病案15--幻灯片.pptVIP

79 YEAR OLD man underwent an off-pump coronary artery bypass graft procedure for recent-onset exeretional angina and significant multivessel disease. a positive stress test. * * DIAGNOSTIC DILEMMAS Steven konstadt,MD Journal of Cardiothoracic and Vascular Anesthesia,Vol 17,No 3(June),2003:pp 403-4 Systemic Air Embolism During Off-Pump Coronary Artery Bypass Surgery cardiac catheterization an ejection fraction of 60%. 50% to 75/%stenosis of left anterior descending. 50% stenosis of the proximal left circumflex . 100% occlusion of the right coronary artery . He was scheduled for elective off-pump coronary artery bypass surgery. On the day of surgery after induction of anesthesia a routine preprocedure transesophageal echocardiographic confirmed normal ventricular and valvular function Specifically ,no intracardiac shunt was detected with color-flow Doppler . After left internal mammary artery(LIMA) And endoscopic saphenous vein harvesting,the LIMA was grafted to the left anterior descending and veins were grafted to the posterior diagonal, the first diagonal and the obtuse marginal arteries. the patient tolerated the procedure well without complication. As the sternal wires were pulled together,a steady trickle of air bubbles was noted in the left atrium passing through the left Ventricle into the aorta(Fig)This did not coincide with any intravascular injections,and no air was detected in the right heart .From where was the air coming? DIAGNOSIS:ACCIDENTAL LACERATION OF THE LEFT UPPER LOBE DURING LIMA HARVESTING CREATING A BRONCHOPULMONARY VENOUS FlSTULA Air in the left ventricle has been described in association with injection of flush through a new venous conduit to check the patency of the distal anastomoses. This event occurred at chest closure and was not associated with any intra vascular injections there was no air in the right heart during and Before this event, intracardiac or intra pulmonary righ-to-left Shunting was ruled out