[HSF] Intramyocardial LADs

[Mitch Lirtzman]

Michael, you'll get lots of postings on this one. My last  was only 5 days 
ago and before that, the guy I mentioned that crashed on induction.
The way I see it, there are two techniques. It virtually always lies to the 
right of the accompanying vein.
1) Start at the point where you see the vessel at/near  the apex and work 
retrograde. Use a 15 blade, just barely laying it on the tissue. Watch for 
those teeny veins and burn/ clip as needed. Once the artery is exposed as 
it arises from the muscle, dissect with a combination of knife and tenotomy 
scissors to the point at which it can receive an anastomosis.Be VERY 
careful not to go too far to the right of the LAD as it can sometimes 
literally form the roof of the RV. If RV is encountered, use 2 or 3 
pledgeted  horizontal mattress   4-0 Prolene/SH needle. Place them 7-10mm 
lateral to the LAD.
2) Dissect retrograde on the easiest diagonal you can find until you get to 
the junction. Go from there.
Simple, right? Hope this helps.
MItch
>I seem to be seeing more and more of these, they dive down deep into the LV
>and finding them without ripping apart the heart is a real pain.  How do
>others deal with these - particularly when the obstruction in distal to the
>only part you can find?  I few that I have seen recently would have been a
>disaster had I been trying to do the case off pump.
>
>Very frustrating
>
>-michael
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