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Management of Right Ventricular Injury After Localization of the Left Anterior Descending Coronary Artery

2009; Elsevier BV; Volume: 88; Issue: 2 Linguagem: Inglês

10.1016/j.athoracsur.2008.12.062

1552-6259

Lucas Sanders, Hamad M.A. Soliman, Bart H. van Straten,

Cardiovascular Issues in Pregnancy

During coronary artery bypass surgery an intramyocardial or intracavitary left anterior descending coronary artery can be difficult to locate and pose problems of inadvertent entry into the right ventricle. We present a literature review of the management of this injury. We report an additional aid to prevent injury to the left anterior descending coronary artery during closure of the right ventriculotomy. During coronary artery bypass surgery an intramyocardial or intracavitary left anterior descending coronary artery can be difficult to locate and pose problems of inadvertent entry into the right ventricle. We present a literature review of the management of this injury. We report an additional aid to prevent injury to the left anterior descending coronary artery during closure of the right ventriculotomy. An intramyocardial coronary artery is reported with a low incidence in surgical studies. A recent computed tomographic scan report demonstrated a frequency of 30% for the left anterior descending coronary artery especially proximally [1Konen E. Goitein O. Sternik L. Eshet Y. Shemesh J. Di Segni E. The prevalence and anatomical patterns of intramuscular coronary arteries: a coronary computed tomography angiographic study.J Am Coll Cardiol. 2007; 49: 587-593Abstract Full Text Full Text PDF PubMed Scopus (133) Google Scholar]. An intracavitary coronary artery is an extreme form of an intramyocardial coronary artery. Localization of an intramyocardial left anterior descending coronary artery can result in inadvertent entry into the right ventricle. Previous reports have described methods to localize the intramyocardial left anterior descending coronary artery (LAD) and to deal with the right ventricular injury [2Ochsner J.L. Mills N.L. Surgical management of diseased intracavitary coronary arteries.Ann Thorac Surg. 1984; 38: 356-362Abstract Full Text PDF PubMed Scopus (35) Google Scholar, 3Fisk R.L. Brooks C.H. Sandhu G. Bates P.D. Expeditious location of the embedded proximal left anterior descending coronary artery.Ann Thorac Surg. 1980; 29: 480-482Abstract Full Text PDF PubMed Scopus (10) Google Scholar, 4Oz M.C. Cooper A.M. Hickey T.J. Rose E.A. Exposure of the intramyocardial left anterior descending coronary artery.Ann Thorac Surg. 1994; 58: 1194-1195Abstract Full Text PDF PubMed Scopus (17) Google Scholar, 5Eckstein P.F. Technique for finding the left anterior descending artery.Ann Thorac Surg. 1995; 59: 1040PubMed Google Scholar, 6Zamvar V. Lawson R.A.M. Technique of finding the left anterior descending coronary artery.Ann Thorac Surg. 1995; 60: 1457-1458Abstract Full Text PDF PubMed Scopus (6) Google Scholar, 7Fisk R.L. Locating the embedded anterior descending coronary artery: follow-up comment.Ann Thorac Surg. 1996; 62: 320-321Abstract Full Text PDF PubMed Google Scholar, 8Tovar E.A. Borsari A. Landa D.W. Weinstein P.B. Gazzaniga A.B. Ventriculotomy repair during revascularization of intracavitary anterior descending coronary arteries.Ann Thorac Surg. 1997; 64: 1194-1196Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar, 9Hendrick B. Barner, Invited Commentary.Ann Thorac Surg. 1997; 64: 1196Abstract Full Text PDF Google Scholar, 10Suzer K. Omay O. Ozker E. Ozgol I. Wijers T.S. A novel approach to surgical treatment of diseased intracavitary coronary arteries and ventriculotomy closure.Ann Thorac Surg. 2008; 85: 1110-1112Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar]. We recently encountered a patient with an intracavitary (right ventricular) LAD. The only visible distal subepicardial LAD appeared small. During superficial exploration in the anterior interventricular fat groove, the right ventricle was entered after dissection of only 3 mm of epicardial fat and 1 to 2 mm of muscle. Further dissection was abandoned and the proximal segment of the LAD was located using distal arteriotomy and retrograde probing. The LAD wall and the intraluminal probe could be detected in the right ventricle through the inadvertent right ventriculotomy. The probe was left in the LAD lumen to provide visual and tactile feedback, while the ventriculotomy was closed with horizontal pledgeted mattress sutures beneath the LAD. The left internal mammary artery was anastomosed to the proximal LAD and the distal arteriotomy was closed by indirect approximation of the arteriotomy edges (adventitia and epicardium). After weaning from cardiopulmonary bypass, a troublesome ooze of dark blood was present that originated either from the right ventricle or cardiac veins. Ischemia developed after blind placement of an additional deep horizontal mattress suture intended to be beneath the LAD. This suture was removed and the ischemia disappeared. The bleeding was