Authors Abbas Ardehali MD Professor of Surgery and Medicine Division of Cardiothoracic Surgery William E. Connor Endowed Chair in Cardiothoracic Transplantation Director, UCLA Heart, Lung, and Heart-Lung Transplant Programs David Geffen School of Medicine at UCLA Los Angeles, California Jonathan M. Chen MD Professor of Surgery Sam and Althea Stroum Endowed Chair in Pediatric Cardiovascular Surgery Chief of Congenital Cardiac Surgery Seattle Children's Hospital University of Washington School of Medicine Seattle, Washington Illustrators Timothy C. Hengst, CMI, FAMI BodyScientific International, LLC Dedication To our families: Mitra, Leila, and Sara Ardehali and Abbie, Maddie, and Atlas Chen Foreword The concept of Cardiac Surgery: Safeguards and Pitfalls in Cardiac Surgery came to me over 35 years ago. I wanted to provide a tool to help surgical residents master the techniques of cardiac surgery while avoiding the pitfalls that often result in suboptimal or even fatal outcomes. After five years of preparation, the work was completed and published in late 1987. Many prominent cardiac surgeons from Europe and the United States reviewed each chapter and made useful suggestions, thus benefitting the work with their vast experiences. The book would not have been completed without the support and invaluable encouragement of the late Professor Gerry Brom of Leiden. The superb “telling” illustrations by Joanie Livermore and Timothy Hengst have been the hallmark of the work. The success of the book is reflected in the present (fifth) edition and the fact that it has been translated into Portuguese, Japanese, and Chinese. It has been gratifying to visit operating rooms in many countries and see a copy of the book or photocopies of its various chapters there. My partner and colleague of close to 30 years, Dr. Colleen Sintek, was my coauthor on the second, third, and fourth editions, and I am very much indebted to her and grateful for her support. My good fortune does not end here. For this fifth edition, I have been blessed to have Dr. Abbas Ardehali, professor of surgery, David Geffen School of Medicine at University of California, Los Angeles, an esteemed friend and colleague, accept the baton of responsibility to ensure the continued success of the book. Dr. Jonathan Chen, professor of surgery and chief of pediatric cardiovascular surgery at University of Washington, Seattle, has been gracious to edit and update the Congenital section. I am very impressed with their contributions and am grateful for their efforts in bringing the fifth edition of Cardiac Surgery: Safeguards and Pitfalls in Cardiac Surgery to fruition. Siavosh Khonsari, MB, FRCS, FACS, FACC Clinical Professor of Surgery University of California Los Angeles, California Preface Khonsari's Cardiac Surgery: Safeguards and Pitfalls in Operative Technique is a unique book in the field of cardiac surgery. It details the important technical aspects of cardiac surgery in a concise, readable, and illustrative format. It also highlights technical misadventures and offers preventive and corrective measures. It serves as a great resource for the novice and/or trainee as well as the seasoned surgeon. The popularity of this book since the first edition has been due to Dr. Khonsari's unmatched surgical intuition, wisdom, judgment, and attention to details, as is evident throughout this book. Illustrative and detailed figures have been and continue to be an important feature that emphasizes salient points. Dr. Sintek's collaboration on the previous two editions has only enhanced these qualities of this popular book. We, the present editors, have tried very hard to maintain the character of this book: emphasizing technical aspects of cardiac surgery, highlighting pitfalls, striving for brevity, and using clear illustrations to convey the message to the readers. Organizationally, the first two sections remain dedicated to adult cardiac surgery, while the third section covers pediatric cardiac surgery. All chapters have been updated, new illustrations have been added, and some of the illustrations have been colorized for greater clarity. Additionally, new topics have been added to reflect the advances in the field: endovascular procedures, transcatheter aortic valve replacement, new approaches to the Norwood reconstruction, repair of Ebstein anomaly, and alternative anatomic repairs of congenitally corrected transposition. The format of this book follows the previous editions: the technical pitfalls are denoted by a hazard sign . The mechanism of technical errors and the techniques to prevent and correct these errors are emphasized. Important points are highlighted by special Nota Bene notations. Khonsari's Cardiac Surgery: Safeguards and Pitfalls in Operative Technique has long been considered a great reference text in technical aspects of cardiac surgery. We have worked hard