1. 1. Basics Of Open HeartBasics Of Open Heart SurgerySurgery Soumya Ranjan Parida
2. 2. Requirements of SurgeryRequirements of Surgery part to be operated should be Still Dry Relaxed only a dead heart is still, dry and relaxed
3. 3. Basic Steps of OHSBasic Steps of OHS Opening of the chest Cannulate & connect the pt to CPB after heparinisation total CPB Cool the patient Cross clamp aorta and stop the heart by delivering cardioplegia Open the heart - perform intracardiac operation Close cardiotomies - deair the heart Declamp aorta , give rest to the heart , Off CPB Reverse Heparin with Protamine Close the chest by keeping drains
4. 4. CPB Circuit
5. 5. Parts of a Membrane Oxygenator Reservoir Oxygenator Heat exchanger
6. 6. DeBakey Roller Pump
7. 7. Incisions for OHS
8. 8. Median sternotomyMedian sternotomy advantagesadvantages Access for any cardiac operation Any cardiac complication can be managed No separate incision for cannulation Cannulae under view
9. 9. Prepare all Exposed parts
10. 10. Water Blanket , Plastic Drapes
11. 11. Incision and scouring of sternum
12. 12. Vibrating saw
13. 13. Oscillating saw
14. 14. Structures could be injured during sternotomy
15. 15. Wax applied to sternal marrow surface
16. 16. Wax applied with a gause padding
17. 17. Thymus dissection
18. 18. Thymic Fat separated
19. 19. Pericardium opened longitudinally
20. 20. Peritoneum accidentally opened
21. 21. Pericardial retraction suture
22. 22. CannulationCannulation principlesprinciples Minimal number of cannulae in the op field Arterial cannula first Avoid at all cost: kinking, dislocation
23. 23. Purse stringPurse string Material Anatomical position Tissue Surgical technique Economics Prolene : Monofilament : smooth, no cut through Ethibond: Braided : rough, tough, cut through
24. 24. Arterial CannulationArterial Cannulation any appropriate sized artery Aorta: routine Femoral: MICAS, emergency, redo Axillary: Cerebral perfusion combined
25. 25. Aortic purse string Two , diagonally opposite placed , concentric purse strings, as distally as possible
26. 26. Purse string bites : multiple small bites and multiple jumps
27. 27. Aortic purse string
28. 28. Different purse- string sites for venous cannulation 1. Direct SVC 2. Direct IVC 3. RA appendage for RA cannula or 2 stage cannula
29. 29. Bicaval cannulationBicaval cannulation avoid air lock: RA / RV Communication : VSD with AR Right atriotomy : TVR LA Retraction affect venous return: MVR
30. 30. A: Bicaval Cannulation with snugging of cave B: Drainage through a two stage- Cavo-Atrial cannula
31. 31. SVC purse string
32. 32. IVC purse string
33. 33. IVC purse string
34. 34. Snugger/ Snare Hook: Types
35. 35. ALL purse strings completed
36. 36. Aorto PA dissection
37. 37. Looping aorta
38. 38. Aortic cannulation: pull aorta down , sucker
39. 39. Aortic cannulation : cutting the adventitia
40. 40. Aortic cannulation : Scouring the adventitia
41. 41. Aortic cannulation :cannulation site scoured
42. 42. Aorta Cannulated
43. 43. Cannulation with stab knife
44. 44. Snugg, tip direction
45. 45. Tie cannula and snugger
46. 46. Cannula Cap
47. 47. What is this ?
48. 48. Deair the lines and clamp
49. 49. Priming SolutionPriming Solution Fluid initially added to CPB circuitry Type : Crystalloid ( Ringer ) Colloid Albumen, Plasma , Blood
50. 50. Colloidal Prime
51. 51. Aortic Cannula connected to arterial line
52. 52. Check for air
53. 53. Disconnection if air found
54. 54. Aortic Cannula Fixed to Skin
55. 55. Placing arterial line
56. 56. Fixing the arterial line
57. 57. Covering aortic cannula with a towel
58. 58. SVC Cannulation : retraction
59. 59. SVC Cannulation : venotomy dilated
60. 60. SVC cannulation: Grip
61. 61. SVC Cannulated. Cannula tied
62. 62. IVC cannulation : RA retracted , site stabbed
63. 63. IVC opening dilated : long instrument
64. 64. IVC cannulation complete, cannula tied
65. 65. Dissection for SVC Looping : scissors
66. 66. Dissection for SVC Looping : cautery
67. 67. SVC Looped & taped
68. 68. IVC Looping
69. 69. Cannulation through RA appendage : direct
70. 70. Cannulation through RA appendage : Clamping RAA tech
71. 71. Cannulation through RA appendage :Snugger at marker
72. 72. On bypass ????
73. 73. Position of tubings ,Colour code
74. 74. Various suction tips
75. 75. Venous cannula and line arranged
76. 76. CardioplegiaCardioplegia Aim: to arrest the heart quickly in diastole preserve cellular structure Types according to Base Temperature K+ /Na+ concentration St. Thomas cardioplegia is most popular Delivery method: Antegrade( root, ostium, graft) Retrograde ( CS) Combination
77. 77. Cardioplegia cannula insertion
78. 78. ACC Ao CAN CARDIO PLEGIA Aortic cross clamp & Antegrade cardioplegia
79. 79. ACC Ao CAN CARDIO PLEGIA Problem with regurgitant aortic valve
80. 80. Antegrade & Retrograde cardioplegia Routes
81. 81. Purse string for retrograde cardioplegia
82. 82. Retrograde cardioplegia cannulation completed
83. 83. Cardioplegia through grafts
84. 84. Ostial cardioplegia cannulae
85. 85. Graft + ostial cardioplegia delivery
86. 86. Cross clamps
87. 87. Aorta cross-clamped LV distension checked
88. 88. Left Heart ReturnLeft Heart Return 1% of CO returns to heart via Ao-- Br art -- Br V PV -- LA This blood is from CPB , hence warm Warm the heart , distend heart, occlude field Suck (vent) out through RSPV, LA, LV, Ao, ASD
89. 89. Two limbs of cannula : cardioplegia delivery
90. 90. Vent is started after delivery of cardioplegia
91. 91. CardiotomyCardiotomy principlesprinciples AS FAR AS POSSIBLE. small incisions RA, LA, Ao, PA opened RV: if required, infundibulum opened LV : is rarely opened avoid damaging arteries/ conduction tissue
92. 92. Air removal : use suction
93. 93. Removal of Cross Clamp
94. 94. Rest to Heart
95. 95. Defibrillation
96. 96. Different sizes available in Internal Paddles Main two types in Internal Paddles a) Switched b) Switchless 3 stage energy protocol 1-2 j/kg 2-3 j/kg and 3-4 j/kg to maximum 50j
97. 97. Partial CPB: SVC cannula removed
98. 98. SVC purse string tied
99. 99. Aortic cannula removed last , after returning pump blood
100. 100. Empty venous line
101. 101. Bleeding Checked
102. 102. Pericardium closed, drains inserted
103. 103. Wires passed
104. 104. Wire through manubrium : wire bleeding
105. 105. Wiring completed, drains placed
106. 106. drains placed
107. 107. Wires twisted, cut , tightened
108. 108. Burying of wires
109. 109. SC closure : Long needle : bite of periosteum
110. 110. SC closure : second layer
111. 111. Cuticular closure : Monocryl
112. 112. Skin Closure with Ethilon
113. 113. Concept of Off Pump SurgeryConcept of Off Pump Surgery Ill effects of CPB : on ALL organs Coronary arteries are superficial vessels Development of accessorial equipment