Interact CardioVasc Thorac Surg 2008;7:522-523. doi:10.1510/icvts.2007.173682
© 2008 European Association of Cardio-Thoracic Surgery
Case report - Cardiac general |
The use of intra-aortic balloon pump as cerebral protection in a patient with moyamoya disease undergoing coronary artery bypass grafting
Ichiro Kashima*,
Yoshito Inoue and
Ryuichi Takahashi
Department of Cardiovascular Surgery, Saiseikai Utsumomiya Hospital, 911-1, Takebayashi-machi, Utsunomiya, Tochigi, 321-0974, Japan
Received 12 December 2007;
received in revised form 17 January 2008;
accepted 18 January 2008
*Corresponding author.
E-mail address: ichirokashima{at}saimiya.com (I. Kashima).
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Abstract
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We performed coronary artery bypass grafting in an urgent and rare case of acute coronary syndrome with moyamoya disease in a 75-year-old female. Because of collateral dependent severe cerebrovascular obstruction, additional support for brain protection was necessary; we used high pressure pulsatile perfusion assist to maintain cerebral circulation with an intra-aortic balloon pump support throughout the cardiopulmonary bypass, giving a successful outcome.
Key Words: CABG; ACS; Moyamoya disease; Pulsatile perfusion; Brain protection; IABP
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1. Introduction
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Ischemic heart disease (IHD) concomitant with moyamoya disease (MMD) is very rare; we are aware of only 12 previously reported cases. None of these is in elderly people; the age varied from 14 to 48 years (median: 30 years) [1]. MMD is characterized by progressive steno-occlusive changes in the distal internal carotid and proximal cerebral arteries, with development of telangiectasia-like appearance, the so-called ‘moyamoya’ vessels at the base of the brain. Concomitant steno-occlusion occurred mainly in the renal artery, and occasionally in other arteries [2, 3]. Brain protection from hypotension is a critical issue during coronary artery bypass grafting (CABG) in MMD sufferers, because autoregulation of cerebral blood flow (CBF) is malfunctioning in these patients. We report an elderly female having IHD with MMD who was successfully treated by urgent CABG under brain protection, using high pressure pulsatile perfusion assist.
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2. Case
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A 75-year-old woman was admitted to our hospital as an emergency because of electrocardiographic abnormality showing ST-segment depressions in the II, III, aVf, and V3 to V6 leads with angina. She experienced onset-of-effort angina for the previous six months, which was recently worsening. She had suffered the handicap of left hemiplegia because of a stroke at age 64 years, and stayed at an institution for rehabilitation following the diagnosis of MMD. Her MMD was diagnosed as stage 3 on Suzuki's scale [2] (Fig. 1). She had also hypertension and diabetes mellitus, though she was being treated successfully and was within the normal ranges of blood pressure and glycosylated hemoglobin (HbA1c). Urgent coronary angiography revealed 90% stenosis of the left main coronary artery, a 99% stenosis of the left anterior descending coronary artery (LAD) and the proximal right coronary artery, and 90% stenosis of the circumflex coronary artery. She was treated immediately by an intra-aortic balloon pump (IABP) in view of her hemodynamic instability. Urgent on-pump CABG was subsequently performed. During cardioplegic arrest, IABP support was continued to maintain pulsatile flow above 70 mmHg of mean pressure throughout the cardiopulmonary bypass (CPB), using the internal mode for active brain perfusion. The perfusion flow of CPB was from 2.2 to 2.5 l/min/m2 and the bottom of rectal temperature reached 35 °C. A left internal mammary graft was anastomosed to the LAD, and a saphenous vein graft was anastomosed sequentially to the second diagonal artery, the second obtuse marginal artery, and the posterior descending artery. CPB time and aortic cross-clamping time were 53 and 35 min, respectively. Although the hemodynamics were unstable until the first postoperative day, the woman recovered well, and was discharged four weeks after admission with no further onset of cerebral infarction. She remained free of chest pain, and had no additional neurological deficits as of 17 months after the operation.
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Fig. 1. Magnetic resonance image showing lack of bilateral anterior cerebral arteries, stenosis of bilateral internal carotids, and dimly traceable bilateral middle cerebral arteries (arrows). Arrowheads indicate the moyamoya vessels.
IC, internal carotid; PC, posterior cerebral artery; BA, basilar artery.
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3. Discussion
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In the previous 12 reports, only two described implementation of CABG, but no details were given of the operative procedure or circulation assist. Brain protection during CABG for patients with severe cerebrovascular disorder is a crucial issue, but is not discussed in MMD cases. In general surgery, onset of stroke has been reported for systolic pressure between 60 and 70 mmHg for approximately 1 h [4, 5]. Off-pump CABG is an alternative, but during distal anastomosis it might induce unexpected hemodynamic instability and impede cerebral circulation [6]. It is commonly believed that preserving autoregulation of CBF is the most important means to prevent brain ischemia in cases of cerebrovascular disorder, and some techniques for CBP have been reported: maintenance of the mean perfusion pressure above 70 mmHg,  -stat blood gas management, and pulsatile flow with systolic pressure above 100 mmHg [6, 7]. We maintained stable high pressure pulsatile perfusion within the optimal range using IABP support throughout CPB with a low dose of vasoconstrictor, and there was no resulting stroke.
In conclusion, on-pump CABG assisted by high pressure pulsatile perfusion with IABP support is a good solution for preventing brain ischemia in cases of severe cerebrovascular disease, such as MMD.
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References
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Abstract
1. Introduction