Ann Thorac Surg 2000;70:2169-2170
© 2000 The Society of Thoracic Surgeons
How to do it
Heart positioner: a device to easily expose all coronary arteries during beating heart operations
Ruggero De Paulis, MDa,
Luisa Colagrande, MDa,
Mirella De Cotiis, RNa,
Luigi Chiariello, MDa
a Department of Cardiac Surgery, Università di Roma Tor Vergata, Rome, Italy
Accepted for publication May 20, 2000.
Address reprint requests to Dr De Paulis, Divisione di Cardiochirurgia, Università di Roma Tor Vergata, European Hospital, via Portuense 700, 00149 Rome, Italy
e-mail: depauli{at}tin.it
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Abstract
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The increasing number of coronary operations performed on a beating heart has prompted the development of new techniques and instruments to expose the coronary arteries without major hemodynamic derangements. We describe an expandable surgical pad combined with a series of tapes that help to control rotations and positioning of the heart. The empty surgical pad is fixed at the bottom of the pericardial cavity. After injection of warm saline, the pad elevates and displaces the heart, and the tapes rotate and immobilize the heart in the desired position. Easy access to all coronary arteries with minimal effect on hemodynamics is possible.
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Introduction
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The growth of coronary artery bypass graft operations on a beating heart [1] has prompted the development of new instruments and techniques to expose and immobilize the coronary arteries. A comfortable surgical procedure (through a sternotomy) requires that the coronary arteries are brought close to the midline where they can be more easily immobilized by the use of mechanical stabilizers. These maneuvers may cause hemodynamic instability and a decrease in cardiac output. Shennib and Bastawisy [2] described a simple method to subluxate the heart using a surgical glove connected to a silicone elastomer tube and positioned under the heart. By injecting warm saline into the glove the lateral wall of the left ventricle could be rotated and displaced to a more anterior and central position. Because the water inside the glove absorbs the movement of the ventricle, it prevents any undue compression of the cardiac chambers. However, once the glove is filled with water it can slip away, failing to appropriately elevate and rotate the left ventricle. Furthermore, any traction on the glove to more precisely rotate the heart causes the glove to slip from under the heart and prevents good exposure of the vessel of the lateral and posterior walls.
We describe a heart positioner that overcomes the drawbacks of the surgical glove yet retains all the advantages of a fluid-filled chamber and allows easy access to all coronary vessels.
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Technique
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The heart positioner or surgical pad (Fig 1) (Sulzer Vascutek Ltd, Renfrewshire, Scotland; patent pending) is an oval pouch or sock (with a dimension of approximately 12 x 7 cm) made of polyester to which two heavy tapes of the same material are sutured on each side. On one side of the pad the tapes have two tails. Through the opening of the sock a surgical glove or any other latex balloon of the appropriate size can be inserted and tied around a silicone elastomer tube (Fig 2). In this way the sock is retained around the expandable chamber positioned inside. The heavy tapes are used to fix the pad in its position and to appropriately rotate and expose the heart once the pad is in place.
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Fig 1. Upper view of the sock or receptacle. Through the open end of the receptacle (open arrow) an expandable surgical pad (surgical glove or latex balloon) is inserted. Two ends of the positioning tapes (black arrows) are passed around the great vessels and the inferior vena cava to secure the pad at the bottom of the pericardial cavity. After the pad has been filled with a variable amount of water, the other two ends of the tapes are used to rotate and immobilize the heart into the desired position.
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Fig 2. Side view of the heart positioner after the expandable surgical pad has been inserted into the receptacle and the open end tied shut around the fluid supply tubing. In this way the receptacle is retained around the expandable surgical pad. The positioning tapes are used to fix the pad at the bottom of the pericardial cavity and to better rotate the heart, obtaining fine adjustment of its position.
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Once the pericardium has been opened and the heart exposed, the empty surgical pad is positioned under the left ventricle. Next, it is secured into position by using two tails of the tapes on one side of the pad (Fig 1, arrows) that are passed around the great vessels (aorta and pulmonary artery from one side and inferior vena cava from the other side) and then fixed to a towel draping the surgical field. By slowly injecting saline through the silicone elastomer tube the pad increases volume and gently displaces the lateral wall of the left ventricle to provide easy access to the left anterior descending and diagonal branches. To expose the intermediate branches or the obtuse marginal arteries, more saline is injected until the heart is "verticalized." Because of the rough surface of the sock and its fixation at the bottom of the pericardial cavity, the pad does not slip out and maintains elevation of the heart. The other two tails fixed at the bottom of the pericardial cavity are used to further rotate the heart and to obtain an optimal position. Similarly, the tapes on the other side of the pad can be used to make small adjustments. With the pad kept inflated all arteries of the lateral, posterior, and inferior walls can be retracted medially and anteriorly and immobilized by changing the position of the tapes [2]. When the pad is partially deflated the right coronary artery can be easily exposed by using the two tails of the tapes surrounding the inferior vena cava.
Serial hemodynamic measurements with the heart positioner in place were recorded in 10 consecutive patients. Changes in cardiac output, systemic arterial pressure, and pulmonary arterial pressure were recorded before and during exposure of the anterior vessels, the marginal branches, and for the right or posterior descending coronary arteries, and are reported in Table 1. The Trendelenburg position and low doses of vasopressive agents were used routinely during exposure of the lateral and posterior coronary branches.
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Comment
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The major problem of coronary bypass grafting on a beating heart is optimal exposure of the coronary arteries. The approach to the anterior vessels of the heart is relatively easy and can be obtained without major hemodynamic problems. However, when complete revascularization is required, exposure of the lateral and posterior vessels can be challenging and often requires placement of sutures deep in the pericardial sac, or use of a sling to elevate and rotate the heart [3]. Elevation and rotation of the heart are usually done slowly and progressively to prevent any sudden drop in cardiac output. The use of a water bed to slowly modify the position of the heart reduces hemodynamic changes [2]. The heart positioner described here combines the advantages of an expandable fluid chamber and tapes that are needed to obtain a stable and satisfactory position of the coronary artery before it is immobilized by a mechanical stabilizer. The texture of the pad and its fixation at the bottom of the pericardial cavity prevent slippage of the fluid-filled chamber. This permits expanding the chamber without deteriorating hemodynamics until the heart is more vertical and the apex is exposed. Once the heart is elevated, the positioning tapes rotate the heart to achieve optimal exposure of the target coronary artery. Should a sudden drop of cardiac output occur, the tapes are released leaving the beating heart in a vertical position. When adequate circulatory factors are restored, the heart can be rotated again. By simply changing the amount of water injected into the surgical pad and by gently modifying the position of the tapes attached to the receptacle, all coronary arteries can be easily exposed and immobi-lized. Using this surgical pad avoids the need for pericardial retraction sutures or any other technique to hold the heart. It facilitates coronary artery grafting on a beating heart.
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Footnotes
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Doctor Ruggero De Paulis has a consultantship agreement with Sulzer Vascutek Ltd.
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References
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Contini M., Iaco A., Iovino T., et al. Current results in off pump surgery. Eur J Cardiothorac Surg 1999;16(Suppl 1):S69-S72.[Abstract/Free Full Text]
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Shennib H., Bastawisy A. Coronary artery bypass grafting on the beating heart: a simple technique for subluxating the heart. Ann Thorac Surg 1999;67:870-871.[Abstract/Free Full Text]
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Bergsland J., Karamanoukian H.L., Soltoski P.R., Salerno T.A. "Single suture" for circumflex exposure in off-pump coronary artery bypass grafting. Ann Thorac Surg 1999;68:1428-1430.[Abstract/Free Full Text]
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Abstract
Introduction
