Asian Cardiovasc Thorac Ann 2003;11:177-179
© 2003 Asia Publishing EXchange Ltd
Starfish Heart Positioner and Harmonic Scalpel for Redo Off-Pump Coronary Bypass
Hiroshi Niinami, MD,
Yuji Suda, MD,
Yasuo Takeuchi, MD
Department of Cardiovascular Surgery, Daini Hospital, Tokyo Women’s Medical University, Tokyo, Japan
For reprint information contact: Hiroshi Niinami, MD Tel: 81 3 3810 1111 Fax: 81 3 3810 4064 email: niinamca{at}dnh.twmu.ac.jp Department of Cardiovascular Surgery, Daini Hospital, Tokyo Women’s Medical University, 2-1-10 Nishiogu, Arakawa-ku, Tokyo 116-8567, Japan.
 |
ABSTRACT
|
|---|
In a redo off-pump coronary artery bypass operation through a repeat median sternotomy, use of the Starfish Heart Positioner in combination with the Harmonic Scalpel may facilitate dissection of adhesions without hemodynamic impairment.
|
INTRODUCTION
|
|---|
Owing to the development of stabilizers, coronary artery bypass grafting (CABG) without cardiopulmonary bypass (CPB) has gained acceptance and is now used widely for coronary revascularization. Stabilizers and beating-heart surgical instruments are continually being improved to allow multivessel off-pump CABG (OPCAB) with the same ease and consistency as under CPB. Redo OPCAB through a repeat median sternotomy can be difficult, especially for grafting to the posterolateral wall. In this situation, the heart (except the right atrium) should be completely dissected from adhesions to obtain optimal exposure. To dissect posterolateral and inferior wall adhesions with scissors or electrocautery, the heart is usually pushed manually against the remaining pericardium or the diaphragm. However, manual oppression of the heart may cause hemodynamic instability, and electrocautery may induce ventricular arrhythmia. To avoid these potentially fatal complications during OPCAB, we used the Starfish Heart Positioner (Medtronic, Inc., Minneapolis, MN, USA) to minimize manual compression of the heart, and the Harmonic Scalpel (Ethicon Endo-Surgery, Inc., Somerville, NJ, USA) for dissection of adhesions.
|
TECHNIQUE
|
|---|
Detailed information on the previous surgery is important in planning the procedure. Careful preoperative angiographic assessment of patent grafts, the native circulation, and ventricular function are essential. A lateral chest radiograph shows the retrosternal space. Computed tomography or magnetic resonance imaging is helpful in delineating the position of the right ventricle, aorta, and grafts, and their relationship to the sternum. The patient is placed in the supine position. Disposable defibrillation pads are routinely placed under both axillary sites. Before opening the chest, a 19-gauge cannula is inserted percutaneously into the femoral artery by the Seldinger technique for possible intraaortic balloon pumping or percutaneous cardiopulmonary support. All bypass grafts except the internal thoracic artery (ITA) and right gastroepiploic artery should be prepared prior to sternotomy. When re-opening the sternum, an incision is made at the sternal wires, the wires are then cut and removed. Small rake retractors which are connected to the rakes of the ITA retractor (Rultract, Inc., Independence, OH, USA), are hooked to both ends of the left side of the sternum. The ITA retractor is slightly wound up to lift up the sternum. An oscillating saw is applied to divide the anterior table of the sternum. When the posterior table has been carefully divided, the left side of the sternum is automatically elevated slightly. Complete division of the sternum can be confirmed by this slight elevation of the left side.1 While lifting the left side of the sternum with the ITA retractor, dissection around the left side of the sternum should be carried out until a chest spreader can be applied. Then, dissection around the right side of the sternum is undertaken. The left and right ITA and the gastroepiploic artery are prepared as required. A chest spreader (Octobase; Medtronic, Inc., Minneapolis, MN, USA) is applied and the chest is opened gently to avoid lacerating the heart. Dissection of adhesions between the heart and surrounding tissue usually starts at the level of the diaphragm as these are less dense and the correct plane can be easily identified.2 To find the correct plane, dissection should be performed with scissors rather than the Harmonic Scalpel. Once the correct plane is identified, the Harmonic Scalpel with the dissecting hook is used to dissect the acute margin of the right ventricle from the diaphragm. The Starfish Heart Positioner is placed on the right ventricular free wall and pulled towards the head to make room between the inferior surface of the heart and the diaphragm (Figure 1
). This dissection is extended along the diaphragm out to the left of the apex of the heart. Repositioning the Starfish makes it easier to make a space during dissection. It is not necessary to dissect around the right atrium for OPCAB. For proximal anastomosis, the ascending aorta needs to be dissected with the Harmonic Scalpel. When the apex of the heart is identified, the pericardium can be divided in a cephalad direction to the left of the left anterior descending coronary artery. Two pericardial sutures are placed at the edge of the left side of the pericardium, gently pulled upward, and secured to the suture holder attached to the Octobase or the surgical drape, with the hemostat on the left side. The Starfish is positioned at the apex and the heart is gently pulled towards the right side by lifting it up (Figure 2). While pushing the left side of the pericardium with forceps or a suction tip, the Harmonic Scalpel is applied to dissect adhesions. This is performed continuously down to the posterolateral wall while repositioning the Starfish, depending on the degree of the dissection.
