Off-pump or on-pump coronary-artery bypass grafting at 30 days
- A Lamy, PJ Devereaux, D Prabhakaran
- N Engl J Med
IS C EL LA N EO U S is cut with a bevel. A narrow-diameter pump sucker is placed through the graft and into the distal pulmonary artery, with the sucker used as a retractor to open the vessel. Anastomosis of the graft to the side of the pulmonary artery is performed by use of the parachute technique, starting with the toe (Fig 1). Once the anastomosis is completed, the right side of the heart is temporarily filled with blood, and the graft is stapled with a vascular load endo-GIA stapler. The rest of the LVAD implantation is performed as routine. After the patient has been weaned from bypass, if an RVAD is urgently needed, the pulmonary graft is easily sewn to the “chimney.” If no RVAD is needed, the graft is stapled parallel to the pulmonary artery, leaving a 4–5 ring (1-cm) stub. If an RVAD is needed in the early postoperative period, a straight vascular clamp can be applied nearly flush with the pulmonary artery, the graft opened, each end grabbed with a pickups, and the clamp opened briefly to confirm that it is patent and not clotted After reclamping the “chimney,” an RVAD outflow graft is sewn to the stub. Arguably, if the stub is not used, it could be a source of thrombus that could cause pulmonary embolus. However, the stub is small, the patients are usually receiving anticoagulant agents, and it is a common clinical practice in RVAD or LVAD removal for cardiac recovery to leave a graft stump without clinical sequelae. If the patient ultimately receives a transplant, the graft stub is low and easily removed with the native heart. As a corollary, we have similarly sewn a piece of appropriately sized vascular graft to the aorta during crossclamping in patients in shock who are undergoing salvage coronary artery bypass grafting (much like an additional, but larger, vein graft proximal Fig 1. Anastomosis of the graft to the side of the pulmonary artery by the parachute technique, starting with the toe.