
The LIMA harvesting can be performed either robotically, thoracoscopically, or
directly via a small left anterior thoracotomy.
Our preferred approach is robotically using the Da Vmci system. The robotic system
allows for very precise and reproducible harvesting of the LIMA from the first rib to its
bifurcation.
There is no retraction of the ribs as it is in the traditional MID CAB approach.
Robotics ports are placed on the third, fifth, and seventh intercostal space slightly
anterior to the left anterior axillary line. C02 insufflation is established via a trocar side port. We
prefer high flow at low pressure to avoid hemodynamic compromise (20 L/min at 6 to 8 mmHg).
Patient hemodynamics should be carefully monitored during the time the chest is insufflated. The
intrathoracic pressure may need to be adjusted and vasoconstrictors may be necessary to maintain
blood pressure and cardiac output during the procedure. Excessive volume infusion should be
avoided to prevent right ventricular dilatation that may compromise the performance of a totally
endoscopic procedure.
Fig. 51j. Positioning and port iocatonfor robotic left internal mammary artery takedown. Note left shoulder retracted mferioiiy to avoid conflicts with the nght robotic
arm. Ports are located in the third, fifth, and seventh intercostal spaces anterior to the antenor axillary line Uiaaed kne\ 11» fifth inter costal pert incision is conversed
to a left ante her minithcraoatcmy.

The internal mammary artery is taken down in a skeletonized manner using the
electrocautery and bipolar forceps.
Side branches are cauterized or clipped. After heparin is administered to achieve an
ACT > 300 seconds, the distal end of the mammary is divided between clips.
The left phrenic nerve should be identified and avoided. A pericardium window is
performed robotically as a trapdoor incision with the base on the diaphragm. One incision is
placed anterior and parallel to the left phrenic nerve and another in the midline.
Both pericardial incisions are connected at the base of the heart. The LIMA, the target
area, and its relationship to the chest wall are identified after careful release of the left chest
insufflation. This reestablishes the normal anatomic relation between the heart and the chest wall
and allows for identification of the intercostal space closer to the target area minimizing the size
of the thoracotomy incision. The robotic instruments and ports are then removed. There is a
learning curve associated with the procedure with decrease in robotic time, rate of injury to the
LIMA, and conversion rate as operators became more experienced.
TECAB can also be performed. The mammary is taken down as previously described
with the Da Vinci system. A robotic endostabilizer, placed through an additional port under the
xyphoid, is used to immobilize the target vessel. The anastomosis is performed with the robotic
instruments either with sutures or with U clips (Medtronic, Minneapolis, MN). It is a more
technically demanding and time-consuming procedure that has been mastered only by a few
centers of excellence. TECAB can be performed on cardiopulmonary bypass either in the arrested
heart or on a beating heart. Cardiopulmonary support can be instituted through the groin with
cannulation of the left common femoral artery and vein. On-pump beating heart bypass can be
used to avoid the hemodynamic and pulmonary disturbances associated with single-lung
ventilation, chest
insufflation, hypercarbia, cardiac manipulation, and coronary occlusion. Decompression of the
heart also increases the intrathoracic space, which is especially important for TECAB procedures.
TECAB can also be performed with an arrested heart occluding the aorta with an EndoClamp
aortic occlusion catheter (Edwards Lifesciences, Irvine, CA).
A
dditional
bypasses
to the
diagonal,
ramus
intermedi
us, and
obtuse
marginal coronary arteries can also be performed with the MIDCAB or TECAB approach.
Revascularization of the non-LAD vessels can be staged (PCI followed by CABG or CABG
followed by PCI) or performed concomitantly in the same setting as the minimally invasive
CABG.

