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.