View larger version (141K):
[in this window]
[in a new window]
|
Figure 1. Operative view of dissection of adhesions between the inferior surface of the heart and the diaphragm, using the Harmonic Scalpel. Note that the Starfish Heart Positioner is set on the right ventricular free wall just above the acute margin.
|
|
View larger version (162K):
[in this window]
[in a new window]
|
Figure 2. Operative view of dissection of adhesions between the left ventricle and the pericardium, using the Harmonic Scalpel. Note that the Starfish Heart Positioner is set on the left ventricular apex and retracts the heart towards the right side.
|
|
|
DISCUSSION
|
|---|
Although OPCAB is often employed for isolated first-time CABG, it is rarely used for redo CABG. If the patient needs only a graft to the left anterior descending or right coronary artery, a small left thoracotomy and small laparotomy approach, respectively, can be applied to avoid reopening the sternum. However, patients with multivessel disease need a repeat sternotomy. There are several advantages in using the off-pump technique rather than conventional CABG on CPB. The main advantage is less bleeding due to less dissection, particularly around the right atrium, and a lower dosage of heparin. The major disadvantage is the difficulty in mobilizing the left side of the heart, especially in patients with patent ITA or saphenous vein grafts. It is generally recommended to use CPB and crossclamp the aorta when mobilizing the left side of the heart in order to decompress the heart, which makes dissection easier and avoids hemodynamic instability induced by manual oppression. We applied the Starfish Heart Positioner to pull the heart instead of pushing it for dissection of adhesions. There is another type of suction-cup heart positioner (Expose; Guidant Co., Cupertino, CA, USA) which is applied only to the left ventricular apex; the Starfish can be applied to any surface of the heart.
Dissection of adhesions is usually accomplished with diathermy or scissors, but diathermy can disturb heart rhythm and possibly induce ventricular fibrillation.3 To avoid this risk, since 1999, we have been using the Harmonic Scalpel to dissect adhesions not only for redo heart operations but also in cases of constrictive pericarditis. When the Harmonic Scalpel is applied for dissection, it is important to find the correct plane first with scissors. Since the Harmonic Scalpel melts fat (either surrounding fat tissue or epicardial fat) or breaks it into pieces by the cavitation effect, incorrect dissection of the plane may occur.
The best candidates for this technique would be those undergoing redo CABG without patent vein grafts. All vein grafts more than 3 years old must be considered potentially atherosclerotic; even angiographically nondiseased grafts might cause myocardial infarction during dissection of adhesions, due to atheromatous debris.4 However, patent IMA grafts should not be a problem with this technique. To accomplish redo OPCAB safely, one of the key factors is dissection of the heart from adhesions. The combination of the Starfish Heart Positioner and Harmonic Scalpel may facilitate this goal without hemodynamic impairment.
|
REFERENCES
|
|---|
- Niinami H, Takeuchi Y. Sternal re-entry using the retractor for harvesting internal thoracic artery. Kyobu Geka
2002;55:471–3. (Japanese)[Medline]
- Lytle BW. Coronary reoperations. In: Edmunds LH, editor. Cardiac surgery in the adult. New York: McGraw-Hill, 1997:573–96.
- De Leon SY, LoCicero J III, Ilbawi MN, Idriss FS. Repeat median sternotomy in pediatrics: experience in 164 consecutive cases. Ann Thorac Surg
1986;41:184–8.[Abstract]
- Cosgrove DM, Loop FD. Reoperations for coronary artery disease. In: Stark J, Pacifico AD, editors. Reoperations in cardiac surgery. London: Springer-Verlag, 1989;315–23.
This article has been cited by other articles:
|
|
|
|
 
A. Fukumoto, M. Yamagishi, K. Doi, M. Ogawa, T. Inoue, and H. Yaku
Off-pump Pericardiectomy Using an Ultrasonic Scalpel and a Heart Positioner
Asian Cardiovasc Thorac Ann,
December 1, 2007;
15(6):
e69 - e71.
[Abstract]
[Full Text]
[PDF]
|
|
|
TOP
ABSTRACT
INTRODUCTION
