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Ann Thorac Surg 2004;78:2212-2213
© 2004 The Society of Thoracic Surgeons
a Department of Cardiothoracic Surgery, St. Mary's Hospital, London, 70 St. Olaf's Rd, Fulham, London, SW6 7DN, UK
tathan5253{at}aol.com
To the Editor:
The advent of off-pump coronary artery bypass grafting (OPCAB) has led to the development of specialized devices that stabilize the heart (epicardial and apical suction devices). We [1, 2] have previously reported our experience with the expanded use of these stabilizers in situations that would otherwise require cardiopulmonary bypass, such as pericardiectomy, division of adhesions, redo operations, penetrating trauma of the posterior and inferior left ventricular wall, epicardial microwave ablation for chronic atrial fibrillation, and extra-anatomic aortic–aortic bypass in recurrent aortic coarctation. Motallebzadeh and Kanagasabay have added to this list in using stabilization devices as tissue retractors to facilitate proximal anastomoses during OPCAB and as retraction instrument holders. Of note, we have found that the use of these devices with their suction on when retracting the right atrium can cause right atrial surface trauma and hematoma formation and can be arrhythmogenic. In our experience, removing the suction and placing a wet swab between the stabilizer and the heart surface provides suitable retraction with minimal trauma.
A technically demanding aspect of OPCAB is the application of a partial-occlusion clamp to perform the proximal anastomosis of the coronary graft. Serious complications can occur during this maneuver [3, 4], but they might be prevented by reducing blood flow in the ascending aorta using both pharmacological and technical measures. The latter can be achieved in three ways. First, venous return can be reduced by temporary occlusion of the inferior vena cava and reverse Trendelenburg's positioning of the patient. Second, a pericardial stitch can be placed next to the superior vena cava to lift up, and thereby ease access to, the ascending aorta. Finally, a tape sling around the ascending aorta can facilitate exposure of the right aortic border.
Epicardial stabilization devices also have a role during combined (valve and coronary artery bypass) procedures requiring cardiopulmonary bypass. Their use can substantially reduce cross-clamp time and also can allow trainees an opportunity to perform their first coronary anastomoses under conditions simulating the beating-heart environment while in a hemodynamically controlled setting. We have also used epicardial stabilizers as retractors to facilitate aortic or mitral valve exposure during replacement instead of existing hand-held retraction systems that tie up the assistant surgeon. The Octopus 3 stabilization system (Medtronic, Inc, Minneapolis, MN) deserves special mention here for several reasons. First, its feet are flexible and longer than those of the Axius Vacuum 2 stabilizer system (Guidant Corp, Cupertino, CA) and, the Octopus 4 (Medtronic, Inc). Second, one of the feet can be bent and the other inserted into the aortic root, thereby taking up less space than the traditional leaflet or Ross retractor. Third, during mitral valve replacement, both feet can be placed into the left atrium and thus facilitate exposure. Finally, a shorter arm length means the Octopus 3 offers more firm stabilization compared with the Octopus 4. Such versatility is a feature of epicardial stabilization devices that ultimately may lead to modifications to better suit some of the functions mentioned here.
References
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