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.