Case 6-1 location: inpatient, hospital patient: a. g. vanyo attending/admit physician: frank gaul, md surgeon: james noonar, md preoperative diagnosis: atherosclerotic heart disease. postoperative diagnosis: atherosclerotic heart disease. procedure: coronary artery bypass graft times two of the left internal mammary artery to the left anterior descending bypass and a single saphenous vein bypass from the aorta to the obtuse marginal branch of the left circumflex. anesthesia: general. indication: this 76-year-old male patient with accelerating angina was noted on cardiac catheterization to have high-grade ostial left main coronary disease. he also had a 70% obtuse marginal branch lesion. the left ventricular function was normal. findings at surgery: the left anterior descending artery was diffusely diseased throughout and measured 1.5 mm in diameter where it was grafted and was of poor quality. the internal mammary artery was a 2-mm vessel of good quality with excellent flow. the vein was a 6-mm diameter vessel of poor quality, somewhat varicosed, and was used in a reversed fashion. it was not harvested with the endoscopic technique because of the patient’s unstable presentation. the obtuse marginal branch was a 2-mm diameter vessel and was of good quality. procedure: on may 8 of this year the patient was brought to the operating room and placed in the supine position, and under general intubation anesthesia, the anterior chest, abdomen, and legs were prepped and draped in the usual manner. a segment of greater saphenous vein was harvested from the left thigh and prepared for grafting. the sternum was opened in the usual fashion, and the left internal mammary artery taken down and prepared for grafting. the pericardium was incised sharply, and pericardial well created. the patient was systemically heparinized and placed on single right atrial to aortic cardiopulmonary bypass with a sump in the main pulmonary artery for cardiac decompression. the patient was cooled to 26°c, and on fibrillation, the aortic crossclamp was applied to potassium-rich cold crystalline cardioplegic solution administered through the aortic root with satisfactory cardiac arrest. subsequent doses were given via the coronary sinus in retrograde fashion and down the vein graft as the anastomosis was completed. the end of the greater saphenous vein was then anastomosed to the proximal portion of the obtuse marginal branch with 7–0 prolene. the left internal mammary artery was then brought down to the junction of the middle and distal one third of the left anterior descending and anastomosed thereto with 8–0 continuous prolene. note that all grafts were pro patent prior to closure. the aortic crossclamp was removed after 47.6 minutes with spontaneous cardioversion to a normal sinus rhythm. the patient was then warmed to 37°c esophageal temperature and weaned from cardiopulmonary bypass without difficulty after 72 minutes. no inotropes were used. the patient was decannulated, protamine given, and hemostasis achieved. temporary pacer wires were placed in the right atrium and right ventricle. the chest was drained with two chest tubes and closed in layers in the usual fashion. the leg was closed similarly. sterile compression dressings were applied, and the patient returned to surgical intensive care unit in satisfactory condition. sponge count and needle count correct times two.