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J Thorac Cardiovasc Surg 2002;123:1008-1009
© 2002 The American Association for Thoracic Surgery
Brief Communications |
From the Departments of Cardiothoracic Surgery,a Anesthesiology,b and Cardiology,c the Hospital São José do Avaí, Itaperuna/RJ, Brazil.
Received for publication July 11, 2001. Accepted for publication Dec 14, 2001. Address for reprints: Gladyston Luiz Lima Souto, Rua Lenira Tinoco Calheiros, 242-Centro, Itaperuna/RJ, Brazil-Cep: 28.300-000 (E-mail: gladystonsouto{at}uol.com.br/).
In past decades, multiple organ dysfunctions
1 provoked by cardiopulmonary bypass (CPB) have been studied. The short- and long-term results and higher cost of CPB changed the scientific focus, causing less harm to the patient and giving more emphasis to off-pump and minimally invasive surgery. Many articles appeared. Benetti 2 and Karagoz and associates 3 contributed to the progress of minimally invasive direct coronary artery bypass (MIDCAB).
With further investigation, we believe in the possibility of performing a MIDCAB in the ambulatory patient. We therefore operated on a series of selected patients who were totally awake and without orotracheal intubation. They were discharged from the hospital within 24 hours after the operation.
Methods
Between January 2000 and May 2001, 20 patients were subjected to coronary artery bypass while fully awake, without the use of CPB or an orotracheal tube. All patients had a lesion in the left anterior descending artery, and none had important chronic pulmonary disease. Ages varied between 41 and 75 years, and the predominant sex was male. All patients were subjected to preoperative psychologic preparation.
Operative technique
An epidural thoracic anesthetic was used. The 10-mL solution was composed of 8 mL of 0.5% bupivacaine plus 2 mg of morphine, injected by a needle at the T4 level, with posterior positioning of an 18-gauge catheter, and 1 mL of 0.5% bupivacaine that was injected for blocking in the second, third, fourth, and fifth left intercostal spaces. During the operation the patients were monitored through the arterial saturation with pulse oximetry, arterial gasometry before opening the thorax, and each 30 minutes after thoracotomy.
The access used was a thoracotomy in the fourth left intercostal space with the patients in the dorsal decubitus position, slightly turned to the right. The incision varied between 14 and 16 cm. The left internal thoracic artery was dissected through the incision until its exit through the subclavian artery. The pericardium was opened longitudinally on the anterior face, having its edges well fixed to the edges of the wound. The anastomosis between the left internal thoracic artery and left anterior descending artery was performed with continuous sutures with the use of an intracoronary shunt and stabilizer. The left lung remained partially collapsed throughout the operation. After the pleural cavity was drained and the thoracic wall closed, to end the pneumothorax, we asked the patients to breathe deeply and cough until the lung was totally expanded.
Results
The 20 patients withstood the operation well. The pneumothorax time varied between 60 and 190 minutes. During the procedure there was no hemodynamic instability or arrhythmia. No important modifications occurred in the PO2 and PCO2 (Table 1). There were no electrocardiographic, echocardiographic, or enzymatic alterations that characterized postoperative necrosis or clinical pulmonary or radiologic alterations.
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Discussion
The techniques used in this group of patients are different because of the thoracic epidural block and the psychologic preparation, which permit the patients to be kept awake and able to talk the whole time. During the operation, when the patient breathes deeply the heart tends to dislocate to below the sternum. This will happen with less intensity when the pericardium is well fixed at the edges, principally on the sternal side, which does not permit dislocation. At the time of anastomosis, the anesthetist asks the patient to cooperate by avoiding deep breathing and moving.
Respiratory exercise is done as soon as the patient arrives in the intensive care unit. This is made easier by the type of anesthesia that permits the exercises to be pain free, avoiding complications. The epidural anesthesia can also reduce the incidence of postoperative arrhythmias 4 and graft thrombosis. 5 We believe that we can expand the revascularization to more vessels and use this technique for the surgical treatment of other conditions, such as lung and mediastinal diseases. A hospital discharge within 24 hours after the operation and sending the patient to a home care regimen for some days, which is ideal, avoids the inconveniences of atrial fibrillation that could eventually occur.
Conclusion
Pneumothorax did not cause postoperative morbidity and permitted good anastomosis. This technique can be done in a large number of patients. We believe that in the future, with more experience, it can be performed routinely in ambulatory patients.
References
This article has been cited by other articles:
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  M. A. Chaney Intrathecal and Epidural Anesthesia and Analgesia for Cardiac Surgery Anesth. Analg., January 1, 2006; 102(1): 45 - 64. [Abstract] [Full Text] [PDF]
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