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Last modified on Tue 15 Jul 2014

OR setup

The OR room should be kept warm until the patient is fully draped with the goal of keeping the patient’s core temperature above 36.8C for the duration of the procedure. The most effective method for maintaining this ideal body temperature is to prevent cooling of the patient during the setup. A heated mattress is placed immediately beneath the patient; intravenous fluids and inhaled gases are also warmed.
The table should be capable of raising the patient’s legs independent of the thorax. A magnetic mat stabilizes the most important instruments and is positioned on top of the legs, allowing unobstructed movement of the table.

A suction tree is used, with separate controls for apical suction, stabilizer, and cell saver. The apical suction device is set no higher than 200 mmHg and the suction stabilizer is set no higher than 320 mmHg. The reason for such specific parameters is twofold: First, high rates of suction can cause haematomas and/or trauma to the myocardium. Second, the amount of force needed to expose the heart should be distributed between the suction device and the sling support( to be described). The patient’s legs are secured with a padded block secured to the right side of the table to allow rotation of the table to the right, important for unloading the heart from the sling.

Fig. 1 : The leg block, avoiding a drop of the leg

General exposure

A standard median sternotomy is used for exposure. Once one or both (90 % of patients) mammary arteries have been harvested, the pericardium is opened along the midline. The inverted T of the pericardial incision is carried out toward the apex, along the diaphragm, to allow unobstructed enucleation.

Fig. 2 : incision towards apex

The T is then extended to the right, to create sufficient workspace. The trough for one or both (if the right IMA is used in situ) mammary arteries is cut prior to suspending the left side of the pericardium.

Fig. 3 : IMA trough

The right side of the pericardium is suspended and the left side is released if the right-sided target is on the proximal right coronary artery (RCA).