Paul's Heart

Friday, April 18, 2008 – Saving A Life

*** please note – the following is the actual transcript of my emergency life saving double bypass surgery.  While fascinating, for some who have gone through this procedure, or know someone who has, this may be too intense of a post.  Please do not read this if this is the case.

My purpose for this, today is the 5th anniversary of my double bypass.  I read the transcript five years ago.  It is fascinating and amazing the efforts that went into saving my life.

Patient was brought to the operating room and identified as Mr. Edelman.  After routine lines were places and hemodynamic monitoring, general anesthesia was achieved via endotracheal tube, prophylactic antibiotics were administered, and the patient was prepped and draped in routine fashion for open heart surgery.

A median sternotomy incision was made.  With the sternum divided the left internal mammary artery was able to be harvested on a pedicle from the sixth intercostal space up to its origin above the first rib.  Topical Papaverine was placed at the mammary artery pedicle.  Standard self-retaining retractor was placed.  The anterior pericardium was opened and reflected anteriorly.  Simultaneous to this portion of the procedure a segment of saphenous vein was harvested from the left lower extremity in its mid portion and evaluated for use as a bypass conduit.  It was adequate at 4mm internal diameter.

Epiaortic ultrasound of the ascending aorta was normal.  Heparin was given to create systemic anticoagulation with an activated clotting time greater than 450 second.  This was achieved.  We harvested the distal portion of the mammary artery with excellent flow.  I made a slit in the pericardium anterior to the phrenic nerve on the left side of the pericardium, and measured the mammary artery for proper length and rotation for bypass to the proximal LAD.  We still had ample length almost 2cm beyond this area of the mammary artery and on measuring the distance from the obtuse marginal to the pericardial slit there was ample room to use the mammary artery in a Y graft fashion to the obtuse marginal.

In an effort to give arterial graft to this young gentleman we then sewed the mammary artery in a Y graft fashion dividing the mammary artery at the junction between the mid and distal third of the mammary artery where it would be placed to the LAD without tension and sewing that in end-to-side to the mammary artery where it comes through the slit in the pericardium anterior to the phrenic nerve on the left side.  This was done with running 8-0 Prolene suture.  We completed the anastomosis and removed the atraumatic vascular clamp from the Y graft with excellent flow down both grafts with the Y anastomosis hemostatic.

It was treated with topical Papaverine.  Standard cannulation took place with an arterial inflow cannula in the ascending aorta, atriocaval cannula in the right atrium, a cardioplegia delivery cannula in the ascending aorta, retrograde cardioplegia cannula in the right atrium of the coronary sinus.  The patient was placed on bypass, cooled, and emptied.  With the heart emptied, a crossclamp was placed and 1 liter of antegrade cardioplegia solution was given through the catheter in the ascending aorta.  The heart became asystolic.

We then switched the patient over to retrograde cardioplegia delivery through the coronary sinus catheter utilizing the catheter in the ascending aorto to vent the left ventricle.  With no cardioplegia running and the heart well vented and decompressed we placed on branch of the mammary artery end-to-side to the obtuse marginal with running 8-0 Prolene suture.  We completed the anastomosis, initiated retrograde cardioplegia delivery, and removed atraumatic vascular clamp from the mammary artery pedicle finding the anastmosis to be hemostatic.

We placed back the atraumatic vascular clamp on the mammary artery pedicle, opened the LAD in its proximal segment, and placed the mammary artery end-to-side to this vessel running 8-0 Prolene suture.  Completing the anastomosis, we tacked down the mammary artery pedicle to the epicardium with two 6-0 Prolene suture to the circumflex system on its inferior side.

Hot shot of warm oxygenated blood cardioplegia solution was given.  We completed the two anastmoses.

With this done, the patient was placed in the Trendelenburg position.  A Valsalva maneuver was performed.  The heart was allowed to fill and the aortic crossclamp was cracked and released, de-airing the patient’s heart through the cardioplegia delivery site in the ascending aorta, keeping it under gentle suction.  The heart fibrulated at this time and was cardioverted to an idioventricular rhythm.  We placed left and 2 mediastinal chest tubes as well as two atrial and two ventricular pacing wires, slowly weaning the patient from bypass without complications in sinus rhythm on no inotropic support.  Off bypass, we found excellent indices with an EKG which showed no evidence of ischemia.  After all pump blood was reinfused, we decannulated the patient in routine fashion., oversewed all cannulation sites, and gave Protamine for systemic anticoagulation.  I inspected the Y graft.  The anastomoses were found to be hemostatic and cannulation sites finding them to be hemostatic.  I closed the pericardium loosely to mediastinal tissues, rewired the sternum, and closed the wound in routine fashion after all layers were irrigated with antibiotic solution.  The lower extremity for harvest of the saphenous vein graft conduit for bypass with endoscopic technique was closed in routine fashion.  The patient tolerated the procedure well and brought to the Open Heart Unit in stable condition in sinus rhythm on no inotropic support.  No blood was given during the operative procedure.

Thank you Dr. Phillips and everyone who saved my life 5 years ago.