An Altemtive Method of
Left Ventricular Decompression during Aortocoronary Bypass Frank J. Bolgan, M.D., Anthony J. Federico, M.D., a n d Ross L. Guarino, M.D. ABSTRACT A method is described that allows decompression of the left ventricle without the necessity of inserting a carinula into the cardiac chambers. The left ventricle may be completely decompressed through the vein grafts attached to the aortic root opened to the pericardial sac.
The desirability of decompressing the left ventricle during performance of the distal anastomoses in aortocoronary bypass surgery is well established 131. It is especially useful when the graft is being anastomosed to branches of the circumflex coronary artery [21. A completely empty and flaccid left ventricle reduces the technical problems in performing these anastomoses ill. The usual methods of decompressing the left ventricle involve direct cannulation of the left ventricle through the apex or indirect cannulation, usually through the superior pulmonary vein [7]. Each of these methods can, at times, cause intraoperative complications and also may result in postoperative problems such as hemorrhage, apical infarction, or apical dyskinesia [4,61. The following method of decompressing the left ventricle avoids these potential problems.
Technique The patient is heparinized and cannulation is carried out in preparation for cardiopulmonary bypass. Before bypass is started, a tangential clamp is placed on the ascending aorta. Two buttons of aortic wall are removed with a medium-sized bone rongeur. Two reversed From the Department of Thoracic and Cardiovascular Surgery, Millard Fillrnore Hospital, Buffalo, NY. Accepted for publication Nov 9, 1976. Address reprint requests to Dr. Bolgan, Department of Thoracic and Cardiovascular Surgery, Millard Fillmore Hospital, 3 Gates Circle, Buffalo, NY 14209.
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segments of saphenous vein are then sutured end-to-side to the ascending aorta. After completing these anastomoses, cardiopulmonary bypass is instituted. In order to minimize the accumulation of blood in the left ventricle arising from the pulmonary circuit, tapes may be passed around the superior and inferior venae cavae and secured. The patient is cooled to 30°C, and the aorta is then crossclamped. The heart is fibrillated, the fibrillating wire is then removed, and the left ventricle is decompressed through the open grafts bleeding into the pericardial sac. Blood is returned to the pump through the coronary sucker. One of the vein grafts is occluded with an atraumatic clamp, and the distal anastomosis is then made to the circumflex coronary artery. The ventricle continues to be decompressed through the proximal aorta by way of the second graft. After completion of the distal anastomoses, the aortic cross-clamp is removed. Spontaneous normal rhythm usually resumes. If ventricular fibrillation persists, defibrillation is carried out immediately. Further ventricular decompression may not be necessary for grafts to the diagonal, anterior descending, posterior descending, or right coronary artery. However, if three or more grafts are contemplated and further decompression is desirable [5], then the additional vein is anastomosed to the ascending aorta and the ventricle decompressed through the additional graft, using the procedure outlined above. In the last 200 operations we have performed using this technique, there have been no operative complications; we have found the use of this technique to be totally satisfactory.
References 1. Buckberg GD: The importance of venting the left ventricle (editorial). Ann Thorac Surg 20:488, 1975
477 How to Do It: Bolgan, Federico, and Guarino: Left Ventricular Decompression during Bypass
2. Cheanvechai C, Effler DB, Groves LK, et al: Aorta- 5. Hottenrott C, Buckberg G: Studies of the effects of ventricular fibrillation on the adequacy of regional to-circumflex artery saphenous vein bypass graft. Ann Thorac Surg 14:390, 1972 myocardial flow: 11. Effects of ventricular distention. J Thorac Cardiovasc Surg 68:626, 1974 3. Favaloro RG, Effler DB, Groves LK, et al: Severe segmental obstruction of the left main coronary 6. Siderys H: The superior approach for operative decompression of the left side of the heart. Ann and its divisions. J Thorac Cardiovasc Surg 64:469, Thorac Surg 17:277, 1974 1970 4. Heimbecker RO, McKenzie FN: A new approach to 7. Sproul G, Pinto J, Trummer MJ, et al: Simplified left heart decompression. Ann Thorac Surg 21:456, left ventricular venting. J Thorac Cardiovasc Surg 65:433. 1973 1976
Left Ventricular Decompression during Aortocoronary Bypass Frank J. Bolgan, M.D., Anthony J. Federico, M.D., a n d Ross L. Guarino, M.D. ABSTRACT A method is described that allows decompression of the left ventricle without the necessity of inserting a carinula into the cardiac chambers. The left ventricle may be completely decompressed through the vein grafts attached to the aortic root opened to the pericardial sac.
