Chassot P. -G. , van der Linden P , Zaugg M , Mueller X. M. , Spahn D

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Presentation transcript:

Off-pump coronary artery bypass surgery: physiology and anaesthetic management† Chassot P.-G. , van der Linden P , Zaugg M , Mueller X.M. , Spahn D.R. British Journal of Anaesthesia Volume 92, Issue 3, Pages 400-413 (March 2004) DOI: 10.1093/bja/aeh064 Copyright © 2004 British Journal of Anaesthesia Terms and Conditions

Fig 1 Changes in volume of the left atrium and the left ventricle during heart verticalization. (a) TOE two-chamber view at 90° of the patient's heart in its supine position. The left atrial (LA) volume is about one-third of the left ventricular (LV) volume. (b) Without modifying the position of the TOE probe, the heart has been lifted up in a vertical position in order to operate on its postero-inferior wall. The relative dimensions of LA and LV in this new 90° two-chamber view are reversed: the atrium, being now under the ventricle, is larger than the ventricle in which the end-diastolic volume is reduced by 50%. Both pictures are taken in protosystole. British Journal of Anaesthesia 2004 92, 400-413DOI: (10.1093/bja/aeh064) Copyright © 2004 British Journal of Anaesthesia Terms and Conditions

Fig 2 Modification of a mitral regurgitation with heart manipulation. (a) When the heart is in its normal position, a trivial regurgitation is present. (b) When the heart has been lifted up in a vertical position, the regurgitation has increased to a grade II. British Journal of Anaesthesia 2004 92, 400-413DOI: (10.1093/bja/aeh064) Copyright © 2004 British Journal of Anaesthesia Terms and Conditions

Fig 3 Modification of mitral shape with heart manipulation reconstructed in its three-dimensional aspect, as viewed from above (from reference 49, with permission). (a) Normal saddle shape of the mitral ring when the heart is in its normal position. (b) When the heart is moved to the vertical position, the mitral ring is severely distorted. (c) When the lifted heart is rotated to gain access to the lateral wall, the ring is further folded and twisted. British Journal of Anaesthesia 2004 92, 400-413DOI: (10.1093/bja/aeh064) Copyright © 2004 British Journal of Anaesthesia Terms and Conditions

Fig 4 The heart position using the technique of ‘rocking’ with a tissue stabilizer device. The right ventricle is squeezed between the left ventricle and the right hemi-sternum; the right ventricular outflow tract is compressed (courtesy of Medtronics™). British Journal of Anaesthesia 2004 92, 400-413DOI: (10.1093/bja/aeh064) Copyright © 2004 British Journal of Anaesthesia Terms and Conditions

Fig 5 Exposure of the heart with the posterior pericardial stitch of the ‘no-touch’ technique. (a) Location of the stitch in the oblique sinus of the posterior pericardium on the right side of the spine, halfway between the level of the right inferior pulmonary vein and the inferior vena cava.13 Ideally, the stitch should be placed slightly to the right of the spine (arrow); this allows TOE imaging from the oesophagus. (b) The suture is passed through a half-folded swab and snared down, bringing the folded end of the swab in close contact with the posterior pericardium. For exposing a specific wall of the heart, both limbs of the swab are pulled (arrows) in a direction opposite to the target wall with the target artery located between both limbs, in order to avoid any compression of the heart. This represents ‘no-touch’ handling of the heart.84 (c). In the final position, the heart is enucleated from the pericardium in a vertical position, the apex at the zenith; each cardiac wall is accessible to surgery. On the picture, the tissue stabilizer is applied on the posterior wall with minimal compression. British Journal of Anaesthesia 2004 92, 400-413DOI: (10.1093/bja/aeh064) Copyright © 2004 British Journal of Anaesthesia Terms and Conditions