Intermediate Format: Pericardiectomy/Pericardial Window Procedures STST Ch 22 p. 919: Picture above shows pericardial window: approach is thru median sternotomy and decortication begins with left ventricle Q for Further Study: During a pericardiectomy, what should the STSR be prepared to give the surgeon if calcified portions of the parietal pericardium penetrate the heart’s chambers? Be prepared to provide a 4-0 or 5-0 pledgeted Prolene suture for the repair. Type of procedure: Ablative or Palliative CDC classification I Intermediate Format: Pericardiectomy/Pericardial Window

Objectives Assess the related terminology and pathophysiology of the heart. Analyze the diagnostic interventions for a patient undergoing a pericardiectomy. Plan the intraoperative course for a patient undergoing_____________. Assemble supplies, equipment, and instrumentation needed for the procedure.

Objectives Choose the appropriate patient position Identify the incision used for the procedure Analyze the procedural steps for pericardiectomy. Describe the care of the specimen

Terms and Definitions Pericardium Decortication Pericardial effusion Cardiac tamponade Pericardium: the outermost layer of the heart. It is a two-layer membranous sac with a thin layer of serous fluid (normally no more than 30-50 mL) separating the layers. It protects and cushions the heart and great vessels, provides a barrier to infectious processes in adjacent structurs, prevents displacement of the myocardium and blood vessels, and prevents sudden distention of the heart. Decortication: removal of the surface layer of an organ or structure, as removal of a portion of the cortex of the brain frm the underlying white matter (Tabers) Pericardial effusion: abnomral collection of fluid between the pericardial layers that threatens normal cardiac function. The fluid may consist of pus, blood, serum, lymph, or a combination. Cardiac tamponade: a life threatening condition in which elevated intrapericardial pressures impair the filling of the heart during diastole. Tampanode may result from injuries to the heart or great vessels, or other causes of large pericardial effusions. If fluid accumulates rapidly, as little as 250mL can create an emergency. Slow accumulation and a rise in pressure, as in pericardial effusion assoc w/cancer, may not produce immediate signs and symptoms, as the pericardial sac can gradually stretch to accommodate at much as 1-2 L of fluid. It may be diagnosed by Chest x-ray showing slightly widened mediastinum and enlargement of cardiac silhouette; EKG and pulmonary artery pressure monitoring. A hallmark is paradoxical pulse (markedly decreases in amplitude during inspiration) L & B p. 896

Definition/Purpose of Procedure Partial excision of adhered, thickened fibrotic pericardium to relieve constriction of compressed heart and large blood vessels Removal of a segment of pericardium, permitting pericardial fluid to drain into the pleural space for treatment of cardiac tamponade Surgical stripping of the pericardium Alexanders p. 1156 This adhered portion of the scarred, thickened pericardium restricts myocardial contractility. As the pericardial space is obliterated and calcification of pericardium occurs, there is even more compression of the heart. Lemone & Burke p. 897: a rectangular piece of the pericardium or window may be excised to allow collected fluid to drain into the pleural space. Partial or total paricardiectomy is removal of allor part of the pericardium, to relieve the ventricular compression and allow adequate heart filling May be performed to relieve a pericardial effusion responsible for cardiac tamponade

Pathophysiology Chronic pericarditis Tubular Rheumatic Viral Neoplastic Constrictive Pericarditis: Inflammation of the pericardium caused by infection, autoimmune disorders, open heart surgery, etc. It may be a primary disorder or develop secondarily to another cardiac or systemic disorder. Pericardial tissue damage triggers an nflammatory response. Inflammatory mediators released from the injured tissue cause vasodilation, hyperemia, and edema. Capillary permeability increases, allowing plasma proteins, including fibrinogen, to escape the pericardial space. White blood cells amass at the site of injury to destroy the causative agent. Exuduate is formed, usually fibrinous or serofibrinous. In some cases, the exudate may contain red blood cells or purulent material. The inflammatory process may resolve without long-term effects, or scar tissue and adhesions may form between the pericardial layers. Fibrosis and scarring of the pericardium may restrict cardiac function. Pericardial effusions may develop as serous or purulent exudate (depending on causative agent) collects in the pericardial sac. Pericardial effusion may be recurrent. Chronic inflammation causes the pericardium to be rigid.