Fig. 51 A. Minimally invasve coronary artery bypass. (A) The left internal mammary arteiy E harvested robotically using the
Da Vina System. (B) Then a left antencr m mi thoracotomy is performed in the fifth or fourth inter costal space and a direct hand
sewn left internal mammary artery to left anterior descending anastomosis E performed. Note the use of endostabilizer that E
placed through the seventh intercostal space port site: (Q. End result with dosed incision and chest tube placed through the sev
enth intercostal spaceport ate. Note exiting fromthe third space port site the OnQ pump catheters. They are placed in the subpleu-
ral space lor postoperative pern central

There are advantages and disadvantages associated with each approach:

(a) PCI first followed by CABG: This approach minimizes the risk of ischemia during
minimally invasive bypass to the LAD by providing collateral circulation through the PCI
revascularized targets. If PCI is unsuccessful or the result is not satisfactory, the revascularization
strategy can be converted to conventional CABG. This approach can also be used in the setting of
and acute MI where the culprit vessel is not the LAD. PCI is initially performed to the non-LAD
culprit lesion and it is later followed by minimally invasive CABG to the LAD. The
disadvantages include the risk of stent thrombosis during discontinuation of antiplatelet therapy
during the staged CABG. If antiplatelet therapy is not discontinued, there is an increased risk of
bleeding during the staged CABG.
(b) CABG followed by PCI: It is the most common approach used for HCR. In our
practice, we perform PCI 48 hours after the minimally invasive CABG when the chest tube has
been removed. Since minimally invasive CABG can be associated with a lower early patency rate
than CABG performed through a median sternotomy, this approach allows for routine
angiography of the LIMA to LAD bypass. It provides quality control and confirms the patency of
the graft. Dual antiplatelet therapy can be instituted once the risk of surgical bleeding has
subsided and continued indefinitely.
 The presence of a patent LIMA to LAD graft minimizes the risk of PCI to critical
coronary lesions. An example of such lesion is a left main lesion at the bifurcation requiring
stenting into the circumflex.
The disadvantages of this approach include increased risk of ischemia in non-LAD
territories during CABG. If the staged PCI is unsuccessful, the patient is faced with the
possibility of requiring conventional CABG or incomplete revascularization. Concomitant
CABG-PCl- Both procedures are performed in a single setting under general anesthesia with
confirmation of LIMA patency and PCI before chest closure. Even though it is the most attractive
and convenient approach for the patient, it is associated with the most challenges. The most
important one is the management of antiplatelet therapy with a fresh open wound that may result
in increased bleeding.

VENTRICULAR ANEURYSM
Anterior Left Ventricular Aneurysm
One of the most common sequelae of severe transmural myocardial infarction is
development of an aneurysm of the left ventricle. Acquired ventricular septal defect occurs as a
consequence of myocardial infarction with necrosis of the septal myocardium and perforation of
the ventricular septum.
Morphology
Acquired left ventricular aneurysm is usually caused by extensive transmural infarction
of the anterolateral wall of the left ventricle and the anterior portion of the ventricular septum in
the distribution of the blood supply from the left anterior descending coronary artery. Less
common but even more complicated is a posterior aneurysm caused by infarction in the
distribution of the distal dominant right coronary artery with associated circumlex coronary artery
disease.
The usual location of acquired ventricular septal defect is the anterior portion of the
ventricular septum near the apex of the heart, in the distribution of the left anterior descending
coronary artery. Less common are high and posterior septal perforations, which are the
consequence of interruption of myocardial blood low in the distribution of the posterior
descending coronary artery.
Operative photograph of postinfarction ventricular septal defect, anterior type. There is
extensive scarring surrounding a defect in the ventricular septum. This appearance of the
endocardium is also typical for postinfarction left ventricular aneurysm. The approach to the
septum is by incision of the thinned-out (aneurysmal) anterior wall of the left ventricle. Septal
scarring and thinning of the left ventricle indicate that this is more than three months after the
myocardial infarction and healing is complete.
Operative photograph of repaired postinfarction ventricular septal defect, anterior type.
The ventricular septal defect has been closed with a Dacron patch.

