Ann Thorac Surg 2000;69:1280-1281
© 2000 The Society of Thoracic Surgeons
HOW TO DO IT
The heart string: a simple, inexpensive exposure of the heart during coronary artery operations
Hiroshi Niinami, MD, PhDa,
Hitoshi Koyanagi, MDa,
Peter W. Brady, FRACSb,
Donald E. Ross, FRACSa
a Department of Cardiovascular Surgery, The Heart Institute of Japan, Tokyo Women’s Medical University, Tokyo, Japan
b Department of Cardiothoracic Surgery, Royal North Shore Hospital, Sydney, Australia
Address reprint requests to Dr Niinami, Department of Cardiovascular Surgery, The Heart Institute of Japan, Tokyo Women’s Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo 162-8666, Japan
 |
Abstract
|
|---|
A method of heart retraction during coronary artery bypass operations is described. The technique improves exposure of the coronary arteries, especially of the circumflex and posterior descending coronary branches during grafting. In addition, it is simple, safe, and inexpensive. Furthermore, this technique can be applied for off-pump coronary artery bypass surgery.
|
Introduction
|
|---|
Steady positioning of the heart and good exposure of the coronary artery to be grafted are sometimes difficult to obtain when trying to expose the posterior surface of the heart through a median sternotomy. Usually, this exposure is obtained with the help of an assistant, who rotates, lifts, and holds the apex of the ventricle in an upward position using one hand. However, a steady position is not easy to maintain because of slippage, and, in addition, pressure and local warming may damage the myocardium in contact with the assistant’s fingers. To avoid this, various retraction methods to expose the posterior surface of the heart have been described [1–7]. Most methods depend upon specially manufactured or prepared devices, which consist of slings and fabric nets or slings alone [1–4]. These slings have to be passed through the transverse sinus and inferior vena cava, which might be too dangerous for off-pump grafting. Another alternative is the use of gauze sponges [5, 6]. However, this method is limited when exposing the circumflex branches close to the atrioventricular groove.
The method described here is really simple, safe, and economical for heart retraction. It eliminates the need for an assistant, while offering an excellent view of the coronary arteries, especially on the posterior surface of the heart.
|
Technique
|
|---|
After median sternotomy and pericardiotomy, the right-sided pericardial holding sutures are temporarily attached to the surgical drape with hemostats. No sutures are tied to the right-sided pericardium. A two-stage venous cannula is used for venous drainage. The cannula is brought out at the cranial portion of the incision. After institution of cardiopulmonary bypass, two heart strings are placed. One is placed into the pericardium between the left lower pulmonary vein and the left phrenic nerve, and parallel to the left phrenic nerve with a length of 2 cm, using a 1 Nylon suture with a big tapered needle (A985H; Ethicon, Somerville, NJ) (heart string 1). The left phrenic nerve can be identified easily from the pericardium, because it can be seen through the thin pericardium. The other one is placed on the diaphragmatic surface of the pericardium and a little deeper from the inferior vena cava with a length of 2 cm using a 1 Vicryl suture with a big tapered needle (J359H Ethicon) (heart string 2). These maneuvers can be done without cardiopulmonary bypass. To expose the left anterior descending artery and the diagonal branches, heart string 1 is gently pulled upward and secured to the surgical drape with the hemostat on the left side. For exposure of the circumflex and posterior descending arteries, the right pleura is opened wide, while leaving its anterior margin intact to allow for its reattachment to the anterior chest wall before chest closure, and the right-side pericardial holding sutures are loosened. To expose the obtuse marginal branch and lateral circumflex artery, heart string 1 is gently pulled upward and clamped to the surgical drape with the hemostat on the left side, then the heart is flipped over the venous cannula into the right chest. It is supported there by moist pack sponges, which are inserted between the under-surface of the right hemisternum and posterior surface of the left ventricle. To expose the posterolateral branch and the posterior descending artery, heart string 2 is gently pulled upward and secured to the surgical drape, with the hemostat on the right side, in addition to the procedure of exposing the marginal branch. In this case, when the heart is flipped over, its apex should be gently rotated counter-clockwise to position the posterolateral ventricular surface in the middle of the surgical view (Figs 1, 2).
View larger version (26K):
[in this window]
[in a new window]
|
Fig 2. Cross-section of the chest as seen from below when exposing the posterior surface of the heart. (Cx = circumflex coronary artery.)
|
|
|
Comment
|
|---|
Several techniques for circumflex exposure have been described [1–7]. The circumflex artery lesion can be displaced medially only by flipping the heart into the right chest. However, target vessels to be grafted can still be deep, especially those vessels that are close to the atrioventricular groove. The point of using the heart string technique is to lift the heart almost to the level of the sternum in order to make a three-dimensional situation two-dimensional without passing any slings around the transverse sinus. The strings should be pulled gently so as not to injure the myocardium. We reuse heart string 1 as a chest-drain fixation suture, and heart string 2 as a chest closure suture. Baumgartner and associates placed rubber snares on these sutures to prevent injury to the myocardium [7]. We have not encountered any problems using this technique without rubber tourniquets. It might be safer to use these; however, we have to cut the needles from the heart strings, which loses the advantage of reusage of these sutures. We always reestablish continuity between the right mediastinal and the anterior chest wall, so that it is not necessary to insert a right pleural drain. Despite atrial distortion caused by flipping the heart into the right chest, venous return appears to be uncompromised. We have been applying these strings to expose the left anterior descending and posterior descending arteries not only with cardiopulmonary bypass but also without a pump.
|
References
|
|---|
-
Janke W.H. Heart support for coronary bypass surgery involving the circumflex artery system. J Thorac Cardiovasc Surg 1974;67:883-884.[Medline]
-
Kazama S., Ishihara A. Fabric heart retractor for coronary artery bypass operations. Ann Thorac Surg 1993;55:1582-1583.[Abstract/Free Full Text]
-
Matsuura A., Yasuura K., Maseki T., et al. A new device for exposing the circumflex coronary artery. Ann Thorac Surg 1995;59:1249-1250.[Abstract/Free Full Text]
-
Galvin I.F., Newman D.C. Circumflex exposure using a cardiac sling. Ann Thorac Surg 1990;49:833-834.[Abstract/Free Full Text]
-
Badellino M.M., Cavarocchi N.C., Kolff J., Alpern J.B., McClurken J.B. The cardiac rag. Simple exposure of the heart. Tex Heart Inst J 1988;15:134-135.[Medline]
-
Splittgerber F.H., Friedrich I., Falk B., Kroncke G., Talbert J.G. Exposing the circumflex coronary artery. Ann Thorac Surg 1996;61:1019-1020.[Abstract/Free Full Text]
-
Baumgartner F.J., Gheissari A., Capouya E.R., Panagiotides G.P., Katouzian A., Yokoyama T. Technical aspects of total revascularization in off-pump coronary bypass via sternotomy approach. Ann Thorac Surg 1999;67:1653-1658.[Abstract/Free Full Text]
Accepted for publication November 30, 1999.
This article has been cited by other articles:
|
|
|
|
 
H. Niinami, H. Ogasawara, Y. Suda, and Y. Takeuchi
Single-Vessel Revascularization With Minimally Invasive Direct Coronary Artery Bypass: Minithoracotomy or Ministernotomy?
Chest,
January 1, 2005;
127(1):
47 - 52.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
H. Niinami, Y. Takeuchi, S. Ichikawa, and Y. Suda
Partial median sternotomy as a minimal access for off-pump coronary artery bypass grafting: feasibility of the lower-end sternal splitting approach
Ann. Thorac. Surg.,
September 1, 2001;
72(3):
S1041 - S1045.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