Pathophysiology Signs & Symptoms Chest pain Fever Cough Dyspnea Palpitations Friction Rub Signs and symptoms: a. chest pain that varies with respiration is the MAIN symptom. The pain often worsens when the patient lies down and improves when the patient sits up. Other manifestations: fever, cough, dyspnea, and palpitations The classic sign is audible friction rub—a multicomponent abnormal heart sound that some describe as scratchy, raspy, or leathery. Patient care: the pt is observed for symptoms of cardiac tamponade, such as weak or absent peripheral pulses, distended neck veins, decreased BP, and narrowing pulse pressure. Alexanders p. 1156 This adhered portion of the scarred, thickened pericardium restricts myocardial contractility. As the pericardial space is obliterated and calcification of pericardium occurs, there is even more compression of the heart. The manifestations are that of Right sided heart failure: (blood backs up in the liver causing abdominal fluid retention and distention) ; Blood returning to the RT heart dos not sufficiently empty into the heart snce the thickened pericardium contrains the RT ventricle from expanding enough to receive the venous blood. Physiological results are: ascites, elevated venous pressure, elevated neck veins, decreased arterial pressure, lower extremity edema, and hepatic enlargement. Constrictive pericarditis involves scarring of the pericardium after one or more episodes of pericarditis. This limits normal cardiac filling during diastole. Impaired filling of the heart’s chambers reduces the volume of blood ejected by the heart with each contraction.

Surgical Intervention: Special Considerations Patient Factors anxiety Room Set-up For heart surgery Possibly cardiac bypass on standby

Surgical Intervention: Positioning Position during procedure Supine, arms on armboards at 90 degrees Supplies and equipment Special considerations: high risk areas

Surgical Intervention: Special Considerations/Incision State/Describe incision Median sternotomy # 10, # 15 blades Alexanders p. 1143: skin incision for full sternotomy extends from the sternal notch to the linea alba below the xiphoid process. The sternum is divided with a saw, and a sternal retractor is inserted. The pericardium is incised and retracted with sutures. For ministernotomy, the sternum is partially divided starting from either the sternal notch or the xiphoid process (depending on the cardiac structures to be exposed).

Surgical Intervention: Supplies General: Cardiac pack Specific Suture 4-0 & 5-0 Prolene, wire for sternum Pledgets Medications on field (name & purpose) Heparinized saline solution and other meds as indicated on preference card (may have protamine on standby) Catheters & Drains: Chest Tubes

Surgical Intervention: Instruments General: Chest and Heart sets Specific Have all cardiac bypass instrumentation available if needed

Surgical Intervention: Equipment General Specific Cardiac defibrillator on standby with internal and external paddles Cardiac bypass on standby

Surgical Intervention: Procedure Steps The lungs are displaced laterally, and the right and left phrenic nerves are identified and protected The pericardium is incised Decortication begins with the left ventricle To prevent development of pulmonary edema and Rt Side Heart Failure, which could happen if one starts w/right ventricle A plane is developed between parietal & visceral pericardium Caution must be taken to prevent calcified portions of the parietal pericardium from penetrating the heart’s chambers, esp the atria. The outer, thickened pericardium is removed as indicated Have cartilage scissors ready

Surgical Intervention: Procedure Steps Fibrous portions adhering to the atria and ventricles are carefully dissected w/dry dissectors and scissors Extreme caution used to prevent perforation of atria and right ventricle—small areas of adherent pericardium may be retained STSR is prepared with loaded 4-0 or 5-0 pledgeted Prolene sutures. Dissection is continued; large blood vessels are exposed and freed as needed; the Atria, Ventricles, and both Cavae are freed Drainage catheters are placed near the heart or through the pleural spaces STSR has chest tubes ready with closed drainage system Sternum is closed w/ stainless steel wire, and remainder of wound closed “usual manner”

Counts Initial: Sponges, Sharps, instruments First closing Final closing Sponges Sharps Instruments

Specimen & Care Identified as pericardium Handled: routine

Resources STST Ch 22 pp. 918, 919 Taber’s Cyclopedic Medical Dictionary Alexanders Ch 27, p. 1143, 1156-1157 Lemone and Burke pp. 895-897

