Acute coronary syndrome as a first presentation of systemic lupus erythematosus in a teenager: revascularization by hybrid coronary artery bypass graft surgery and percutaneous coronary intervention: case report.

Patients with systemic lupus erythematosus (SLE) may present with acute coronary syndrome (ACS) due to coronary vasculitis or premature atherosclerosis. There is a paucity of data on invasive management strategies for young adults who present with an ACS secondary to active vasculitis. This article describes the case of a teenager who presented with an ACS secondary to lupus vasculitis as his first presentation of active SLE. Coronary angiography showed a left main equivalent lesion involving a proximal very large left anterior descending artery (LAD) and diagonal stenosis (with a diminutive left circumflex artery). The boy underwent a successful endoscopic coronary bypass surgery to his LAD followed by percutaneous coronary intervention to his diagonal artery. This case demonstrates the feasibility and safety of a hybrid coronary revascularization in a teenager with acute coronary syndrome due to coronary vasculitis.

Off-pump grafting of the main circumflex coronary artery in the atrioventricular groove via sternotomy.

BACKGROUND: We report our off-pump technique for grafting of the main circumflex coronary artery in the atrioventricular groove performed through a median sternotomy. METHODS: Six patients with significant proximal stenoses of the circumflex coronary presented with small obtuse marginal branches. In each case, three-vessel coronary artery disease was present requiring median sternotomy. Each patient underwent off-pump grafting of the main circumflex coronary artery in the atrioventricular groove. Hemodynamic indicators were recorded every 60 seconds. RESULTS: In all six cases, the main circumflex coronary artery was bypassed using off-pump techniques. There was no significant hemodynamic compromise during the procedure and all patients did well postoperatively. Follow-up stress echocardiography and angiography was obtained. CONCLUSIONS: Grafting of the main circumflex coronary artery in the atrioventricular groove can be successfully and safely performed off pump through a median sternotomy.

Alternative approaches in off-pump redo coronary artery bypass grafting.

BACKGROUND: The recent development of off-pump and minimally invasive techniques in coronary artery bypass grafting (CABG) has provided the surgeon with multiple options in performing redo revascularization procedures. METHODS: We retrospectively analyzed our early results in off-pump redo CABG procedures. Between January 1998 and January 2000, we performed 55 off-pump redo CABG procedures: 25 through a full sternotomy, 21 through a left posterolateral thoracotomy, 5 using a lower hemi-sternotomy and 4 using a mini anterior thoracotomy with thoracoscopic internal mammary artery harvesting. The mean age of this group was 67.7 years (range 37-85). The mean number of grafts performed in earlier operations was 2.7 (range 1-6) with 51% of grafts still partially or fully open at the time of re-operation. Twenty-six patients (47.3%) had a functioning left internal mammary artery graft to left anterior descending. Preoperative clinical severity scoring predicted a mortality of 9% and morbidity of 30%. RESULTS: There were no operative or thirty-day infarctions or deaths. Morbidity included pulmonary complications (8), renal failure (1) and bleeding (1) for a total complication rate of 18.9%. The average number of grafts performed was 2.7 (range 1-5) for sternotomy patients and 1.4 (range 1-3) for thoracotomy patients. CONCLUSIONS: By employing alternative approaches in performing off-pump redo CABG procedures, the surgeon can often avoid injury to pre-existing patent internal mammary grafts as well as the morbidity associated with the use of cardiopulmonary bypass.

Minimally invasive direct coronary artery bypass grafting: intermediate-term results.

BACKGROUND: Intermediate- and long-term clinical outcome and graft patency in minimally invasive direct coronary artery bypass grafting (MIDCABG) procedures remain a concern. METHODS: Over a 13-month period, 66 MIDCABG procedures were performed utilizing robotic-assisted internal mammary artery (IMA) harvesting and direct CABG through a 5-cm thoracotomy without cardiopulmonary bypass. Clinical follow-up was obtained on all patients. Graft patency was assessed in 61 of 66 consecutive patients 6 months (range 2 to 15 months) postoperatively. Group I consisted of 45 patients who underwent IMA angiography and group II consisted of 16 patients who underwent both a nuclear stress test and transthoracic Doppler examination. All group II patients had abnormal preoperative nuclear stress tests for comparison. RESULTS: To date, all 66 patients are alive. Graft patency rates in the two groups were 97.8% (45 of 46 grafts in 45 patients) in group I and 100% (15 of 15 grafts), with one indeterminate study, in group II. The overall patency rate for the entire study group was 98.3% (60 of 61 grafts). Sixty-two of 66 (93.9%) patients were able to return to their normal level of activity within 3 weeks. CONCLUSIONS: This study demonstrates that the MIDCABG with thoracoscopic IMA harvesting can achieve effective intermediate-term revascularization and an acceptable clinical outcome.