Case 5--2000. Redo coronary revascularization without cardiopulmonary bypass.

The patient was a 53-year-old man with a history of 3 previous coronary artery bypass graft (CABG) operations (1978, 1991, 1997) who presented to an outside hospital with severe unstable angina and tachycardia (heart rate 140 BPM). Because of his extensive cardiac history and unfavorable coronary anatomy, he was deemed a poor surgical candidate for a fourth reoperation. During his third revascularization procedure, the right ventricle had been entered at sternotomy; the aorta was also noted to be densely adherent and heavily calcified with no sites for proximal graft anastomosis (vein grafts to the left anterior descending and right coronary artery had their proximal anastomoses to a previously existing circumflex saphenous vein graft near the coronary graft ostium). The heart was supplied entirely by this single vein graft with its 3 divisions; all native coronary vessels were totally occluded. The patient was transferred to this institution for further surgical evaluation. Past medical history was significant for myocardial infarction, permanent pacemaker, history of hepatitis C, gastritis, depression, bipolar disorder, posttraumatic stress disorder, remote 30 pack-year smoking history, recent history of alcohol abuse, and history of marijuana use. The patient was not considered a transplant candidate. Medications at presentation included captopril, 12.5 mg orally three times a day; furosemide, 40 mg orally two times a day; omeprazole (prilosec), 20 mg orally daily; heparin infusion, 1200 U/h; digoxin, 0.125 mg orally daily; aspirin daily; sertraline (Zoloft), 50 mg orally daily; and diazepam, 5 mg orally daily. The preoperative electrocardiogram (ECG) showed an incomplete left bundle-branch block with diffuse STand T-wave abnormalities. Pulmonary function tests showed forced expiratory volume in 1 second, 2.03 L, and forced vital capacity, 2.87 L. A preoperative chest radiograph showed cardiomegaly with pulmonary congestion. Laboratory data, including a complete blood count, renal and electrolyte panel, coagulation profile, and liver panel, were normal except for activated partial thromboplastin time, 46.7 seconds; hematocrit, 31.5%; and elevated CK-MB fraction suggestive of acute non–Q wave myocardial infarction. Preoperative testing included a dual isotope cardiac study, which showed a large reversible perfusion defect involving the anteroapical region; a small reversible perfusion defect involving the septum, left ventricular hypokinesia, and a calculated left ventricular ejection fraction of 19%. A dipyridamolethallium scan was strongly positive for global ischemia. A transthoracic echocardiogram was significant for severe global left ventricular dysfunction, normal right ventricular function, and mild-to-moderate mitral regurgitation. Cardiac catheterization revealed a single 50% proximal stenosis of the circumflex saphenous vein graft compromising flow to the existing associated right coronary artery and left anterior descending artery vein grafts, whose proximal anastomotic sites were distal to this obstruction. Despite aggressive medical management, the patient could not be weaned from intra-aortic balloon pump support. Percutaneous transluminal coronary angioplasty was not considered to be an option. He presented for elective coronary artery bypass graft (CABG) surgery without cardiopulmonary bypass by a left thoracotomy approach. His estimated operative risk was 50%. In the operating room, routine monitors, a femoral arterial catheter, a femoral venous catheter (8F introducer sheath), and a left internal jugular 12F central venous pressure (CVP) catheter were placed. External defibrillator pads were also applied. A right internal jugular pulmonary artery catheter and a left femoral intra-aortic balloon pump at 1:1 counterpulsation were already in situ. The patient was on no inotropic support at this time. Preinduction vital signs were heart rate (HR), 80 beats/ min; mean arterial pressure (MAP), 95 mmHg; CVP, 17 mmHg; pulmonary artery pressure (PAP), 62/39 mmHg; and cardiac index (CI), 2.8 L/min/m2. The ECG showed diffuse ST-T wave changes in all leads. Anesthetic induction with etomidate, midazolam, and fentanyl proceeded uneventfully. A 39F leftsided double-lumen endotracheal tube was inserted easily, and the position was verified with a pediatric fiberoptic bronchoscope. Postinduction transesophageal echocardiography (TEE)