It is not possible to resect all scarred and thinned portions of the left ventricle. The
septal portion cannot be conveniently excised without entering the right ventricle, and
reconstruction of the heart would be unnecessarily complicated. To avoid sacriicing normal
contractile myocardium, the line of resection is just inside the conines of the aneurysm on the free
wall of the left ventricle anteriorly and laterally, preserving a rim of scar for secure closure of the
ventricle. Cardiopulmonary bypass is established prior to manipulating or mobilizing the left
ventricle or the aneurysm because there is often mural thrombus in the left ventricle attached to
the inside of the aneurysm. To reduce the chance of embolism during manipulation, the aorta
should be occluded and the heartbeat arrested with cold cardioplegia before the adhesions
between the aneurysm and the pericardium are divided. A vent catheter placed in the left
ventricle via the right superior pulmonary vein collapses the thin parts of the ventricle. The
aneurysm is opened in its center portion, parallel to the ventricular septum. Allis clamps are
placed at each end of the incision into the aneurysm. Mural thrombus is removed from the left
ventricle. Removing all the clot from the trabeculations of the left ventricle may be quite tedious.
The wall of the aneurysm is excised, retaining about 1 cm of scar at the rim. The medial edge of
the excision is near the septum but does not enter the right ventricle. The left ventricle, left
atrium, and aortic root are thoroughly irrigated with cold electrolyte solution and carefully
inspected for retained debris.
The illustrated method of repair is still considered standard by many surgeons. The left
ventricle is repaired by closure of the large ventriculotomy between strips of Telon felt to
strengthen the suture line and enhance hemostasis. Interrupted mattress stitches of 0
polypropylene are placed through the felt and the rim of the scarred ventricle. The stitches may
be placed obliquely in the ventricular septum so that the closure is inverted against the septum,
eliminating some of the paradoxical septal motion. The mattress stitches are tied to approximate
the edges of the ventriculotomy. To ensure hemostasis, a second layer of closure stitches of 2/0
polypropylene is placed as a continuous row down and back over the ventriculotomy. As these
stitches are pulled up, the edges of the ventriculotomy are compressed with the ingers rather than
by applying tension on the suture, in order to avoid cutting through the heart.

