A 76-year-old woman visited our hospital for chest pain and dyspnea. The symptoms had started about five years before the visit and had gradually worsened. Her medical history included diabetes mellitus and hyperlipidemia. At the time of admission, her symptoms were Canadian Class 3. Her heart rate was 73/min, and her blood pressure was 150/45 mmHg. No rales or murmur were heard on auscultation.
Electrocardiography with right chest lead showed ST depression in the V1r to V4r lead and ST elevation in the aVL lead. Transthoracic echocardiography revealed diffuse hypokinesis with a left ventricular ejection fraction of the 35%. Blood test findings were within normal limits. Computed tomography (CT) confirmed highly calcific coronary arteries and situs inversus totalis (Fig. 1). Coronary angiography demonstrated 99% stenosis of the proximal part of the morphologic left anterior descending artery (LAD), 99% stenosis of the right coronary artery (RCA), and 90% stenosis of the left circumflex artery (LCx) (Fig. 2). The treatment choice was discussed among the heart team, and CABG was recommended to the patient.
During the operation, the surgeon first stood on the right side of the patient. After median sternotomy was performed, the left and right internal thoracic arteries (LITA and RITA) and saphenous vein graft (SVG) were harvested. Cardiopulmonary bypass was established by cannulation of the aorta and the physiological right atrium. At this time, the surgeon switched to the left side of the patient, placed a root cannula, and then cross-clamped the aorta. The SVG was anastomosed to the RCA, and the LITA was anastomosed to the LCx as free grafts. Finally, the RITA was anastomosed in situ to the LAD (Fig. 3). Surgery was completed without any problems. She was extubated four hours after surgery.
The post-operative course was uncomplicated. Post-operative coronary artery angiography showed a sufficient flow.