Asian Cardiovasc Thorac Ann 2003;11:174-176
© 2003 Asia Publishing EXchange Ltd
Right Pleuropericardial Release: a Useful Technique in Off-Pump Coronary Surgery
Theodore Velissaris, AFRCS,
Robert G Stuklis, FARCS,
David A Hett, FRCA1,
Sunil K Ohri, FRCS
Department of Cardiac Surgery
1 Department of Anaesthesia, Wessex Cardiothoracic Centre, Southampton General Hospital, Southampton, UK
For reprint information contact: Theodore Velissaris, AFRCS Tel: 44 23 8079 6233 Fax: 44 23 8079 8508 email: theo{at}velissaris.com Wessex Cardiothoracic Centre, Southampton General Hospital, Tremona Road, Southampton, SO16 6YD, UK.
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ABSTRACT
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We describe the use of right pleurotomy combined with right pericardial release during off-pump coronary surgery. The maneuver releases the compression exerted on the right cardiac chambers during cardiac verticalization and improves hemodynamic stability during exposure of the posterior or lateral coronary vessels.
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INTRODUCTION
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Exposure of the posterior or lateral coronary vessels during off-pump coronary artery bypass (OPCAB) surgery requires significant cardiac displacement, which results in transient hemodynamic impairment and may occasionally prevent the completion of the operation. The hemodynamic impairment during cardiac verticalization is primarily due to dysfunction of the right ventricle (RV) as it is compressed between the interventricular septum and the surrounding right fibrous pericardium and pleura.1,2 Therefore, some centers have explored the use of right ventricular assist devices as an adjunct to maintain hemodynamic stability during OPCAB.1 In addition, the use of the Trendelenburg position partly restores right ventricular dimensions during cardiac verticalization by augmenting the preload and filling pressures.3,4 We describe the use of a technique comprising right pleurotomy and pericardial release in OPCAB. The technique aims to decompress the right cardiac chambers and improve hemodynamic stability during cardiac manipulation.
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TECHNIQUE
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After induction of general anesthesia, a median sternotomy is performed and the required venous or arterial conduits are harvested and prepared. To prevent ventricular arrhythmias during cardiac manipulation, 5 g magnesium sulphate is given intravenously at the beginning of the operation. Baseline activated clotting time is measured, and heparin is given to maintain activated clotting time above 300 seconds throughout cardiac manipulation and revascularization.
Following preparation of the conduits, the sternum is retracted and the pericardium is fully opened using a midline incision from the superior pericardial reflection on the ascending aorta to the diaphragmatic level, where the incision is extended laterally in an inverted T-shaped fashion. Gentle traction is applied to the incised left pericardial edge to ensure adequate exposure of the heart and great vessels, while no traction is applied to the right pericardial edge. The right pleura is then opened by the surgeon’s assistant using diathermy or scissors. The incision runs laterally to the incised right pericardial edge starting at the level of the superior vena cava where it joins the right atrium and continuing down to the level of the diaphragm, where it extends vertically towards the inferior vena cava in an L-shaped fashion. The incision stops just anterior to the inferior vena cava. Care is taken to avoid injury to the right phrenic nerve.
The patient is then placed in the Trendelenburg position, and a long gauze tape is fixed through its midpoint to the oblique sinus of the posterior pericardium using a "single suture" technique5 to facilitate vertical displacement and anticlockwise rotation of the heart if exposure of the posterior or lateral coronary arteries is required (Figure 1
). Coronary revascularization is performed with the help of a suction-based myocardial stabilizer (Octopus 3; Medtronic Inc., Minneapolis, MN, USA) and an intraluminal coronary shunt (Flo-Thru; Biovascular Inc., St. Paul, MN, USA) to maintain coronary blood flow during anastomosis. During cardiac verticalization, the lack of traction to the right pericardium combined with the right pleurotomy ensures that there is adequate space in the right hemithorax to accommodate the right cardiac chambers (Figure 2). Once revascularization is completed, the gauze tape is removed and the patient is returned to the horizontal position. Any blood that may have collected in the right pleural cavity is salvaged using a cell saver, and the right pleural incision is closed around a 24F drain in a continuous fashion. Routine heparin reversal and sternotomy closure follow without closure of the pericardium.
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Figure 1. Verticalization of the heart using the "single suture" technique. A saphenous vein graft to the diagonal artery and a left internal mammary artery graft to the left anterior descending coronary artery have already been fashioned.
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Figure 2. The right cardiac chambers are allowed to herniate into the right hemithorax during cardiac verticalization following right pericardial release and right pleurotomy.
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DISCUSSION
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The technique described is commonly used to facilitate exposure of the less accessible coronary targets and to improve hemodynamics during cardiac manipulation in OPCAB. The idea of right pleuropericardial release stems from the observation that hemodynamic impairment during cardiac verticalization is primarily due to reduced preload and mechanical dysfunction of the RV.1 A previous echocardiographic study demonstrated that during cardiac elevation the RV is compressed between the left ventricle and the surrounding tissues so that part of the right ventricular free wall is pressed against the interventricular septum during the entire cardiac cycle.2 Our technique decompresses the RV by allowing the retracted right cardiac chambers to herniate into the right hemithorax. It is easy to perform, is safe, and can be used in conjunction with the Trendelenburg position to optimize hemodynamic stability during OPCAB.
We are currently evaluating the hemodynamic impact of right pleuropericardial release during OPCAB. Our preliminary data on 8 patients suggest that there is significantly less hemodynamic disturbance during cardiac verticalization when this maneuver is employed. Using a real-time cardiac output monitoring technique, we observed a drop of 12.1 ± 8.6% in cardiac output during control cardiac verticalization compared to a 4.8 ± 5.2% drop when verticalization was repeated following right pleuropericardial release (p < 0.05). We have employed this technique routinely in more than 100 cases with excellent hemodynamic stability during cardiac manipulation. We have found it particularly beneficial when there is right or left ventricular dysfunction with dilatation of the cardiac chambers.
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Acknowledgments
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Dr. T Velissaris is supported by a Research Fellowship sponsored by Ethicon and awarded by the Royal College of Surgeons of Edinburgh.
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REFERENCES
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ABSTRACT
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