Postoperative care
The overall rate of major morbidity or operative mortality in the 2008 STS Report
(including all of year 2008) for patients undergoing isolated on-pump CABG was 16.9% (risk
adjusted rate 13.6%) [1]. Providing the patient with a technically successful and complete
myocardial revascularization is the first step in reducing postoperative morbidity.
Postoperatively, an adequate cardiac index (> 2.0 L/min/m2) should be maintained with the use
of inotropic or mechanical support as needed, as a reduced cardiac index is associated with poor
survival.
Graft failure or coronary spasm
Graft patency may be enhanced by the administration of antiplatelet agents including
aspirin and/or Plavix that are reinstituted when safe, the use of inotropes or mechanical support to
maintain an adequate cardiac output, and the use of calcium channel blockers or nitrates for the
prevention of arterial graft spasm [13].
Continuous electrocardiogram monitoring is utilized in the early postoperative period to
immediately detect ischemic changes that may be indicative of graft closure or graft or native
vessel coronary spasm. The awake and alert patient may complain of chest pain in this situation.
Unexplained hypotension, cardiogenic shock, and unexplained arrhythmias may also indicate
myocardial ischemia. An urgent transthoracic echocardiogram may reveal wall motion
abnormalities. A high index of suspicion for myocardial ischemia or graft compromise must be
maintained, and early coronary angiography with possible angioplasty or stent placement may be
indicated to diagnose and/or treat such conditions. In addition, a prompt return to the operating
room may also be indicated.
Infection
The STS 2008 Report observed rate of deep sternal wound infection was 0.4% (risk
adjusted 0.3%) in patients undergoing isolated CABG [1]. Perioperative intravenous antibiotics
are administered prior to incision and continued for 48 hours or less postoperatively. Additional
antibiotic use should be guided by specific culture and sensitivity studies. In addition, aggressive
blood sugar management (often with insulin infusion) is utilized to limit the occurrence of sternal
wound infection [2, 3, 26]. Central lines and chest tubes are promptly discontinued when no
longer necessary or useful. In addition, other sites (conduit harvest sites, urinary tract, and lungs)
are closely monitored and promptly treated should an infection occur.
Postoperative bleeding/early tamponade
Most importantly, appropriate surgical hemostasis should be obtained prior to chest
closure to avoid postoperative bleeding. In the postoperative period, coagulopathy is corrected
with appropriate blood products, patients are adequately warmed if hypothermia exists, and chest
tubes are frequently monitored for patency to prevent tamponade. Tamponade requires immediate
operative drainage. Heparin rebound should be considered as a possible cause for continued
bleeding. The postoperative CXR may indicate an undrained hemothorax that may require
surgical reexploration in the case of excessive bleeding.
Renal failure
The STS 2008 Report observed rate of renal failure (postoperative creatinine > 2 mg/dL
or doubling of the preoperative creatinine) following isolated CABG in patients not previously on
dialysis was 3.7% (risk adjusted 3.2%) [1]. To limit renal injury in the postoperative period, an
acceptable cardiac index and mean arterial pressure must be maintained. Nephrotoxic agents
should be avoided or limited, and any renally excreted medication should have dose adjustment
[4]. Renal injury postoperatively may be multifactorial, unpredictable, or related to the
intraoperative course.
Cerebrovascular accident
The STS 2008 Report observed rate of permanent stroke in patients undergoing isolated
CABG was 1.3% (risk adjusted 0.9%) [1]. Neurologic complications may be manifested by a
wide range of signs and symptoms from delirium and confusion to permanent stroke. These
complications may also be directly related to intraoperative or perioperative events. Similar to the
strategy to prevent renal injury, an acceptable cardiac index and mean arterial pressure must be
maintained. Patients with postoperative atrial fibrillation or documented poor ejection fraction
with intracardiac clot should be anticoagulated to prevent cerebral embolization.
Respiratory failure
The STS 2008 Report observed rate of prolonged ventilation in patients undergoing
isolated CABG was 11.6% (risk adjusted 8.8%) [1]. Prolonged ventilation is defined by the STS
as greater than 24 hours on the ventilator. Many preoperative risk factors may indicate a higher
risk for the development of respiratory failure in the postoperative period. A prompt
postoperative trial of extubation when appropriate, the limitation of sedation, tracheostomy, and
early nutritional support may be appropriate in the individualized care of these patients.
Appropriate antibiotics are administered when ventilator-associated pneumonia occurs as a result
of prolonged intubation.
Urinary tract infection In an attempt to combat urinary tract infections postoperatively,
indwelling urinary catheters are removed promptly, urinary retention is treated aggressively, and
antibiotics are administered when appropriate.
Gastrointestinal complications
As with many postoperative complications, the risk of gastrointestinal complications
increases as CPB time increases. The prompt diagnosis and treatment of gastrointestinal
complications following CABG requires a high index of suspicion. Gastrointestinal ischemia may
occur following periods of hypoperfusion due to low cardiac output, hypotension from blood
loss, and as a result of intravascular emboli [27]. Gastrointestinal bleeding may be exacerbated by
the use of antiplatelet agents and anticoagulation. Adequate gastric mucosal protection should be
provided with proton pump inhibitors to prevent stress ulceration. In addition, early enteral
feeding should be initiated in the case of prolonged ventilation. Antibiotics should be
discontinued promptly when they are no longer clinically indicated to prevent the complication of
Clostridium difficile diarrhea and colitis.
Atrial fibrillation
Postoperative atrial fibrillation is the most common cause of morbidity following
isolated CABG as it occurs in up to 40% of patients [28, 29]. The onset of postoperative atrial
fibrillation prolongs the length of hospitalization and increases hospitalization costs. Medical
therapy to limit heart rate (P blockers and calcium channel blockers) and to attempt medical
cardioversion (amiodarone), electrical cardioversion, and anticoagulation are utilized in the
postoperative treatment of this arrhythmia.
Delayed tamponade
Tamponade occurring after the acute postoperative period may be extremely difficult to
diagnose, and a high index of suspicion for this diagnosis must be maintained. A decline in renal
or liver function, poor urine output, or an elevated coagulation profile may be the initial clue. An
echocardiogram may be helpful in making the diagnosis. This complication must be rapidly
treated with reexploration of the chest and evacuation of the mediastinal fluid.

