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Intraoperative Detection Of Coronary Stenosis In The Lack Of Preoperative Coronary Angiography: The role of High-Resolution Epicardial Ultrasonography
Gabriele Di Giammarco, MD1, Daniele Marinelli, MD2, Massimiliano Foschi, MD2, Donato Micucci, MD2, Sabina M. A. Diso, MD2, Carlo Canosa, MD2.
1University "G.D'Annunzio", Chieti, Italy, 2University, Chieti, Italy.

The prevalence of coronary atherosclerosis in candidates to valvular surgery range from 35.6% to 50%. Intra-operative High-Resolution Epicardial Utrasonography (HR-ECUS) is a validated diagnostic method. We report on three patients candidate to non-coronary surgery whose comorbidity or clinical status represented a contraindication to coronary angiography. The use of HR-ECUS facilitated critical LAD stenosis detection intraoperatively.
Patient 1:83 years-old female with diagnosis of severe aortic stenosis symptomatic for dyspnea and severe stenosis of the right internal carotid artery. Due to a recent episode of pulmonary edema and acute kidney injury (AKI) she was refused contrast dye injection.
Patient 2:84 year-old female with a recent acute coronary syndrome and a peduncolated mass of 2.7 cm in left atrium impinging in the mitral annulus. A moderate carotid stenosis and moderate chronic renal failure were present. The patient, after pre-syncopal episodes, was emergently led to the operation without coronary angiography.
Patient 3: 67 year-old man was referred for severe Aortic Regurgitation (AR) due to Staphylococcus Galloliticus infective endocarditis with a large vegetation on non-coronary cusp. He was refused for coronary angiography for the high risk of embolism.
In all cases intraoperative HR-ECUS detected severe stenosis of left Anterior Descending Artery(LAD). Patient 1 was submitted to aortic valve replacement, Safenous Vein(SV)-to-LAD CABG and carotid thrombo-endarterectomy. Patient 2 was submitted to left atrial mixoma resection and SV-to-LAD CABG. Patient 3 was submitted to aortic valve replacement and left internal mammary artery-to-LAD CABG. In all three cases Transit Time Flow Measurement showed in all cases good functioning grafts. The graft patency was confirmed postoperatively by coronary CT-scan.
To the best of our knowledge this is the first report of coronary revascularization guided by intraoperative HR-ECUS. In our experience this method represents an feasible alternative to coronary angiography in selected situations.

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