ABSTRACT
A 75-year-old male with a previous history of coronary artery bypass grafting (LITA-LAD, RITA-RA-4PD-14PL) was referred to our hospital for congestive heart failure. Cardiac workup revealed severe ischemic mitral regurgitation which required surgical correction. His preoperative coronary arterial computed tomography demonstrated total occlusion of both orifices of the native coronary arteries, and the complete dependence of his myocardial blood supply on the patent bypass grafts without any evidence of ischemia. Therefore, antegrade cardioplegia could not be applied for cardiac protection during the procedure. Continuous retrograde cardioplegia was planned to be applied in a case where both arterial grafts could be dissected and clamped whereas systemic hyperkalemia and mild hypothermia would be applied in case where the clamp would be impossible. Intraoperatively, both arterial grafts could be dissected and clamped and we performed mitral annuloplasty and tricuspid annuloplasty using continuous retrograde cardioplegia. The patient could be weaned off cardiopulmonary bypass without difficulty, and his postoperative course was uneventful. We conclude that continuous retrograde cardioplegia is a safe and viable option, especially when antegrade cardioplegia is not securely delivered due to an occluded coronary ostia.
ABSTRACT
Retrograde myocardial protection plays an important role in cardiac surgery and is widely used. We herein report a rare cardiac surgical case complicated with small coronary sinus ostium in which the cannula of retrograde cardioplegia could not be inserted. A 58 years old man was referred for the treatment of regurgitation and aortic regurgitation. Preoperative ECG gated computed tomography (CT) showed that the orifice of the largest coronary sinus was located in the right atrium with a diameter of only 4 mm with an other 3 smaller orifice in the right atrium and ventricle, which appeared to make it difficult to perform retrograde myocardial protection. The operative finding was consistent with the preoperative CT finding and mitral valve repair and aortic valve replacement were performed using only selective antegrade myocardial protection. We should bear in mind that small coronary ostium exists and preoperative assessment of the size of coronary sinus might be important.
ABSTRACT
We herein report a rare case of unruptured, giant left coronary sinus of Valsalva aneurysm and discuss surgical pitfalls associated with sinus of Valsalva aneurysms. A 63-year-old man was referred to us for clinical diagnosis and surgical treatment of a huge mass in the mediastinum. Enhanced computed tomography (CT) imaging revealed that the mass was a left coronary sinus of Valsalva aneurysm with a diameter of 74×57 mm ; moreover, the left coronary artery originated from the aneurysmal wall. In addition, echocardiography showed moderate aortic regurgitation (AR) caused by dilatation of the aortic annulus. Based on these findings, the Bentall procedure was selected for the Valsalva aneurysm and significant AR. The orifice of the aneurysm was 15×15 mm in size, and the aortic wall of the left coronary sinus was relatively thin. The left main trunk was injured due to severe adhesion between the trunk and the aneurysm ; therefore, vein patch repair was performed with a saphenous vein graft. Since the aortic annulus of the left coronary cusp was fragile, proximal anastomosis of the composite graft to the lesion had to be placed in the fibrous continuity between the aortic and mitral valves. With respect to the proximal anastomosis at the aortic annulus of the left coronary cusp, the suture line was covered with a bovine pericardium patch as there were no remnants of the normal aortic wall. The postoperative course was uneventful, and postoperative CT revealed complete resection of the aneurysm with no evidence of stenosis of the left main trunk.