Ann Thorac Surg 2004;78:1130-1131
© 2004 The Society of Thoracic Surgeons
Correspondence
Recommendations for the proper placement of the deep pericardial retraction suture in off-pump coronary artery bypass graft surgery
Vipin Zamvar, FRCS(CTh)
Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh EH16 4SU, UK
zamvarv{at}hotmail.com
To the Editor:
Deep pericardial retraction (DPR) sutures are routinely used to lift the heart during off-pump coronary artery surgery [1]. The single-suture technique [2] is now used by most surgeons in preference to 2 or 3 sutures.
Retropericardial hematomas after deep pericardial sutures traverse the wall of the aorta [3] or pulmonary vein [4] have been described. I [5] have previously described bleeding requiring reexploration due to the DPR suture penetrating the parenchyma of the lower lobe of the left lung.
I recommend the following steps to facilitate proper placement of the DPR suture:
- Ask the anesthesiologist to stop ventilation for 30 or 40 seconds before the suture is placed. As the lungs fall back, the surgeon has slightly more room and is less likely to injure the lung when the suture is placed.
- Aspirate blood from the pericardial cavity before the heart is lifted.
- As soon as the heart is lifted, the assistant must aspirate any remaining blood from the depths of the pericardial cavity (it is usually the small amount of blood in the bottom of the pericardial well that impairs proper visualization for placing the suture). The assistant must then move out of the field so that he or she is not competing with the surgeon for space.
- Use a long needle holder (at least 24 cm long) and a long curved needle (Ethicon Mersilk 60 mm 3/8c works well for me). A shorter needle holder means the surgeon's right fist must compete for space with the heart in the cavity.
- Finally, the suture must take a good bite of pericardium (a suture that tears off during the construction of an obtuse marginal anastomosis can be very irritating) and at the same time avoid taking any of the deeper structures.
- Using a forceps, as recommended by Dr Salerno [3], is usually not feasible because the surgeon's left hand must hold the heart up. Asking the assistant to use a forceps crowds 2 hands in the limited pericardial space.
As with any surgical procedure, attention to the smaller details is important for a good outcome. A properly placed retraction suture can make all the difference between easy and difficult access to the obtuse marginal territory.
References
- Fukui T, Suehiro S, Shibata T, Hattori K, Hirai H. Retropericardial hematoma complicating off-pump coronary artery bypass surgery. Am Thorac Surg. 2002;73:1629–1631[Abstract/Free Full Text]
- Bergsland J, Karamanoukian HL, Soltoski PR, Salerno TA. "Single suture" for circumflex exposure in off-pump coronary artery bypass grafting. Ann Thorac Surg. 1999;68:1428–1430[Abstract/Free Full Text]
- Salerno TA. A word of caution on deep pericardial sutures for off-pump coronary bypass procedures. Ann Thorac Surg. 2003;76:339[Free Full Text]
- Fukui T, Suehiro S. A word of caution on deep pericardial sutures for off-pump coronary bypass procedures. Ann Thorac Surg. 2003;76:339[Free Full Text]
- Zamvar V, Deglurkar I, Abdullah F, Khan NU. Bleeding from the lung surface: a unique complication of off-pump CABG. Heart Surg Forum. 2001;4:172–173[Medline]
This article has been cited by other articles:
|
|
|
|
 
J. S. Lawton and R. J. Damiano Jr
Pericardial Sling Increases OPCAB Safety and Applicability: Reply
Ann. Thorac. Surg.,
October 1, 2005;
80(4):
1566 - 1567.
[Full Text]
[PDF]
|
|
|
