62-year-old white male status post MI and angioplasty in 1988
presents with increasing fatigue upon exertion.
Cardiac Catheterization Results (Figure 1)
- EF = 70% and LVEDP = 11 mmHg
- 99% occluded proximal RCA with very large PDA and PLB
- 90% occluded proximal LAD prior to take-off of first diagonal
- 100% occluded mid LAD (distal vessel fills by collateral flow)
- 90% occluded OM-1
Beating Heart Grafting Sequence
1. LIMA to LAD: Occlusion time 8 minutes
- Relatively easy exposure
- Low-risk occlusion (collateralized vessel)
- Immediate blood flow stabilizes the anterior wall and septum.
2. RIMA to OM-1 via the transverse sinus: Occlusion time
- Vessel is already partially exposed.
- Immediate blood flow stabilizes the lateral wall.
3. SVG to diagonal artery: Occlusion time 8 minutes
- Vessel is already exposed.
4. Proximal grafts for the diagonal and PDA
- Single placement of partial occlusion clamp on aorta
- Establishes blood flow in the diagonal
5. SVG to PDA: Occlusion time 8 minutes
- Occlude only the PDA to keep the large PLB patent and minimize
- The anterior wall is no longer dependent on collateral flow
originating from the posterior vessels because it has already
been revascularized with the LIMA.
- Immediate blood flow is established because the proximal graft
is already constructed
"Anterior wall vessels are usually grafted first. If both
the LAD and diagonal grafts are planned, the diagonal is grafted
first, followed by the LIMA to LAD. Following anterior grafting,
usually right coronary branches are approached next. Last but
not least, the marginal branches of the circumflex artery are
grafted. I do the proximals after all of the distals are completed."12
-James C. Hart, M.D. Surgeon
The general concepts presented above are guidelines and can
be adapted to meet surgeon preferences.