to maintain the core strengths of this book: a concise, illustrative, and focused description of techniques in cardiac surgery. We believe that with the many improvements implemented in this fifth edition, it will continue to be a valuable resource for cardiac surgery trainees and senior surgeons alike. Abbas Ardehali, MD Los Angeles, California June 2016 Jonathan Chen, MD Seattle, Washington June 2016 Acknowledgments First and foremost, Dr. Chen and I would like to thank Dr. Khonsari and Dr. Sintek for their many contributions to the field of cardiac surgery and the legacy they have left with this book. I am privileged to have been trained by them, and I remain grateful for the imparted wisdom, support, and importantly their friendship. I would also like to thank Dr. Peyman Benharash of the Division of Cardiac Surgery at UCLA for his contributions to endovascular procedure topics and many helpful suggestions in other chapters. Finally, we would like to thank the editorial staff at Wolters Kluwer, particularly Brendan Huffman and Keith Donnellan, for their assistance and dedication. We also would like to thank Lik Kwong and Carolina Hrejsa from BodyScientific for their tireless work to create and update the artwork in this new edition. We believe that the fifth edition carries on the tradition of its predecessors while delivering the most current and concise reference book on techniques and pitfalls in the field of cardiac surgery. Abbas Ardehali 1 Surgical Approaches to the Heart and Great Vessels PRIMARY MEDIAN STERNOTOMY Median sternotomy remains the most widely used incision in cardiac surgery because it provides excellent exposure for most surgeries involving the heart and great vessels. Technique The skin incision normally extends from just below the suprasternal notch to the tip of the xiphoid process. A saw with a vertical blade is most commonly used to divide the sternum. In young infants, the sternum is divided with heavy scissors. An oscillating saw is used for repeat sternotomies and some primary surgeries through limited skin incisions. Its use requires that the surgeon develop a “feel” for when the blade has penetrated the posterior table of the sternum (see Repeat Sternotomy section). Bleeding A small vein is usually evident running transversely in the suprasternal notch. At times, however, it may be large and engorged, particularly in patients with elevated right heart pressure. Excessive bleeding may occur if this vein is inadvertently injured. It is important to be aware of its presence and to coagulate it (if tiny) or to occlude it with a metal clip. If the vein has been cut and its ends have retracted, thereby making hemostasis difficult, control of bleeding can be gained by packing the suprasternal notch area and proceeding with the sternotomy. After the two sides of the sternum have been spread apart, the sites of bleeding can be easily identified and controlled. Sternal Infection Not only is dissection of the suprasternal notch unnecessary, but it can also open up tissue planes in the neck. Tracheostomy is now rarely necessary but always remains a possibility. Whenever tracheostomy is performed, a separate incision is kept as high in the neck as possible so that a superficial tracheostomy wound infection does not spread into the suprasternal notch and eventually into the mediastinum, leading to wound complications and mediastinitis. Entry into the Peritoneal Cavity During the division of the linea alba or the lower part of the pericardium, the peritoneal cavity may be entered. The opening should be closed immediately to prevent any spillage of blood or cold saline used for topical cooling into the peritoneal cavity, which may promote postoperative ileus. Asymmetric Division of the Sternum The sternotomy should be in the midline of the sternum. By dipping the thumb and index finger into the incision and spreading them against the lateral margins of the sternum into the intercostal spaces, the proper site for sternal splitting can be located and marked by an electrocautery on the periosteum. Unequal division may leave one side of the sternum too narrow and allow the closure wires to cut through the narrower segments of the bone, leading to an increased incidence of sternal dehiscence. Similarly, the costochondral junction may be damaged (Fig. 1.1). Pneumothorax and Hemothorax The anesthesiologist is always asked to deflate the lungs while the surgeon is using the sternal saw so that the pleural cavities can be kept intact. This is particularly important in patients with chronic obstructive pulmonary disease and hyperinflated lungs. Occasionally, however, the pleural cavities are opened by the sternal saw or during dissection of the thymus and pericardium. If the opening is small and no fluid has entered the pleural cavity, at the close of the procedure, the tip of the mediastinal chest tube may