ARRHYTHMIA SURGERY
History and physical
Attempt to determine the pattern of afib (paroxysmal - spontaneous conversion,
recurrent requires ECV/antiarrythmics or persistent), medications (anticoagulation,
antiarrhythmics), and complications of afib (stroke, peripheral emboli). Identify signs and
symptoms of diseases that predispose to a high recurrence rate after catheter ablation:
hypertension, hypercholesterolemia, persistent AF, or obstructive sleep apnea. Predisposing
factors include age, male sex (because of the tall stature), hypertension, hyperthyroidism, chronic
kidney disease, alcohol, PE, obesity (BMI > 30 kg/m2) and family history. Ask about any known
ischemic or valvular issues.

Tests
• Labs: CBC, BMP, Coags.
• 12 lead EKG to establish the rate and rhythm.
• 24 Holter monitoring especially if the patient is currently in sinus rhythm.
• CT scan or MRI: pulmonary vein protocol in patients with a failed catheter ablation
(to rule out pulmonary stenosis).
• Echo: complete valvular assessment, septal anatomy, right and left function, and left
atria size. Severely dilated left atrium decreases the likelihood of achieving sustained sinus
rhythm.
• Left heart catheterization: for IHD and for establishing coronary anatomy (left
dominant patients are at slightly increased risk of injury to their coronary arteries while ablating
close to the coronary sinus). • Electrophysiological mapping: which utilizes the combination of
pace/anatomic/activation mapping to identify potential sites for ablation.

Treatment/management
• Indications for catheter or surgical ablation include paroxysmal (PAF), persistent or
recurrent AF in patients who do not tolerate or have failed antiarrhythmics. Catheter ablation is
usually attempted first once or even twice prior to referral for surgery unless the patient is
undergoing surgery for a concomitant lesion.
• This patient has failed medical and catheter based interventions and is thus a
candidate for stand alone surgical ablation. Options include pulmonary vein isolation (works well
for
PAF), or Cox MAZE IV (cut and sew or the modified ablation protocol). For this patient Cox
MAZE IV will give her the greatest chance of sinus rhythm control.
 Operative steps
Goals - establishing atrioventricular synchrony, return and preservation of atrial
mechanical function to enhance ventricular diastolic filling and abolish electrophysiologic
substrates propagating the arrhythmia.
Cox maze IV

• Many different ways to do this but here we describe the critical lesion sets using a
single cryoablation catheter (nitric oxide).
• Standard median sternotomy, aortic and bicaval cannulation, antegrade cardioplegia.
• Initiate CPB, clamp, antegrade arrest, snares around the IVC/SVC, right atriotomy,
place the retrograde coronary sinus catheter in directly and administer cardioplegia (although
may also do the case entirely with antegrade).
• Left atrial incision through Sondergaards groove. Alternative is transeptal incision
through the fossa ovalis.
• Left sided lesions: the unipolar cryoablation (nitric oxide), can be used for all the
lesions in the Cox Maze IV and may be more cost effective than using both bipolar
radiofrequency (RF) and cryoablation. 1) Start with a box lesion around the four pulmonary
veins. Success may be documented by demonstrating exit block from each PV. Note that this
lesion can also be done with the bipolar ablation device. If using the cryoprobe you need to have
the TEE probe pulled up towards the upper mediastinum and lift anteriorly on the backwall of the
atrium during freezing so as to avoid esophageal injury. 2) Excise the LAA and make a lesion
from here to the left superior pulmonary vein. Close the left atrial appendage incision. 3) Lesion
from the atrial incision to the posterior mitral annulus (P3) - this is the circumflex lesion and
should be performed both inside and outside of the atrium for transmural ablation. De-air and
close the septal incision. Care with the phrenic nerves while doing left sided lesions. A moist lap
pad to insulate the nerve maybe helpful.
• Right sided lesions (can be done with the heart beating). 1) Right transverse
atriotomy.
2) Epicardial surface of the SVC to the IVC (can use bipolar here, watch for the SA node).
3) Right atrial appendage (RAA) incision with a free wall lesion down the anterior RA wall with
a cut or ablation (be sure to keep a 2 cm uninvolved atrial bridge between this lesion and the
transverse atriotomy). 4) RAA lesion to the 10’oclock position on the tricuspid annulus. 5)
Atriotomy to the 2 o’oclock position on the tricuspid valve. • Close the right atriotomy, and
release your snares.