arrested by application of a TachoSil patch (Nycomed Laboratory, Roskilde, Denmark). Postoperatively there were no signs of myocardial ischemia or infarction, and the maximum aspartate aminotransferase was 66 U/L on postoperative day 2. An echocardiogram showed improvement in left ventricular function from moderate to slight impairment. The prevalence of intramyocardial coronary arteries, also known as myocardial bridging, varies with the type of study performed as follows: cardiac surgery was 0.2% to 0.3%, angiography was 0.8% to 4.9%, and autopsy was 5% to 86% [1Konen E. Goitein O. Sternik L. Eshet Y. Shemesh J. Di Segni E. The prevalence and anatomical patterns of intramuscular coronary arteries: a coronary computed tomography angiographic study.J Am Coll Cardiol. 2007; 49: 587-593Abstract Full Text Full Text PDF PubMed Scopus (133) Google Scholar]. Using coronary computed tomographic angiography (40 to 64 multi-slice computed tomographic scanners), Konen and colleagues [1Konen E. Goitein O. Sternik L. Eshet Y. Shemesh J. Di Segni E. The prevalence and anatomical patterns of intramuscular coronary arteries: a coronary computed tomography angiographic study.J Am Coll Cardiol. 2007; 49: 587-593Abstract Full Text Full Text PDF PubMed Scopus (133) Google Scholar] recently reported an incidence of myocardial bridging of 30.5%, more consistent with autopsy studies. Of the 30.5%, the LAD had the highest overall incidence, 72% (mid-LAD of 57% and distal LAD of 15%). Three types were identified as: superficial intramuscular (29%), deep intramuscular (41%), and a right ventricular (intracavitary) type (29%). Localization of an intramyocardial LAD can be a technical challenge. Dissection can cause injury to diagonal and septal branches, coronary veins, and right ventricle leading to prolonged cross-clamp times [1Konen E. Goitein O. Sternik L. Eshet Y. Shemesh J. Di Segni E. The prevalence and anatomical patterns of intramuscular coronary arteries: a coronary computed tomography angiographic study.J Am Coll Cardiol. 2007; 49: 587-593Abstract Full Text Full Text PDF PubMed Scopus (133) Google Scholar, 2Ochsner J.L. Mills N.L. Surgical management of diseased intracavitary coronary arteries.Ann Thorac Surg. 1984; 38: 356-362Abstract Full Text PDF PubMed Scopus (35) Google Scholar, 3Fisk R.L. Brooks C.H. Sandhu G. Bates P.D. Expeditious location of the embedded proximal left anterior descending coronary artery.Ann Thorac Surg. 1980; 29: 480-482Abstract Full Text PDF PubMed Scopus (10) Google Scholar, 4Oz M.C. Cooper A.M. Hickey T.J. Rose E.A. Exposure of the intramyocardial left anterior descending coronary artery.Ann Thorac Surg. 1994; 58: 1194-1195Abstract Full Text PDF PubMed Scopus (17) Google Scholar, 5Eckstein P.F. Technique for finding the left anterior descending artery.Ann Thorac Surg. 1995; 59: 1040PubMed Google Scholar, 6Zamvar V. Lawson R.A.M. Technique of finding the left anterior descending coronary artery.Ann Thorac Surg. 1995; 60: 1457-1458Abstract Full Text PDF PubMed Scopus (6) Google Scholar, 7Fisk R.L. Locating the embedded anterior descending coronary artery: follow-up comment.Ann Thorac Surg. 1996; 62: 320-321Abstract Full Text PDF PubMed Google Scholar, 8Tovar E.A. Borsari A. Landa D.W. Weinstein P.B. Gazzaniga A.B. Ventriculotomy repair during revascularization of intracavitary anterior descending coronary arteries.Ann Thorac Surg. 1997; 64: 1194-1196Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar]. Right ventricular injury causes additional problems of introduction of air, difficulty in exposure due to blood, postoperative bleeding, and obstruction of the LAD during closure of the ventriculotomy. These complications are more often seen when the LAD is anastomosed proximally due to the higher incidence of an intramyocardial LAD [8Tovar E.A. Borsari A. Landa D.W. Weinstein P.B. Gazzaniga A.B. Ventriculotomy repair during revascularization of intracavitary anterior descending coronary arteries.Ann Thorac Surg. 1997; 64: 1194-1196Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar]. A proximal anastomosis does allow antegrade flow through the entire vessel and the largest lumen possible for anastomosis. In 1973, Robinson first presented the technique of identifying the proximal intramuscular LAD by palpation of a retrogradely inserted probe through a distal arteriotomy [11Robinson G. Location of the proximal left anterior descending coronary artery.Ann Thorac Surg. 1973; 15: 299-300Abstract Full Text PDF PubMed Scopus (8) Google Scholar]. Subsequently Fisk and colleagues [3Fisk R.L. Brooks C.H. Sandhu G. Bates P.D. Expeditious location of the embedded proximal left anterior descending coronary artery.Ann Thorac Surg. 1980; 29: 480-482Abstract Full Text PDF PubMed Scopus (10) Google Scholar] presented a series of 18 cases using this technique, later followed up by Fisk [7Fisk R.L. Locating the embedded anterior descending coronary artery: follow-up comment.Ann Thorac Surg. 1996; 62: 320-321Abstract Full Text PDF PubMed Google Scholar] with 117 cases without ischemia in the LAD territory. They