Situation
A patient with proven non small cell carcinoma in the left upper lobe with stable angina develops unstable angina pre thoracotomy. Angiography shows sever left main stem stenosis and a blocked right with a moderate left ventricular function. What do you do ?
This patient needs surgical revascularisation. If the LIMA is to be used by the cardiac surgeons you should request that it is harvested without opening the pleura. Other options include putting the RIMA on the LAD (depending where you are grafting), or the use of saphenous vein and radial arteries depending on your philosophy.
Off pump may be beneficial in the patient with marginal pulmonary function. There is scant real evidence that CPB causes tumour dissemination, however it would be easy to understand that the relatively low flow and cooling during CPB could cause tumour ischaemia and hypoxia and cause tumour necrosis and cause fragments to embolise, however this is hypothetical.