Ann Thorac Surg 1999;68:272-273
© 1999 The Society of Thoracic Surgeons
How to Do It
Fenestrated felt facilitates anastomotic stability and safety in "off-pump" coronary bypass
John A. Rousou, MDa,
Richard M. Engelman, MDa,
Joseph E. Flack, III, MDa,
David W. Deaton, MDa
a Cardiac Surgery Division, Department of Surgery, Baystate Medical Center, Springfield, Massachusetts, USA
Address reprint requests to Dr Rousou, Division of Cardiac Surgery, Department of Surgery, Baystate Medical Center, 759 Chestnut St, Springfield, MA 01107
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Abstract
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Metal stabilizing devices used in beating heart surgery, although largely effective, occasionally slip or cause lacerations of epicardial veins or myocardium, resulting in blood loss that requires time-consuming corrective maneuvers. The use of a fenestrated felt as a cushion in conjunction with the stabilizers eliminates slipping and/or trauma, thus facilitating coronary anastomoses on the beating heart.
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Introduction
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The concept of performing coronary bypass surgery on the beating heart is not new [1–3]. It has recently gained popularity because of its simplicity, avoidance of cardiopulmonary bypass, and associated morbidity, and the potential for cost reduction. Immobilizing the site of anastomosis on a coronary artery has been achieved by the use of a variety of stabilizers [4, 5] that compress the epicardium in the vicinity of the anastomotic site, eliminating vertical or lateral movement. Occasionally, however, the metal stabilizers do cause superficial lacerations on the epicardium, surrounding veins, or the myocardium, or slip away from the original site of application as a result of the underlying beating heart. A centrally fenestrated piece of felt placed on the epicardium around the anastomotic site before the application of the stabilizer serves as a cushion and enhances stability, safety, and precision of the anastomosis.
After the exact site of anastomosis on the coronary is chosen, a 2 x 2-inch felt (Bard PTFE felt; Bard, Tempe, AZ) is prepared by excising an oval part from its center portion measuring approximately 2 cm in length and 1 cm in width. This fenestration can be adjusted to the length of the coronary anastomosis even after placement of the stabilizer. Once the heart is elevated and positioned for the performance of the anastomosis, proximal and/or distal perivascular coronary snares are placed first. The fenestrated piece of felt is then placed on the epicardial surface of the heart exposing only the segment of coronary artery to be anastomosed in the middle of the oval fenestration along its longest diameter. The stabilizer feet (Cardiothoracic Systems, Inc, Cupertino, CA) are applied onto the felt on either side of the oval fenestration and the coronary artery, as shown in Figure 1. Sufficient pressure is then applied by the stabilizer on the felt to immobilize the segment of coronary artery to be anastomosed. If a longer than anticipated anastomosis becomes necessary, felt can be excised in either direction to allow for a longer arteriotomy. Once proper stability is achieved, the artery is opened and the anastomosis is performed in a standard fashion with or without the use of occluders or shunts.
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Fig 1. The fenestrated felt acts as a cushion on the epicardium, compressed by the stabilizer feet. The coronary anastomotic site is exposed in the long axis of the oval fenestration.
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Comment
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Excellent results of beating heart, "off-pump" coronary bypass surgery depend on a number of factors including a stable anastomotic site and a bloodless field. Dry field has been achieved by perivascular coronary snares, intravascular occluders, and/or blowing devices, which most commonly use carbon dioxide. Stability of the anastomotic site has been achieved by a variety of stabilizers [4, 5] that largely provide satisfactory results. Occasionally, however, despite their textured epicardial surfaces, the stabilizer feet may slip away from the site of application or cause trauma to surrounding epicardial veins or myocardium prompted by the underlying beating heart. This could lead to time-consuming corrective measures, excessive blood loss, or serious trauma.
A fenestrated piece of felt, applied on the epicardium as a cushion to the stabilizer, facilitated stability and prevented epicardial trauma and significant blood loss in a number of patients in whom it was used. Consequently, performance of the anastomosis could proceed uninterrupted, decreasing operative time. It was also observed that the stretched felt across the coronary artery, proximal and distal to the anastomotic site in conjunction with perivascular coronary snares, occluders, and/or shunts, decreased the amount of bleeding from the arteriotomy. Thus, avoidance of trauma to epicardial veins combined with less bleeding through the arteriotomy led to decreased blood loss during "off-pump" coronary bypass operations. It was further observed that the above advantages were more pronounced during the performance of coronary anastomoses of the circumflex system, especially in the vicinity of large epicardial veins.
Comparing data between 18 patients having off-pump coronary bypass (mean number of grafts 3.1, all having at least one arterial graft), without using the fenestrated felt, and 7 patients undergoing the same operation (mean number of grafts 2.3, 86% having at least one arterial graft) using the felt, we noted some expected but also exaggerated differences in blood loss in spite of otherwise similar operative techniques. The duration of operation was 304 ± 19 minutes (range 176–454 minutes), vs 263 ± 17 minutes (range 212–331 minutes), respectively, 41 minutes longer per operation for an additional 0.8 anastomosis in patients without the felt. More importantly, in patients without the use of felt, 4.4 ± 0.6 (range 1–9) cell-saver units were collected during operation, vs 1.8 ± 0.5 (range 0–4) cell-saver units in patients in whom felt was used. We must emphasize that it was not possible and no attempt was made to separate the amount of bleeding resulting from epicardial lacerations vs bleeding via the coronary arteriotomy during operation. Based on our observations, however, we felt that at least part of the difference in blood loss could be secondary to avoidance of epicardial trauma by the use of the fenestrated felt cushion.
In summary, the use of fenestrated felt in conjunction with a stabilizer enhances the performance and safety of coronary anastomoses in "off-pump" coronary bypass operations. It has the potential for cost reduction by decreasing operative time and the need for blood transfusion.
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References
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Nierich A., Lahpor J.R., Bredee J.J. Less invasive off-pump CABG using a suction device for immobilization. Eur J Cardio Thor Surg 1997;12:406-412.[Abstract]
Accepted for publication March 24, 1999.
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Abstract
Introduction