PACEMAKER INSERTION
Permanent pacing systems require the implantation of pacing electrodes in contact with
the myocardium and the placement of a pulse generator in the body. There are a number of
options for accomplishing these tasks. In certain circumstances it may be advisable to implant
permanent myocardial electrodes on the surface of the heart at the time of open cardiac surgery.
Endocardial contact with the electrode, however, appears to be more satisfactory in achieving
long-term, low-threshold function of the electrode. The availability of small-diameter, lexible
electrode catheters and small pulse generators makes electrode implantation via the subclavian
vein and placement of the pulse generator in the chest wall possible and preferable in nearly
every case in both adults and children.

CARDIAC TRANSPLANTATION
Improved means of controlling tissue rejection have made transplantation of the human
heart a useful clinical procedure that is widely applied in cardiovascular centers throughout the
world. Cooperative organizations for the sharing of facilities and long-distance transportation of
cryopreserved tissue for transplantation have made this procedure available to many individuals
who otherwise might have died of congestive cardiac failure. All these organizational and
immunological advances make possible a procedure that is remarkable to observe in total
perspective and offers its own technical challenges.
 Donor Cardiectomy
Operation on the donor is performed after verifying proper donor identification,
consent, blood type, and normal cardiac function. After inspection of the heart, the donor’s
surgeon informs the recipient’s surgeon of the indings and estimates the operating time and
transport time to establish an estimated time of arrival of the donor heart.

REFERENCES
1. Doty, Donald B. Cardiac surgery: operative technique / Donald B. Doty, John R. Doty ;
with illustrations by Jill Rhead,Christy Krames. -- 2nd ed.
2. Kirklin/Barratt-Boyes cardiac surgery: morphology, diagnostic criteria, natural history,
techniques, results, and indications / Nicholas T. Kouchoukos ... [et al.]. - 4th ed.
3. TSRA Clinical Scenarios in Cardiothoracic Surgery / Tom C. Nguyen, Gabriel Loor.
2013. - p. 525.
4. Mangi AA and Agnihotri AK. Postinfarction Ventricular Septal Defect. Spencer and
Sabiston - Surgery of the Chest. 2010; 1449-1456.
5. Gazoni LM. Mechanical complications of coronary artery disease. Mery CM and Turek
JW. TSRA Review of Cardiothoracic Surgery. 2011. 282-289.
6. Madsen JC and Daggett WM Jr. Repair of postinfarction ventricular septal defect.
Semin Thorac Cardiovasc Surg. 1998. Apr;10(2):117-127.
 7. Arnaoutakis GJ, Zhao Y, George TJ et al. Surgical repair of ventricular septal defect
after myocardial infarction: outcomes from the Society of Thoracic Surgeons National Database.
Ann Thorac Surg 2012; 94: 436-44.
8. Barbour JR and Ikonomidis JS. Aortic valve replacement. Yuh D, Vricella LA, and
Baumgartner WA (eds). Johns Hopkins Manual of Cardiothoracic Surgery 2007.
9. Johnston DR and Sabik JF. Acquired aortic valve disease. Selke FW, del Nido PJ, and
Swanson SJ Surgery of the Chest. 2010;1195-1207.
10. Balckstone EH, et al. Prosthesis size and long-term survival after aortic valve
replacement. JTCVS 2003; 126:783-96.
11. Potter DD. Operative risk of reoperative aortic valve replacement. J Thorac
CardiovascSurg 2005
12. Bonow RO, Carabello BA, Kanu C, et al: ACC/AHA 2006 guidelines for the
management of patients with valvular heart disease. Circulation 2006; 114:e84-e231.
13. Chikwe J, Ayanwu AC. Surgical Strategies for Functional Tricuspid Regurgitation.
SeminThoracic Surg 2010;22:90-96.
14. Dreyfus GD, Corbi PJ, Chan KM, Bahrami T: Secondary tricuspid regurgitation or
dilatation: Which should be the criteria for surgical repair?. Ann Thorac Surg 2005; 79:127- 132.

