Redo Coronary Artery Bypass In A Patient With Myasthenia Gravis From Left Axillary Artery To Left Anterior Descending Coronary Artery
Erica Comstock, Zhandong Zhou.
St. Joseph Hospital, Syracuse, NY, USA.
BackgroundPatients with myasthenia gravis (MG) carry high post operative complications after major surgery. Due to high risk and low incidence, literatures on redo open heart surgery in patients with MG are almost not existent. Patient is a 69 year old female with severe myasthenia gravis and recent myasthenia gravis crisis after her abdominal surgery. She is on high dose steroids, Cellcept and periodical plasmaphresis. Two years ago, she had a single coronary artery bypass graft (CABG) done in an outside hospital. The left internal mammary artery (LIMA) was mistakenly grafted to the diagonal artery instead of left anterior descending coronary artery (LAD). Due to a high grade lesion in the diagonal artery, she now has frequent chest pain and shortness of breath.MethodsAfter endoscopic vein harvesting was performed, the left axillary artery was exposed through a 6cm incision. Another small incision was made in the fourth intercostal space to expose the LAD. The saphenous vein graft was anastomosed to the axillary artery first. It was then tunneled into chest through the first intercostal space. The distal part of the vein graft was then anastomosed to the LAD. Excellent flow was established and confirmed with a flow probe after completion of anastomosis. ResultsThe patient was extubated to nasal cannula POD 1. She continued her steroid taper and cellcept for her myasthenia gravis and developed a UTI but did not develop a wound infection. Her pain was well controlled, she was hemodynamically stable and was transferred out of the ICU POD 1. Her chest tubes were removed POD 3. A cardiac catherization was performed POD 4 which demonstrated patient graft was wide open. She was discharged home on POD 6. ConclusionRedo open heart surgeries usually result in increased risk for postoperative complications. Thei risks are likely much higher in patients with neuromuscular diseases like myasthenia gravis. A minimally invasive approach for redo CABG in such patients with careful post operative management likely decreases risk of wound infection, pain, respiratory failure and total hospital length of stay.
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