believe that this technique is safe and reduces the risk of inadvertent injury. Few reports have dealt with the issue of management of inadvertent right ventricular injury during localization of the LAD. Ochsner and Mills [2Ochsner J.L. Mills N.L. Surgical management of diseased intracavitary coronary arteries.Ann Thorac Surg. 1984; 38: 356-362Abstract Full Text PDF PubMed Scopus (35) Google Scholar] report that McAlpine was the first to describe the existence of an intracavitary artery. They subsequently present a series of 13 patients with intracavitary coronary arteries and discuss the options for closure of either inadvertent right atriotomy or right ventriculotomy [2Ochsner J.L. Mills N.L. Surgical management of diseased intracavitary coronary arteries.Ann Thorac Surg. 1984; 38: 356-362Abstract Full Text PDF PubMed Scopus (35) Google Scholar]. For closure of the ventriculotomy, we used mattress sutures below the LAD, analogous to the standard technique for traumatic ventricular injury, similar to reports by Oz and colleagues [4Oz M.C. Cooper A.M. Hickey T.J. Rose E.A. Exposure of the intramyocardial left anterior descending coronary artery.Ann Thorac Surg. 1994; 58: 1194-1195Abstract Full Text PDF PubMed Scopus (17) Google Scholar] and Fisk [7Fisk R.L. Locating the embedded anterior descending coronary artery: follow-up comment.Ann Thorac Surg. 1996; 62: 320-321Abstract Full Text PDF PubMed Google Scholar]. As described by Barner [9Hendrick B. Barner, Invited Commentary.Ann Thorac Surg. 1997; 64: 1196Abstract Full Text PDF Google Scholar], this technique can potentially result in LAD obstruction if not all the overlying muscle fibers have been divided. At the proximal and distal edges of the ventriculotomy closure site, the overlying muscle fibers or right ventricle wall can compress the LAD. Ochsner and Mills [2Ochsner J.L. Mills N.L. Surgical management of diseased intracavitary coronary arteries.Ann Thorac Surg. 1984; 38: 356-362Abstract Full Text PDF PubMed Scopus (35) Google Scholar] present three solutions and provide illustrative graphs. The safest solution is closure of the ventriculotomy above the LAD and selection of an alternative site for anastomosis [9Hendrick B. Barner, Invited Commentary.Ann Thorac Surg. 1997; 64: 1196Abstract Full Text PDF Google Scholar]. Whether this is possible depends on the site of the stenosis, the vessel diameter of the alternative site, and whether the muscle layer above the LAD is thick enough for closure. The second option is complete division of the muscle above the LAD and approximation of the right ventricular free wall to the interventricular septum below the LAD. This could involve a significant amount of dissection and damage to numerous septal perforators, as well as diagonal branches during closure. The mattress sutures pass from the right ventricular wall either through the septum only [8Tovar E.A. Borsari A. Landa D.W. Weinstein P.B. Gazzaniga A.B. Ventriculotomy repair during revascularization of intracavitary anterior descending coronary arteries.Ann Thorac Surg. 1997; 64: 1194-1196Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar] or to the left ventricular epicardium on the left side of the LAD. Approximation is enough and sutures do not need to be tight [9Hendrick B. Barner, Invited Commentary.Ann Thorac Surg. 1997; 64: 1196Abstract Full Text PDF Google Scholar]. A pericardial patch can be used with this technique [10Suzer K. Omay O. Ozker E. Ozgol I. Wijers T.S. A novel approach to surgical treatment of diseased intracavitary coronary arteries and ventriculotomy closure.Ann Thorac Surg. 2008; 85: 1110-1112Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar]. The third solution described by Ochsner and Mills [2Ochsner J.L. Mills N.L. Surgical management of diseased intracavitary coronary arteries.Ann Thorac Surg. 1984; 38: 356-362Abstract Full Text PDF PubMed Scopus (35) Google Scholar] is closure of the ventriculotomy using a pericardial patch through which the graft to the LAD traverses. In our case, closure of the ventriculotomy above the LAD either directly or with the use of a patch was not possible due to the thin right ventricular wall. Fortunately placement of the initial mattress sutures below the LAD did not cause ischemia. Possibly the risk of compression of the LAD due overlying undivided tissue is small when the right ventricle wall is thin. With any of the techniques described, the inherent danger of blind passage of needles, presumably below the LAD, is injury to the LAD itself. The use of an intraluminal probe, during placement of sutures close to the LAD, reduces the risk of damage by providing visual and tactile feedback. This has not been described before. In conclusion, inadvertent right ventriculotomy during localization of the LAD present a technical challenge. We have discussed the different techniques for closure, including a literature review. We believe we are the first to describe the use of an intraluminal probe to provide visual and tactile feedback during placement of mattress sutures beneath the LAD.