Kaplan Medical

USMLE® STEP 2 CK SURGERY - 2018.

p. 72-73, 203-205

ACQUIRED HEART DISEASE

Aortic stenosis produces angina, syncope, and dyspnea. There is a harsh midsystolic heart
murmur best heard at the right second intercostal space and along the left sternal border. Start the
workup with an echocardiogram. Surgical valvular replacement is indicated if there is a gradient
>50 mm Hg, or at the first indication of CHF, angina, or syncope.

Chronic aortic insufficiency produces wide pulse pressure and a blowing, high-pitched, diastolic
heart murmur best heard at the second intercostal space and along the left lower sternal border,
with the patient in full expiration. Patients are often followed with medical therapy for many
years, but should undergo valvular replacement at the first evidence on echocardiogram of the
beginning left ventricular dilatation.

Acute aortic insufficiency because of endocarditis is seen in young drug addicts who suddenly
develop CHF and a new, loud diastolic murmur at the right second intercostal space. Emergency
valve replacement and long-term antibiotics are needed.

Mitral stenosis is caused by a history of rheumatic fever many years before presentation. It
produces dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, cough, and hemoptysis.
There is a low-pitched, rumbling diastolic apical heart murmur. As it progresses, patients become
thin and cachectic and develop atrial fibrillation. Workup starts with echocardiogram. As
symptoms become more disabling, mitral valve repair becomes necessary with a surgical
commissurotomy or mitral valve replacement.

Mitral regurgitation is most commonly caused by valvular prolapse. Patients develop exertional
dyspnea, orthopnea, and atrial fibrillation. There is an apical, high-pitched, holosystolic heart
murmur that radiates to the axilla and back. Workup and surgical indications are as above, with
repair of the valve (annuloplasty) preferred over prosthetic replacement.

Coronary disease can happen to anybody (including women), but the typical patient is as follows:
• Middle-age sedentary man • Has family history, smoking history, type II diabetes and/or
hypercholesterolemia

Progressive, unstable, disabling angina is the main reason to do cardiac catheterization and
evaluate as a potential candidate for revascularization. Intervention is indicated if ≥1 vessels have
≥70% stenosis and there is a good distal vessel. Preferably, the patient should still have good
ventricular function (you cannot resuscitate dead myocardium).

The general rule is that the simpler the problem, the more it is amenable to angioplasty and stent;
whereas more complex situations do better with surgery. • Single vessel disease (that is not the
left main or the anterior descending) is perfect for angioplasty and stent. • Triple vessel disease
makes multiple coronary bypass (using the internal mammary for the most important vessel) the
best choice.

Post-operative care of heart surgery patients often requires that cardiac output be optimized. If
cardiac output is considerably under normal (5 liters/min, or cardiac index 3), the pulmonary
wedge pressure (or left atrial pressure, or left end-diastolic pressure) should be measured. Low
numbers (0–3) suggest the need for more IV fluids. High numbers (≥20) suggest ventricular
failure.

Chronic constrictive pericarditis produces dyspnea on exertion, hepatomegaly, and ascites, and
shows a classic “square root sign” and equalization of pressures (right atrial, right ventricular
diastolic, pulmonary artery diastolic, pulmonary capillary wedge, and left ventricular diastolic)
on cardiac catheterization. Surgical therapy relieves it.

ACQUIRED HEART DISEASE

1. A 72-year-old man has a history of angina and exertional syncopal episodes. He has a harsh
midsystolic heart murmur best heard at the right second intercostal space and along the left
sternal border.

