Open heart surgery

1. Basics Of Open HeartBasics Of Open Heart
SurgerySurgery
Soumya Ranjan Parida

2. Requirements of SurgeryRequirements of Surgery
part to be operated should be
Still
‘Dry’
Relaxed
only a dead heart is still, dry
and relaxed

3. Basic Steps of OHSBasic Steps of OHS
Opening of the chest
Cannulate & connect the pt to CPB after
heparinisation – ‘total’ CPB
 Cool the patient
Cross clamp aorta and stop the heart by
delivering cardioplegia
Open the heart - perform intracardiac
operation
Close cardiotomies - deair the heart
Declamp aorta , give rest to the heart , Off
CPB
Reverse Heparin with Protamine
Close the chest by keeping drains

4. CPB Circuit

5. Parts of a
Membrane Oxygenator
Reservoir
Oxygenator
Heat exchanger

6. DeBakey
Roller Pump

7. Incisions for OHS

8. Median sternotomyMedian sternotomy
advantagesadvantages
Access for any cardiac operation
Any cardiac complication can be managed
No separate incision for cannulation
Cannulae under view

9. Prepare all Exposed parts

10. Water Blanket , Plastic Drapes

11. Incision and scouring of sternum

12. Vibrating saw

13. Oscillating saw

14. Structures could be
injured during sternotomy

15. Wax applied to sternal marrow surface

16. Wax applied with a gause padding

17. Thymus dissection

18. Thymic Fat separated

19. Pericardium opened longitudinally

20. Peritoneum accidentally opened

21. Pericardial retraction suture

22. CannulationCannulation
principlesprinciples
Minimal number of cannulae in the op field
Arterial cannula first
Avoid at all cost: kinking, dislocation

23. Purse stringPurse string
Material
Anatomical position
Tissue
Surgical technique
Economics
Prolene : Monofilament : smooth, no cut
through
Ethibond: Braided : rough, tough, cut
through

24. Arterial CannulationArterial Cannulation
any appropriate sized artery
Aorta: routine
Femoral: MICAS, emergency, redo
Axillary: Cerebral perfusion
combined

25. Aortic purse string
Two , diagonally opposite placed ,
concentric purse strings,
as distally as possible

26. Purse string bites : multiple small bites and multiple jumps

27. Aortic purse string

28. Different purse- string sites for venous cannulation
1. Direct SVC
2. Direct IVC
3. RA appendage for RA cannula or ‘2 stage cannula’

29. Bicaval cannulationBicaval cannulation
avoid air lock:
RA / RV Communication : VSD
with AR
Right atriotomy : TVR
LA Retraction affect venous
return: MVR

30. A: Bicaval Cannulation
with snugging of cave
B: Drainage through a
two stage- Cavo-Atrial
cannula

31. SVC purse string

32. IVC purse string

33. IVC purse string

34. Snugger/ Snare Hook: Types

35. ALL purse strings completed

36. Aorto PA dissection

37. Looping aorta

38. Aortic cannulation: pull aorta down , sucker

39. Aortic cannulation : cutting the adventitia

40. Aortic cannulation : Scouring the adventitia

41. Aortic cannulation :cannulation site scoured

42. Aorta Cannulated

43. Cannulation with stab knife

44. Snugg, tip direction

45. Tie cannula and snugger

46. Cannula Cap

47. What is this ?

48. Deair the lines and clamp

49. Priming SolutionPriming Solution
Fluid initially added to CPB circuitry
Type : Crystalloid ( Ringer )
Colloid Albumen, Plasma ,
Blood

50. Colloidal Prime

51. Aortic
Cannula
connected
to arterial
line

52. Check for air

53. Disconnection if air found

54. Aortic Cannula Fixed to Skin

55. Placing arterial line

56. Fixing the arterial line

57. Covering aortic cannula with a towel

58. SVC Cannulation : retraction

59. SVC Cannulation : venotomy dilated

60. SVC cannulation: Grip

61. SVC Cannulated. Cannula tied

62. IVC cannulation : RA retracted , site stabbed

63. IVC opening dilated : long instrument

64. IVC cannulation complete, cannula tied

65. Dissection for SVC Looping : scissors

66. Dissection for SVC Looping : cautery

67. SVC Looped & taped

68. IVC Looping

69. Cannulation through RA appendage : direct

70. Cannulation through RA appendage : Clamping RAA tech

71. Cannulation through RA appendage :Snugger at marker

72. ‘ On bypass ????

73. Position of tubings ,Colour code

74. Various suction tips

75. Venous cannula and line arranged

76. CardioplegiaCardioplegia
Aim: to arrest the heart quickly in diastole
preserve cellular structure
Types according to Base
Temperature
K+
/Na+
concentration
St. Thomas cardioplegia is most
popular
Delivery method: Antegrade( root,
ostium, graft)
Retrograde ( CS)
Combination

77. Cardioplegia cannula insertion

78. ACC
Ao CAN
CARDIO PLEGIA
Aortic cross clamp &
Antegrade cardioplegia

79. ACC
Ao CAN
CARDIO PLEGIA
Problem with
regurgitant aortic
valve

80. Antegrade
&
Retrograde
cardioplegia
Routes

82. Purse string for retrograde cardioplegia

83. Retrograde cardioplegia cannulation completed

84. Cardioplegia through grafts

85. Ostial cardioplegia cannulae

86. Graft + ostial cardioplegia delivery

87. Cross clamps

88. Aorta cross-clamped LV distension checked

89. Left Heart ReturnLeft Heart Return
1% of CO returns to heart via
Ao-- Br art -- Br V – PV -- LA
This blood is from CPB , hence warm
Warm the heart , distend heart, occlude
field
Suck (vent) out through
RSPV, LA, LV, Ao, ASD

90. Two limbs of cannula : cardioplegia delivery

91. Vent is started after delivery of cardioplegia

92. CardiotomyCardiotomy
principlesprinciples
AS FAR AS POSSIBLE….
small incisions
RA, LA, Ao, PA opened
RV: if required, infundibulum
opened
LV : is rarely ‘opened’
avoid damaging arteries/
conduction tissue

94. Air removal : use suction

95. Removal of Cross Clamp

96. Rest to Heart

97. Defibrillation

98. Different sizes available in Internal Paddles
Main two types in Internal Paddles
a) Switched
b) Switchless
3 stage energy protocol
1-2 j/kg 2-3 j/kg and 3-4 j/kg to maximum 50j

99. Partial CPB: SVC cannula removed

100. SVC purse string tied

101. Aortic cannula removed last , after returning ‘pump blood’

102. Empty venous line

103. Bleeding Checked

104. Pericardium closed, drains inserted

105. Wires passed

106. Wire through manubrium : wire bleeding

107. Wiring completed, drains placed

108. drains placed

109. Wires twisted, cut , tightened

110. Burying of wires

111. SC closure : Long needle : bite of periosteum

112. SC closure : second layer

113. Cuticular closure : Monocryl

115. Skin Closure with Ethilon

117. Concept of Off Pump SurgeryConcept of Off Pump Surgery
Ill effects of CPB : on ALL organs
Coronary arteries are superficial
vessels
Development of accessorial
equipment