[HSF] LIMA in an octogenarian with a suspicious LUL nodule?

[Tea Acuff]

I always take down the mammary extra pleural plus minus a few holes. If the pleura tears widely open it is easy to tack it back over. Just bluntly (finger is best) separate the thymic tissue from the mediatistum so that the LIMA will lie as posteriorly in the extrapleural position as the intrapleural one.Use low cautery to divide the fat that you missed.  Reops is one reason I like anatomic (natural plane) dissections. There will be adhesions but no reason to create them needlessly. Afterall pleurectomy is an operation for spontaneous PTX not routine CAB.
tea


----- Original Message ----
From: "Crittenden, Michael" <Michael.Crittenden at va.gov>
To: OpenHeart-L at lists.hsforum.com
Sent: Wednesday, August 8, 2007 12:57:54 PM
Subject: [HSF] LIMA in an octogenarian with a suspicious LUL nodule?


Scheduled to operate on an 82 yo with 3VD and moderately reduced EF.
S/P NSTEMI last week.  Refused CABG originally, now ready for an
operation.



Due to age, diffuse CAD and other stigmata of atherosclerosis, elected
to get thoracic CT to assess ascending aorta-as you might have guessed
there was a LUL nodule ~1.5 x 1.5 that was NOT seen on plain films.  All
agree that patient should still have an operation given size of mass and
no obvious node or extrathoracic involvement.  PET scan being done
today. FEV1  1.4L thus I believe he would tolerate a LULobectomy.



My questions are:    

(1)     Would you not do a LIMA and keep the left pleural space intact
in this 82 yo male? 

(2)     Take it down in an extrathoracic fashion?  (BTW, I have never
liked the way the LIMA lies when done in this fashion?

(3)     Take it down and cover it somehow to prevent injuring it during
the LUL?



Mike Crittenden

                                    

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