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Patients with porcelain aorta and severe calcification of the great vessels are a challenging dilemma for the cardiovascular surgeon regarding bypass technique, choice of conduit, and selection of proximal anastomotic sites due to the high incidence of devastating thromboembolization and aortic injury. No currently proposed surgical approach avoids manipulation of the heavily calcified ascending aorta. Three patients presented with unstable angina and decreased ventricular function secondary to significant left main coronary artery stenosis and 3-vessel coronary artery disease. In addition to the coronary artery disease, severely calcified ascending aorta and great vessels were discovered. One patient presented with near total distal abdominal aortic occlusion, severe peripheral vascular disease, history of stroke, and carotid endarterectomy. Surgical coronary revascularization was indicated. Coronary artery bypass grafting using internal thoracic artery and greater saphenous vein composite arterial inflow grafts in combination with off-pump beating heart surgery was successfully used. Cardiopulmonary bypass and clamping of the aorta was avoided. No new neurologic deficit was observed. Coronary revascularization with internal thoracic artery composite grafts and avoiding cardiopulmonary bypass and clamping the calcified aorta is an effective method to prevent clamp injury and thromboembolization. Off-pump coronary artery bypass grafting seems to be an ideal indication in patients with porcelain aorta because the surgical techniques of "no-touch" and "no-cannulation" can be applied.

A 48-year-old male patient with AIDS presented with postinfarct unstable angina, decreased left ventricular function (EF 35%), significant left main coronary artery disease, and total occlusion of the proximal left anterior descending and right coronary arteries. In order to avoid the potential immunosuppressive effect of cardiopulmonary bypass (CPB) in an already compromised host with an already low CD4+ helper/inducer T cell count (180/microL) and high retroviral load (165,000 copies/mL), the application of beating-heart technology and off-pump coronary bypass grafting was an ideal indication. The patient underwent successfully off-pump/CPB coronary revascularization. The triple drug combination of highly active antiretroviral therapy (HAART) was resumed postoperatively. The patient was discharged from the hospital on the 7(th) postoperative day. The CD4+ count was 142/microL and the viral load decreased to 450 copies/mL. Seven months post-operatively the patient was free of angina and without shortness of breath. The CD4+ count was 160/(m)L and the viral load undetectable. Improved survival of HIV positive patients has resulted in a shift from caring for terminally ill patients to caring for patients with chronic illness. While protease inhibitors have positively affected survival, they may also cause plasma lipid abnormalities, which can lead to severe premature coronary artery disease. Therefore, an increasing population of AIDS and HIV positive patients with coronary artery disease may require cardiac interventions in the near future. Coronary revascularization without CPB and its potential immunocompromising effect may play an important role in patients with severe coronary artery disease and AIDS.

Background: Off-pump coronary artery bypass grafting (OPCABG) has assumed an increasing role in many surgical practices. The ideal candidate has not been defined, but high-risk patients seem to benefit most when cardiopulmonary bypass (CPB), aortic cross clamping and cardioplegic arrest are avoided., Methods: Fourteen high-risk patients (age 52 to 81 years, 1 female, EF 44%+/-8, Parsonnet score 23+/-4) were studied. They presented with acute coronary syndroms on platelet glycoprotein IIb/IIIa antagonists, acute myocardial infarction, worsening renal failure, decompensating ischemic cardiomyopathy, religious beliefs and denial of blood transfusion, and severe peripheral/cerebrovascular disease (total bilateral internal carotid artery occlusion and/or >90% stenosis). These patients underwent OPCABG via sternotomy with the intention of complete coronary revascularization., Results: An average of 2.3 grafts/patient were performed and the posterior descending artery (PDA) and marginal branches of the circumflex artery (LCX) were grafted in 79% of the patients. There were 3 events of intraoperative cardiac arrest precipitated by occlusion of right coronary artery (RCA) or positioning a cardiomegaly heart leading to immediate intravascular shunting (2) and/or conversion to CPB (1). One patient was converted to CPB and graft revision (intraoperative ultrasound and probing). The mortality rate was 0% and one stroke was observed on post-operative day 1. Coronary angiography (n=6) showed no significant stenosis., Conclusions: OPCABG complete revascularization is feasible in high-risk patients with low morbidity and mortality and excellent early, Results: OPCABG may be indicated in patients on platelet receptor antagonists preventing bleeding complications. Cardiomegaly can cause difficult off-pump LCX and PDA exposure and stabilization. RCA grafting off-pump is less tolerated and PDA grafting is preferred. High-risk patients for CPB are the ones who may benefit the most from OPCABG.