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Ann Thorac Surg 2004;78:1130
© 2004 The Society of Thoracic Surgeons

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Correspondence

Some technical considerations on the prevention of bleeding caused by sutures in the posterior pericardium in off-pump coronary artery bypass operations

Division of Cardiothoracic Surgery, Hospital Universitário Oswaldo Cruz, Rua Arnóio Marques, 310, Santo Amaro, 50100-130 Recife-PE, Brazil

rclima{at}elogica.com.br

To the Editor:

After reading the case report by Fukui and associates [1] and the letter to the editor by Salerno [2] on the same subject, I concentrated on the complications in question for the first time, although I had always had them in mind. The patient operated on by Fukui and colleagues sustained an injury to the left inferior pulmonary vein during placement of deep pericardial sutures, was treated conservatively with bilateral pleural drainage, and achieved a good outcome. The case of the patient mentioned by Salerno was far more serious. The posterior pericardial suture had been placed transversely in the aortic wall, and despite all attempts to reverse the situation, including a left thoracotomy, the patient died.

From our first use of the technique in 1993 to now, my colleagues and I [3, 4] have operated on 2,759 patients and have not seen any complications such as these. However, we are very aware of the structures behind the posterior pericardium during placement of the sutures. At the start of our experience with the technique, we used three sutures in the posterior pericardium: one at the junction between the pericardium with and the left superior pulmonary vein; one at the junction of the pericardium with the left inferior pulmonary vein; and one in the middle portion of the pericardium between the left inferior pulmonary vein and the inferior vena cava.

The simple suture described by Bergsland and associates [5] is a very important contribution, as it simplifies the method and reduces the chances of injury to the left pulmonary veins. Currently we use a single suture corresponding to the third suture we used to place between the left inferior pulmonary vein and the inferior vena cava, thus eliminating the sutures placed near the pulmonary veins and functioning in a way similar to that described by Bergsland and co-workers. In addition to the aorta and pulmonary veins, surgeons should also always bear in mind the presence of the esophagus, damage to which can lead to complications of an infectious nature and even death.

We believe that two factors are important when placing sutures in the posterior pericardium. The first is the use of a single suture. The second is passing the suture through the posterior pericardium twice, first superficially, as emphasized by Salerno. At this time, the assistant should pull the thread in such a way as to leave the pericardium with a convex shape, moving it away from the structures of the posterior mediastinum. Then the surgeon passes the thread through the pericardium again, this time more deeply. When these steps are followed, it is possible to perform the procedure in question without complications.

References

1. Fukui T, Suehiro S, Shibata T, Hattori K, Hirai H. Retropericardial hematoma complicating off-pump coronary artery bypass surgery. Ann Thorac Surg. 2002;73:1629–1631[Abstract/Free Full Text]
2. Salerno TA. A word of caution on deep pericardial sutures for off-pump coronary bypass procedures. Ann Thorac Surg. 2003;76:339 [Letter][Free Full Text]
3. Lima RC, Escobar M, Wanderley Neto J, et al. Revascularização do miocárdio sem circulação extracorpórea: resultados imediatos. Rev Bras Cir Cardiovasc. 1993;8:171–176
4. Lima RC, Escobar M, Lobo Filho JG. Patient selection in off-cardiopulmonary bypass revascularization. Heart Surg Forum. 2002;5:229–233[Medline]
5. 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]

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Ricardo de Carvalho Lima Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Lima, R. d. C. Search for Related Content PubMed Articles by Lima, R. d. C. Related Collections Minimally invasive surgery