The surgical incision most likely for open heart surgery is: Anterolateral thoracotomy Posterolateral thoracotomy Median sternotomy supraclavicular Ans C. It provides the most accessible route and patient positioning is simpler

Which medication is commonly given IV about 3-5 min prior to cross-clamping the artery during Arteriotomy? Epinephrine Protamine sulfate Papavarine Heparin Ans D Arteriotomy is opening into the vascular system—heparin is given to prevent blood clot formation which could later obstruct vessels

Polytetrafluoroethylene (PTFE or Gore-Tex) Polyporpylene (Prolene) All of the following are sutures used in CV surgery to suture vessels or vascular grafts except: Polytetrafluoroethylene (PTFE or Gore-Tex) Polyporpylene (Prolene) Polyester (Dacron) Surgical gut (chromic) Ans D Surgical gut is absorbable and not recommended for the suturing of vessels and vascular grafts. A nonabsorbable, swaged suture is used

Abdominal Aortic Aneurysmectomy with Graft Pneumonectomy Which of the following procedures would commonly require the use of extracorporeal circulation (heart-lung bypass)? Abdominal Aortic Aneurysmectomy with Graft Pneumonectomy Coronary Artery Bypass Graft Vena Cava Umbrella insertion Ans C.

Internal mammary artery The vessel used to increase the overall blood supply to the heart following CABG is the : Saphenous artery Brachial artery Carotid artery Internal mammary artery Ans D. The IMA can be dissected from the chest wall and attached to the coronary circulatory system, increasing the overall volume of blood delivered to supply the heart muscle.

Vena Cava Umbrella Filter Placement Arteriovenous Fistula Formation The creation of a commuication between an artery and a vein for hemodialysis access is called a(n) Bypass Graft Aneurysmectomy Vena Cava Umbrella Filter Placement Arteriovenous Fistula Formation Ans D

Which of the following bypass grafts would require preclotting? Knitted polyester (Dacron) Saphenous vein Human umbilical cord graft Polytetrafluoroethylene (PTFE) Ans A Dacron is porous and enhances in-growth of issue but could allow leakage of blood through its pores if the graft is not preclotted or pretreated

Ligation and stripping The procedure in which a Fogerty Catheter is used to remove blockage of a vessel is referred to as: Arteriovenous shunt Endarterectomy Embolectomy Ligation and stripping Ans C Embolectomy is the procedure in which a Fogerty catheter is used to remove blockage of a vessel.

In-situ saphenous vein graft Human umbilical cord graft PTFE graft The autogenous graft which is left in place after destruction of the internal valves and then sutured into the arterial system is: In-situ saphenous vein graft Human umbilical cord graft PTFE graft ligation and stripping of the saphenous vein Ans A

The artery that carries deoxygenated blood in the adult is the: Aorta Carotid artery Pulmonary artery Coronary artery Ans C

Common artery bypass procedures include all of the following except: axillo-popliteal Femoro-femorol Axillo-femoral Femoro-popliteal Ans A Is NOT commonly performed due to the significant distance the graft must travel throught the subcutaneous tunnel which could lead to clot formation in the graft and obstruction of blood flow

Bi-polar ESU with its patient return electrode applied to the patient Specific equipment used during surgery on a pt with a pacemaker in place should include: A magnet Mono-polar ESU with its patient return electrode applied to the patient Mono-polar ESU without its patient return electrode applied to the patient Bi-polar ESU with its patient return electrode applied to the patient Ans A the magnet is placed over the pacemaker generator andwill assist in blocking stray electricity from reaching the pacemaker generator, since electricity is able either to reprogram or significantly interterfere with the generator’s function. The use of mono-polar should be limited and should always be used with patient return electrode (grounding pad). The use of bipolar does not require use of a pt return electrode.

Suture material used to place vascular grafts would include: PDS Vicryl/Dexon Prolene Stainless steel Ans C. When vasc grafts are placed, they are sutured to the vessel with nonabsorbable suture material, preferably monofilament. Prolene or polypropylene is a synthetic monofilament, nonabsorbable suture material.

A Femoro-popliteal Bypass is scheduled A Femoro-popliteal Bypass is scheduled. Which self-retaining retractor would be used to facilitate exploration of the femoral artery? Harken Debakey Weitlaner Gelpi Ans C. Retracts soft tissues of the groin—(Gelpi is sharp and may cause damage)