What is it? Aortic stenosis with the triad of angina, dyspnea, and syncope.

Management. Diagnose with echocardiogram. Surgical valvular replacement is indicated if there

is a gradient of >50 mm Hg, or at the first indication of CHF, angina, or syncope.

2. A 72-year-old man has been known for years to have a wide pulse pressure and a blowing,
high-pitched, diastolic heart murmur best heard at the right second intercostal space and along the
left lower sternal border with the patient in full expiration. He has had periodic echocardiograms,
and in the most recent one there is evidence of beginning left ventricular dilatation.

What is it? Chronic aortic insufficiency.

Management. Aortic valve replacement.

3. A 26-year-old drug-addicted man develops CHF over a short period of a few days. He has a
loud, diastolic murmur at the right, second intercostal space. A physical examination done a few
weeks ago, when he had attempted to enroll in a detoxification program, was completely normal.

What is it? Acute aortic insufficiency caused by endocarditis.

Management. Emergency valve replacement, and antibiotics for a long time.

4. A 35-year-old woman has dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea,

cough, and hemoptysis. She has had these progressive symptoms for about 5 years. She looks
thin and cachectic and has atrial fibrillation and a low-pitched, rumbling diastolic apical heart
murmur. At age 15 she had rheumatic fever.

What is it? Mitral stenosis.

Management. Start with echocardiogram. Eventually, consider surgical mitral valve repair.

5. A 55-year-old woman has been known for years to have mitral valve prolapse. She now has
developed exertional dyspnea, orthopnea, and atrial fibrillation. She has an apical, high-pitched,
holosystolic heart murmur which radiates to the axilla and back.

What is it? Mitral regurgitation.

Management. Start with the echocardiogram. Eventually, consider surgical repair of the valve
(annuloplasty) or valve replacement.

6. A 55-year-old man has progressive, unstable, disabling angina that does not respond to
medical management. His father and 2 older brothers died of heart attacks age <50. The patient
stopped smoking 20 years ago, but still has a sedentary lifestyle, is a bit overweight, has type 2
diabetes mellitus, and has high cholesterol.

What is it? It’s a heart attack waiting to happen: this man needs a cardiac catheterization to see
whether he is a suitable candidate for coronary revascularization.

7. A 55-year-old man has progressive, unstable, disabling angina that does not respond to
medical management. His father and 2 older brothers died of heart attacks age <50. The patient
stopped smoking 20 years ago, but still has a sedentary life style, is a bit overweight, has type 2
diabetes mellitus, and has high cholesterol. Cardiac catheterization demonstrates 70% occlusion
of 3 coronary arteries, with good distal vessels. His left ventricular ejection fraction is 55%.

Management. The patient is lucky. He has good distal vessels (smokers and diabetics often do
not) and enough cardiac function left. He clearly needs coronary bypass, and with triplevessel
disease he is not a good candidate for angioplasty.

8. A postoperative patient who underwent open heart surgery is determined to have a cardiac
index 1.7 L/min/m2 and left ventricular end-diastolic pressure 3 mm Hg.

The postoperative management of open heart surgery is too esoteric for the exam, but a bit of
applied physiology is not. You should be able to recognize a dangerously low cardiac index,
without a high end-diastolic pressure—a clear indication for increased fluid intake.

9. A 72-kg patient who had a triple coronary bypass is determined on postoperative day 2 to have
a cardiac output of 2.3 L/min. Pulmonary wedge pressure is 27 mm Hg. Cardiac output is low,
but the ventricle is failing.
Management. Cardiac output of 2.3L/min in a 72-kg patient is an indicator of heart failure. Given
the elevated pulmonary wedge pressure, hypovolemia is not the issue. In the post-CABG period,
myocardial dysfunction is common and inotropic support is indicated. Common pharmacological
agents for this scenario include epinephrine, norepinephrine, and dobutamine.

The materials was prepared by Asoc. Professor T. Romaniuk