1. Basics Of Open HeartBasics Of Open Heart SurgerySurgery
Soumya Ranjan Parida
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. 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. CPB Circuit
5. Parts of a Membrane Oxygenator Reservoir Oxygenator Heat
exchanger
6. DeBakey Roller Pump
7. Incisions for OHS
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. Prepare all Exposed parts
10. Water Blanket , Plastic Drapes
11. Incision and scouring of sternum
12. Vibrating saw
13. Oscillating saw
14. Structures could be injured during sternotomy
15. Wax applied to sternal marrow surface
16. Wax applied with a gause padding
17. Thymus dissection
18. Thymic Fat separated
19. Pericardium opened longitudinally
20. Peritoneum accidentally opened
21. Pericardial retraction suture
22. CannulationCannulation principlesprinciples Minimal number
of cannulae in the op field Arterial cannula first Avoid at all
cost: kinking, dislocation
23. Purse stringPurse string Material Anatomical position
Tissue Surgical technique Economics Prolene : Monofilament :
smooth, no cut through Ethibond: Braided : rough, tough, cut
through
25. Aortic purse string Two , diagonally opposite placed ,
concentric purse strings, as distally as possible
26. Purse string bites : multiple small bites and multiple
jumps
27. Aortic purse string
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. Bicaval cannulationBicaval cannulation avoid air lock: RA /
RV Communication : VSD with AR Right atriotomy : TVR LA Retraction
affect venous return: MVR
30. A: Bicaval Cannulation with snugging of cave B: Drainage
through a two stage- Cavo-Atrial cannula
70. Cannulation through RA appendage : Clamping RAA tech
71. Cannulation through RA appendage :Snugger at marker
72. On bypass ????
73. Position of tubings ,Colour code
74. Various suction tips
75. Venous cannula and line arranged
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. Cardioplegia cannula insertion
78. ACC Ao CAN CARDIO PLEGIA Aortic cross clamp & Antegrade
cardioplegia
79. ACC Ao CAN CARDIO PLEGIA Problem with regurgitant aortic
valve
80. Antegrade & Retrograde cardioplegia Routes
81. Purse string for retrograde cardioplegia
82. Retrograde cardioplegia cannulation completed
83. Cardioplegia through grafts
84. Ostial cardioplegia cannulae
85. Graft + ostial cardioplegia delivery
86. Cross clamps
87. Aorta cross-clamped LV distension checked
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. Two limbs of cannula : cardioplegia delivery
90. Vent is started after delivery of cardioplegia
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. Air removal : use suction
93. Removal of Cross Clamp
94. Rest to Heart
95. Defibrillation
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. Partial CPB: SVC cannula removed
98. SVC purse string tied
99. Aortic cannula removed last , after returning pump
blood
100. Empty venous line
101. Bleeding Checked
102. Pericardium closed, drains inserted
103. Wires passed
104. Wire through manubrium : wire bleeding
105. Wiring completed, drains placed
106. drains placed
107. Wires twisted, cut , tightened
108. Burying of wires
109. SC closure : Long needle : bite of periosteum
110. SC closure : second layer
111. Cuticular closure : Monocryl
112. Skin Closure with Ethilon
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