Asian Cardiovasc Thorac Ann 1999;7:250-251
© 1999 Asia Publishing EXchange Pte Ltd
Simple and Cost-Effective Gas Jet for Non-Pump Coronary Bypass Surgery
Hakan Posacio
lu, MD,
Yüksel Atay, MD,
Tahir Yadi, MD,
Tanzer Çalkavur, MD,
Mustafa Çikirikçiolu, MD,
Suat Büket, MD,
Ahmet Hamulu, MD,
Münevver Yüksel, MD,
Önol Bilkay, MD
Department of Cardiovascular Surgery
Ege University Medical Faculty
 zmir, Turkey
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For reprint information contact: Önol Bilkay, MD Tel: 90 232 388 2866 Fax: 90 232 339 0002 email: yatay{at}med.ege.edu.tr Department of Cardiovascular Surgery, Ege University Medical Faculty, Bornova, zmir 35100, Turkey.
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Abstract
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A gas jet is one method of achieving a bloodless surgical field. We describe a simple and cost-effective oxygen blower system for coronary artery bypass surgery performed without cardiopulmonary bypass.
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Introduction
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The aims of avoiding cardiopulmonary bypass during coronary artery bypass surgery are to reduce perioperative mortality and morbidity, promote early hospital discharge, and reduce cost.1,2 Suitable coronary artery anatomy, good stabilization of the coronary arteries, and achieving a bloodless anastomotic field are major determinants of the success of the operation.1–3 Antegrade coronary blood flow frequently compromises a clear view of the anas-tomotic site. A gas jet is one of the important tools used to achieve a bloodless surgical field. At the University of Ege, we have produced a simple and cost-effective gas jet for non-pump coronary artery bypass surgery.
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Technique
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Our gas jet system uses re-sterilizable materials. A Siemens 900D ventilator (Siemens-Elema AB, Solna, Sweden) is used as an oxygen source. A bacterial filter (20 microns), 1/4 inch tubing, and a 16-gauge cannula are the other components of the oxygen delivery system (Figure 1
). Pericardial collapse due to the gas jet can be used as a marker to regulate oxygen flow. An oxygen flow rate of 3 to 5 L•min–1 causes minimal pericardial collapse and is sufficient to maintain a bloodless anastomotic field. Oxygen flow must be directed distally at a distance of approximately 5 cm, to direct the blood away from the anastomosis site. To avoid desiccation of the epicardial surface, we have recently added a simple humidifier to the system by inserting a fine (22 gauge) needle into the gas line close to the cannula. The needle is connected to an intravenous line attached to a bag of normal saline. The fluid flow rate is set at 60 mL•h–1. The epicardial surface can also be washed intermittently with saline to prevent drying. This system costs less than $10 USD and it can be used more than fifteen times.
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Discussion
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Complete and effective coronary anastomosis is the essential objective of coronary artery bypass graft surgery. Minimally invasive techniques of myocardial revascu-larization on a beating heart without cardiopulmonary bypass, are emerging as an alternative to the standard method.2 Methods to achieve a dry operative field during construction of the distal coronary artery anastomoses include saline irrigation, snares, or coronary occluders. Saline irrigation may cause a problem because of the change in refractive index, leading to parallax errors.4 Excessive distal vascular loop traction to obtain a bloodless field may cause native coronary artery constriction beyond the anastomosis.5 Some groups use a commercially available blower to facilitate anastomosis.6 There is a risk of coronary gas embolization involved in the use of a gas jet but this should not be a problem if the cannula is not placed directly into the arteriotomy. Distal vascular loops or slings can protect against gas embolization.
Trauma to the coronary artery is avoided by carefully regulating the flow. We use pericardial collapse due to the gas jet to regulate flow and found that optimal oxygen flow is between 3 and 5 L•min–1. Hoerstrup and colleagues7 showed in a study with a scanning electron microscope that there was no intimal damage with an air flow of 2 to 5 L•min–1. Another study on the effect of oxygen flow on saphenous vein segments by Teoh and colleagues3 showed no vascular endothelial injury. Recently, Burfeind and colleagues8 demonstrated that a high flow rate (15 L•min–1) of carbon dioxide insufflation denuded the coronary artery of endothelium. We have never exceeded a flow of 5 L•min–1. We have applied this method in non-pump coronary artery bypass procedures since 1996 and have observed no side effects or complications related to oxygen delivery.
We recommend this simple and cost-effective system that can be prepared easily to improve visualization of the anastomosis without the need of any special equipment.
Presented at the World Congress on Minimally Invasive Cardiac Surgery, Paris, France, May 30–31, 1997.
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References
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Ankeney JL. To use or not to use the pump oxygenator in coronary bypass operations. Ann Thorac Surg 1975; 19:108–9.[Medline]
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Buffolo E, Silva de Andrade JC, Branco Rodrigues JN, Teles AC, Aguiar FL, Gomes WJ. Coronary artery bypass grafting without cardiopulmonary bypass. Ann Thorac Surg 1996;61:63–6.[Abstract/Free Full Text]
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Teoh KHT, Panos AL, Harmantas AA, Lichtenstein SV, Salerno TA. Optimal visualization of coronary artery anastomosis by gas jet. Ann Thorac Surg 1991;52:564–8.[Abstract]
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Benetti F, Mariani MA, Sani G, Boonstra PW, Grandjean JG, Giomarelli P, et al. Video-assisted minimally invasive coronary operations without cardiopulmonary bypass: a multicenter study. J Thorac Cardiovasc Surg 1996; 112:1478–84.[Abstract/Free Full Text]
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demir O, Karagöz H, Bayazit K. Avoiding early or late failure in "off-pump" coronary artery bypass grafting. Ann Thorac Surg 1996;62:945–6.[Free Full Text]
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Tünerir B, Aslan R, Kural T, Besogul Y. No-touch method for off-pump coronary artery bypass grafting. Asian Cardiovasc Thorac Ann 1998;6:257–9.[Abstract/Free Full Text]
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Hoerstrup S, Lachat ML, Zünd G, Vogt PR, Turina MI. Improved visualization in minimally invasive coronary artery bypass grafting. Ann Thorac Surg 1998;66:963–4.[Abstract/Free Full Text]
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Burfeind WR, Duhaylongsod FG, Annex BH, Samuelson D. High-flow gas insufflation to facilitate MIDCAB: effects on coronary endothelium. Ann Thorac Surg 1998;66:1246–9.[Abstract/Free Full Text]
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Abstract
Introduction
