Figure 1: Right anterior oblique with cranial view (1A) and caudal view (1B) of left coronary system. 1C: Left anterior oblique with cranial view of right coronary system.

He was brought back to the cardiac catheterization lab pre-operatively and an Impella CP Device (Abiomed, Danvers, MA) inserted via the right common femoral artery in the usual fashion. The Impella CP remained in was used during the CABG operation as “in-pump” support and a standard OPCABG was performed utilizing a pedicle left internal mammary artery (LIMA), and endoscopically harvested reverse great saphenous vein (SVG). The LIMA was dissected out, and the distal targets were identified. The heart was elevated with moist lap pads taking care not to disrupt the Impella CP device. The target vessels were stabilized with an Octupus AS tissue stabilizer (Medtronic) and the distal anastomosis were completed. Three revascularization targets were achieved before hypotension began to progress (LIMA to left anterior descending; SVG to right coronary artery; SVG to ramus intermedius). The diagonal artery was left for medical therapy. The two proximal aortic anastomoses were created using HEARTSTRING III proximal seal system (Getinge). The Impella CP remained in place post operatively and the patient was taken back to the cardiac surgery intensive care unit. The Impella CP device was subsequently weaned and removed on post-operative day three in the cardiac catheterization lab and hemostasis obtained by tying down of Perclose Proglide (Abbott) sutures deployed at the time of the index procedure in the “preclose” technique. Completion ileo-femoral angiography acquired via the left radial artery demonstrated no vascular complication. The patient fared well and was transferred out of the intensive care using on post-operative day 5 where the remainder of his hospital stay was uneventful and was discharged on post-operative day 7.