HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Helmut Mair Sabine Daebritz Bruno Reichart Paul Sergeant Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Mair, H. Articles by Sergeant, P. Search for Related Content PubMed PubMed Citation Articles by Mair, H. Articles by Sergeant, P. Related Collections Related Article

Ann Thorac Surg 2005;80:1565-1566
© 2005 The Society of Thoracic Surgeons

---

Correspondence

Pericardial Sling Increases OPCAB Safety and Applicability

^a Cardiac Surgery, University of Munich, Marchioninistr 15, Munich, 81377 Germany
^b Cardiac Surgery, University of Leuven, Herestraat 49, 3000 Leuven, Belgium

(Email: helmut.mair{at}med.uni-muenchen.de; paul.sergeant{at}uz.kuleuven.be).

To the Editor:

Lawton and colleagues [1] reported a case of an atrioventricular tear during off-pump coronary artery bypass (OPCAB) manipulation of the heart using an apical suction positioning device. No deep pericardial traction was applied. Elevated left atrial pressure, overdistention, and the use of inotropic agents were assumed reasons for the spontaneous tear. Other contributing factors included cardiomegaly, previous myocardial infarction, and fragile tissue.

In our opinion the described complication underlines the necessity of combining a deep pericardial sling with an apical suction device to access the left lateral heart. The sling can be anchored at the posterior mediastinum, under the left atrium at its utmost right side (Fig 1). The sling thereby supports and elevates the left atrium and the left ventricle in a gradual fashion without distortion of the atrioventricular axis (Fig 2), way above the level allowed by a single traction suture. The deep pericardial traction lifts the atrioventricular groove, thereby optimizing access to its coronary vessels. In addition, it reduces muscular wall elongation, simultaneously increasing contractility and relaxation (as identified in sheep experiments, personal unpublished data). The apical suction device is used for ventricular remodeling, axial stabilization, and further lateralization of the exposed ventricle. The combination approach avoids torsion and incompetence of the mitral annulus [2], as identified by pressure measurements and by transesophageal echocardiography.

View larger version (144K): [in this window] [in a new window]   Fig 1. Placement of the deep pericardial suture (1) near the right lower pulmonary vein (2). A gauze (sling) is anchored with a tourniquet (2). The sling is pulled toward (3) and (4) to the left side of the patient whereby the heart enucleates vertical. The mass of the left ventricle remains centered within the "V" of the gauze.

View larger version (27K): [in this window] [in a new window]   Fig 2. (A) Kinking of the atrioventricular groove (crooked arrow) caused by single left-sided traction suture(s). (B) Only correct placement of a deep pericardial suture near the right pulmonary vein enucleates the heart without kinking the atrioventricular groove (straight arrow).

1 Placement of deep pericardial anchoring suture and fixation of a supporting gauze to the right posterior mediastinum

2 Enucleation of the heart towards a vertical position, avoiding compression of the left ventricle

3 Rotation of the table toward the surgeon, thereby unloading the heart from the supporting sling

4 Optimization of the ventricular format, stabilization of the ventricular axis, and additional lateralization of the atrioventricular axis, using the apical suction device

5 Stabilization of the anastomotic region using a local suction stabilizer, avoiding suction on top of a collateral vessel.

This protocol has been used in more than 3,000 consecutive cases, even in extremely challenging clinical situations as in the presence of cardiogenic shock, severe left ventricular hypertrophy, or long-term use of steroids.

	References

Top References

 

1. Lawton JS, Deshpande SP, Zanaboni PB, Damiano Jr RJ. Spontaneous atrioventricular groove disruption during off-pump coronary artery bypass grafting Ann Thorac Surg 2005;79:339-341.[Abstract/Free Full Text]
2. Sepic J, Wee JO, Soltesz EG, et al. Cardiac positioning using an apical suction device maintains beating heart hemodynamics Heart Surg Forum 2002;5(3):279-284.[Medline]
3. Sergeant P, Wouters P, Meyns B, et al. OPCAB versus early mortality and morbidityan issue between clinical relevance and statistical significance. Eur J Cardiothorac Surg 2004;25(5):779-785.[Abstract/Free Full Text]

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]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Helmut Mair Sabine Daebritz Bruno Reichart Paul Sergeant Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Mair, H. Articles by Sergeant, P. Search for Related Content PubMed PubMed Citation Articles by Mair, H. Articles by Sergeant, P. Related Collections Related Article