[HSF] A question of conduits

[David Harris]

Please ignore previous message!
I would put skeletonised LIMA on D1 (Not LAD as
previous message - mistake!!), then T the RIMA off the
LIMA, and use it on the marginal and PDA. I struggle
to get a pedicled RIMA to reach the PDA nicely. If I
am grafting the LAD, I use a free RIMA on all the L
sided vessels, then use a vein or radial from the
aorta. ((Also not mentioned in previous message - I
always use shunts - less ischaemia during first grafts
allows easier manipulation for circumflex))

In this case I would in addition put a vein on the
LAD. When I side clamp the aorta, I do it last, as it
can cause the heart to distend a bit. This can cause
problems with subsequent exposure of the circumflex.

Exposing the circumflex, I put a retraction suture
just below the pulm vein, and between pulm vein and
IVC. I sometimes cut the right sided pericardium over
the diaphragm, down to the IVC. The harvest of the
RIMA facilitates elevation of the right hemisternum.
Usually the heart rotates nicely under the sternum
(not in pleura!!)when bed is tilted toward surgeon,
with good exposure (as good as in the pleura).

Recently I usually only use a single deep stay suture
between pulm vein and IVC, but as far medial as
possible. A stockingette swab is placed in the stay
suture, and the heart is easily verticalised. The
exposure is adequate, but the space to work is small.
I initially position with the stabiliser with just
enough pressure to see. The heart will initially
dilate, but if BP is ok, wait, and then gradually push
more across once the heart has adapted and become
smaller. Put snares, stays, cut mammary, etc, and
after this time push down for final exposure, and by
this time the heart has adapted and shrunk even more.
Especially if anaesthesiologist is giving some
nitrates iv. Another trick is to pull upwards on the
stabiliser after applying suction, instead of pushing,
and this can lift the heart out quite a bit without
compromising stability. I never use an apical device,
as this interferes with the apical twisting motion.

Regards,

Dave Harris
--- Mitch Lirtzman <drmitch at cox.net> wrote:

> Let's start a new thread, shall we?
> 
> A 56yo male, non-diabetic smoker, admitted with
> NSTEMI. Cath shows total OM 
> with faint distal flow as the culprit. RCA 100% w/
> collateral to the PDA. 
> D1 is 90% and LAD 40%-50% at most. LVEF~ 45%. Body
> habitus is mesomorph 
> bordering on Cajun-porky.
> 
> My plan would be skeletonized RIMA to the PDA, try
> to get the LIMA from D1 
> to OM and probably leave the LAD alone.
> 
> Any thoughts/ contrary opinions?
> 
> Now, I hope you don't mind my changing directions,
> but for you "OPCAB-ers" 
> out there, for the last several cases, I've been
> able to graft every vessel 
> I need to, but for the last two, in positioning for
> the circ, the BP would 
> just not tolerate the change. Trendelenburg, Rt
> lateral, volume loading, 
> none of it worked. And "putting the heart into the
> rt chest", the worst. 
> Any pearls would be happily accepted.
> 
> Thanks, Mitch
> 
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Dr. David G. Harris, FCS, MMED,
Cardiothoracic Surgeon        
Suite 207                                
Kuils River Private Hospital,        
PO Box 1200, Kuils River, 7579, Cape Town, South Africa.            
Tel +27-21-9006411             
Fax +27-21-9006412      Mobile +27-83-3309587