The desirability of decompressing the left ventricle during performance of the distal anastomoses in aortocoronary bypass surgery is well established 131. It is especially useful when the graft is being anastomosed to branches of the circumflex coronary artery [21. A completely empty and flaccid left ventricle reduces the technical problems in performing these anastomoses ill. The usual methods of decompressing the left ventricle involve direct cannulation of the left ventricle through the apex or indirect cannulation, usually through the superior pulmonary vein [7]. Each of these methods can, at times, cause intraoperative complications and also may result in postoperative problems such as hemorrhage, apical infarction, or apical dyskinesia [4,61. The following method of decompressing the left ventricle avoids these potential problems.
Technique The patient is heparinized and cannulation is carried out in preparation for cardiopulmonary bypass. Before bypass is started, a tangential clamp is placed on the ascending aorta. Two buttons of aortic wall are removed with a medium-sized bone rongeur. Two reversed From the Department of Thoracic and Cardiovascular Surgery, Millard Fillrnore Hospital, Buffalo, NY. Accepted for publication Nov 9, 1976. Address reprint requests to Dr. Bolgan, Department of Thoracic and Cardiovascular Surgery, Millard Fillmore Hospital, 3 Gates Circle, Buffalo, NY 14209.
476
segments of saphenous vein are then sutured end-to-side to the ascending aorta. After completing these anastomoses, cardiopulmonary bypass is instituted. In order to minimize the accumulation of blood in the left ventricle arising from the pulmonary circuit, tapes may be passed around the superior and inferior venae cavae and secured. The patient is cooled to 30°C, and the aorta is then crossclamped. The heart is fibrillated, the fibrillating wire is then removed, and the left ventricle is decompressed through the open grafts bleeding into the pericardial sac. Blood is returned to the pump through the coronary sucker. One of the vein grafts is occluded with an atraumatic clamp, and the distal anastomosis is then made to the circumflex coronary artery. The ventricle continues to be decompressed through the proximal aorta by way of the second graft. After completion of the distal anastomoses, the aortic cross-clamp is removed. Spontaneous normal rhythm usually resumes. If ventricular fibrillation persists, defibrillation is carried out immediately. Further ventricular decompression may not be necessary for grafts to the diagonal, anterior descending, posterior descending, or right coronary artery. However, if three or more grafts are contemplated and further decompression is desirable [5], then the additional vein is anastomosed to the ascending aorta and the ventricle decompressed through the additional graft, using the procedure outlined above. In the last 200 operations we have performed using this technique, there have been no operative complications; we have found the use of this technique to be totally satisfactory.
References 1. Buckberg GD: The importance of venting the left ventricle (editorial). Ann Thorac Surg 20:488, 1975
477 How to Do It: Bolgan, Federico, and Guarino: Left Ventricular Decompression during Bypass
2. Cheanvechai C, Effler DB, Groves LK, et al: Aorta- 5. Hottenrott C, Buckberg G: Studies of the effects of ventricular fibrillation on the adequacy of regional to-circumflex artery saphenous vein bypass graft. Ann Thorac Surg 14:390, 1972 myocardial flow: 11. Effects of ventricular distention. J Thorac Cardiovasc Surg 68:626, 1974 3. Favaloro RG, Effler DB, Groves LK, et al: Severe segmental obstruction of the left main coronary 6. Siderys H: The superior approach for operative decompression of the left side of the heart. Ann and its divisions. J Thorac Cardiovasc Surg 64:469, Thorac Surg 17:277, 1974 1970 4. Heimbecker RO, McKenzie FN: A new approach to 7. Sproul G, Pinto J, Trummer MJ, et al: Simplified left heart decompression. Ann Thorac Surg 21:456, left ventricular venting. J Thorac Cardiovasc Surg 65:433. 1973 1976
