Patient has coronary artery bypass surgery while awake

BMJ 2000; 321 doi: (Published 15 July 2000) Cite this as: BMJ 2000;321:135
  1. Deborah Josefson
  1. San Francisco

    A 51 year old man has undergone a coronary artery bypass graft while awake, marking the first time in the United States that such surgery has been performed without general anaesthesia.

    The operation took place at the Veterans Administration Hospital in Pittsburgh, Pennsylvania, and was led by Dr Marco Zenati, an assistant professor of surgery at the University of Pittsburgh Medical Center, with the help of anaesthesiologist Dr Juhan Paiste.

    Dr Paiste used a combination of epidural anaesthesia, sedatives, and local anaesthesia to numb the chest wall and control pain. The patient, a professional magician, was alert and verbally interactive throughout the procedure.

    Epidural anaesthesia was first used for a coronary artery bypass graft operation in 1998 by Dr Haldun Karagoz of Guven Hospital in Ankara, Turkey. To date, 31 patients have had such surgery under epidural control.

    The technique of minimally invasive direct coronary artery bypass grafting was also used in the Pittsburgh operation. Minimally invasive bypass grafting is a relatively new technique and was pioneered at the University of Pittsburgh Medical Center in 1995.

    About 500 minimally invasive bypasses have been performed so far. Unlike conventional bypass grafting, the procedure is performed on a beating heart. It thus avoids cardioplegia and use of a heart-lung machine.

    Also, a smaller thoracic incision is made in minimally invasive surgery rather than the median sterniotomy used in traditional bypass grafting. It is generally a less expensive procedure than traditional bypass since a heart-lung machine isn't used.

    However, the procedure is necessarily more delicate than traditional bypass grafting because the surgical working field is much smaller and the anastomosis is therefore more difficult to achieve. Also, because the procedure is performed on a beating heart, the risk of bleeding is greater and the heart has to be restrained mechanically.

    The Pittsburgh team envisages combining the techniques of epidural anaesthesia and minimally invasive cardiac surgery routinely and hopes to make the combination a viable alternative to angioplasty and, eventually, an outpatient procedure.

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    A 51 year old patient underwent heart surgery while awake


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    Dr Marco Zenati, who led the surgical team


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