Surgical procedure
Anaesthetic protocol included thiopentone, propofol, opiates for
induction, sevoflurane, desflurane relaxants, opiates for maintenance
and propofol, relaxants and opiates for CPB time. Intraoperative
monitoring included radial artery for pressure monitoring and right
jugular vein for central venous catheter. Swan-Ganz catheter was not
considered as needed as no patient had EF less than 50%. Urinary
catheter and rectal temperature probe were also inserted. All
interventions were performed on-pump, 99% of those through median
sternotomy with ascending aorta and right atrial cannulation for CPB
implantation, after reaching an activating clotting time more than 480
seconds under systemic heparinization. Only 3 patients (1%) underwent
peripheral femoral cannulation for unstable hemodynamic conditions. In
all patients a retrograde cardioplegia catheter was inserted through
right atrium directly into coronary sinus. Myocardial protection was
obtained using cold hematic blood cardioplegia (Buckberg) administered
firstly anterograde and then retrograde every nearly 20 minutes. Patient
was cooled to 32-34°C during the main time of the operation. The
rewarming was achieved with tepid reperfusion and wash-out of the
cardioplegia.
The choice of performing a SAC or a DAC was made by the surgeon,
depending on the pre-operative imaging tests, on the visual and
manipulation appearance of the aorta and on epiaortic ultrasound
performed in the operating room. When it appeared to be fibrotic and
frail based on the first operator experience, the surgeon preferred a
SAC approach.
In case of SAC, the proximal anastomosis was performed during cardiac
arrest.
If the surgeon decided to perform DAC, all the grafts were linked to the
arterial cannula, so that the coronaries could be perfused immediately
after rewarming. After choosing the site of the proximal anastomoses, a
Satinsky tangential clamp was placed to allow safe suturing.
Subsequently, one by one, the proximal anastomoses were performed.
Total heparinization was antagonized with protamine sulphate after CPB
weaning.