Anaesthetic management of minimally invasive direct coronary artery bypass (MIDCAB) surgery in a patient with bullous lung disease and one-lung ventilation

Minimally invasive direct coronary artery bypass (MIDCAB) surgery is a beating-heart procedure that causes minimal tissue injury and leads to faster recovery. It also helps in reducing blood loss, postoperative discomfort, reduced incidence of sternal wound infection leading to sternal non-union. It is performed through an anterolateral mini-thoracotomy that usually requires one-lung ventilation. Anaesthetic management of these surgeries can be very challenging, especially in patients with bullous lung disease who could develop spontaneous pneumothorax and haemodynamic instability, which can be detrimental with underlying ischaemic heart disease. Early recognition of tension pneumothorax intraoperatively, with clinical judgement being supported by various monitoring strategies and early intervention, can be lifesaving in such scenarios. In this case report, we describe the anaesthetic management of a middle-aged patient with ongoing chest pain and an incidental finding of multiple bullae in the bilateral lungs who developed tension pneumothorax during MIDCAB and was managed with intraoperative chest drain.