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.