Case Summary
A 63 years old lady who was admitted with acute coronary syndrome. She was referred for coronary artery bypass surgery. Risk factors included previous PCI and stents to LAD and right coronary artery (RCA); arteriopathy with peripheral vascular disease treated with stents in both iliac arteries; persistent intermittent claudication; pulmonary emphysema and current smoker. Left heart catheterization (LHC) showed severe triple vessel disease with preserved left ventricular systolic function. She underwent a triple vessel coronary artery bypass surgery by Total Arterial Revascularization using cardio-pulmonary bypass. The LIMA and the RIMA were harvested in skeletonized fashion and a T-anastomosis (Tector) was performed. LIMA was grafted to LAD and RIMA sequentially to distal Circumflex (LCx) and posterior descending artery (PDA). (Figure 1)
Temporary atrial pacing wires were placed and the patient was transferred to cardiothoracic intensive therapy unit in haemodynamically stable condition. The patient had an asystolic cardiac arrest with no pacemaker capture 2 hours later. There were no ECG changes suggestive of myocardial ischaemia leading to the event. Cardiac surgery Advanced Life Support (CALS) was initiated and the patient was stabilised on central Veno-Arterial-Extra Corporeal Membrane Oxygenation (VA-ECMO). Bedside transesophageal echocardiogram (TOE) showed a global severe depressed left ventricular function which was confirmed on heart inspection when the chest was reopened. When stabilized, emergency LHC was performed and it showed patent LIMA to LAD with good run off distally. RIMA showed a stenosis just distal to the Y-anastomosis. There was good run off into PDA and obtuse marginal (OM) artery. (Figure 2) We did OCT to evaluate the mechanism of stenosis. A large intramural haematoma was shown to be compressing the lumen. There was no evidence of intimal dissection (Figure 3). Patient was managed conservatively as there was no flow limitation in the grafts.