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+A 69-year-old male diabetic patient was admitted with acute left ventricular (LV) failure and was treated with intensive decongestive therapy.
+He had severe peripheral edema and bilateral basal crepitations.
+Initial workup revealed normal levels of troponine (<0.01 ng/ml) and CPK-MB (4.6 ng/ml), thereby ruling out acute coronary syndrome.
+The level of BNP was 1230 pg/ml confirming the diagnosis of heart failure.
+Echocardiographic assessment revealed LVEF of 10% with dilated cardiac chambers, and estimated pulmonary artery systolic pressure (PASP) was 70 mm of Hg with features of raised LV diastolic pressure.
+Angiography was performed after 3 days of decongestive therapy which revealed critical triple vessel disease with left main coronary artery disease (Fig.1).
+He was referred for CABG.
+The patient was put on frusemide infusion with oral ramipril and aldactone.
+He was taken up for elective OPCAB 1 week after angiography.
+Renal function was monitored regularly to adjust diuretic dose.
+There was no feature of end organ dysfunction.
+STS risk of mortality was 2.4%.
+Repeat echocardiographic assessment revealed improvement of LVEF to 15% and decrease in PASP to 30 mm Hg and decrease in LV filling pressure.
+OPCAB was performed through median sternotomy.
+Left ITA was used for grafting left anterior descending artery (LAD).
+After revascularizing LAD, right ITA (RITA) and RA composite, graft was prepared.
+The distal end of RITA was used for revascularizing the diagonal artery.
+There was significant improvement in systolic blood pressure after this distal anastomosis.
+After these two grafts, heart was lifted for lateral and posterior wall vessels.
+We make a longer skin incision, open the sternum widely, and release pericardium on the right side to displace the heart gradually.
+This was supplemented with headlow and lateral tilt position.
+Liberal doses of inotropic support were used.
+RA was used for sequential grafting of obtuse marginal, posterior LV branch, and posterior descending artery.
+All these five distal anastamoses were performed uneventfully.
+The patient was electively ventilated for 2 days.
+Echocardiography on 1st POD revealed improvement in LVEF to 20%.
+He was started on low dose beta blockers after inotropic supports were weaned off.
+He had slow and uneventful recovery.
+Echocardiography on 4th POD revealed improvement in LVEF to 30% (Table 1).
+He had persistent pleural drainage requiring prolonged intensive care unit stay.
+After pleural drainage subsided and drains were removed, he was discharged on diuretics, low dose beta blocker, and ramipril.