be introduced for 2 to 3 cm into the pleural defect. The pleura may be opened fully, particularly in patients undergoing harvesting of internal thoracic arteries. In these cases, a separate chest tube is inserted subcostally over the lateral aspect of the diaphragm for drainage of fluid and blood and evacuation of air. Use of Bone Wax Excessive use of bone wax to control bleeding from the sternal marrow should be avoided. It can be associated with increased rates of wound infection, impaired wound P.4 healing, and, most serious of all, wax embolization to the lungs. However, the use of small amounts of bone wax is an effective tool to control bleeding from sternal edges. We have found that vancomycin paste (mixing of vancomycin powder with 2.5 ml of saline) is an effective agent for sternal bone marrow oozing, with possible antimicrobial properties. FIG. 1.1 Fracture resulting from improper division of the sternum. Brachial Plexus Injury Brachial plexus injury has been associated with median sternotomy. Stretching of the plexus by hyperabduction of the arm and compression of the nerve trunks between the clavicle and first rib during sternal retraction has been implicated as a cause of injury. Introduction of a Swan-Ganz catheter through the internal jugular vein can injure the brachial plexus, either directly by the introducer itself or indirectly by the formation of a hematoma in the vicinity. The most serious cause of brachial plexus injury is fracture of the first rib (Fig. 1.2). The sternal retractor should be placed with its crossbar superiorly so that the blades spread apart the lower third of the sternal edges. It is then opened gradually in a stepwise manner (one to two turns at a time) to prevent fractures of the first rib or sternum (Fig. 1.3A). If for some reason the crossbar of the retractor is to be placed inferiorly, it is important for the blades to be in the lower part of the incision. Many surgeons use modified sternal retractors with two or three blades on either side, placing the crossbar inferiorly. These retractors are opened just enough to provide adequate exposure (Fig 1.3B). Retractors (e.g., Favaloro) used in harvesting the internal thoracic artery can also cause brachial plexus injury. Therefore, sudden excessive upward pull on the retractor should be avoided. The surgeon should ensure good exposure by manipulating the operating room table and his or her headlight to minimize traction of the upper sternum. Moreover, when the proximal internal thoracic artery is freed, the degree of upper sternal retraction is reduced. These simple measures can often eliminate or reduce the incidence of brachial plexus injury. Innominate Vein Injury The innominate vein may be injured during dissection and division or resection of the thymus or its remnant, particularly when scarring is present from a previous surgery. The scar tissue on each side of the injured vein is dissected free. Brisk bleeding can then be controlled by simple suturing. In rare instances of severe damage to the vein, it is divided and its right end is suture ligated. The other end of the vein is left open for drainage of venous return from left internal jugular tributaries until the patient is ready to come off cardiopulmonary bypass when it is similarly suture ligated. The innominate vein is a useful channel for an additional intravenous line, which can be used to monitor central venous pressure, particularly in infants and patients with poor peripheral veins. The catheter is introduced percutaneously into the center of a 7-0 Prolene purse-string suture buttressed with fine pericardial pledgets on the innominate vein. The purse-string suture must be tied snugly to prevent any bleeding after removal of the venous line. Sometimes, a large thymic vein can be used for the same purpose. REPEAT STERNOTOMY An increasing number of patients require surgical intervention a second, third, or even fourth and fifth time for replacement of prosthetic valves, definitive correction or revision of congenital heart defects, or repeat myocardial revascularization. Because it is anticipated that this trend will continue, all cardiac surgeons must acquire expertise in preoperative procedures. When making the skin incision, it is not always necessary to excise the previous scar unless it is gross and thick. The subcutaneous tissue is incised in the customary manner, and using electrocoagulation, the sternum is marked along the midline. Technique Previous wires or heavy nonabsorbable sutures are divided anteriorly but are not removed. They provide some resistance posteriorly to the oscillating saw, which helps P.5 to prevent any possible right ventricular injury (Fig. 1.4, inset). Only limited, sharp dissection adequate for the placement of a small Army-Navy retractor can be safely carried out in the suprasternal notch or around the xiphoid process. FIG. 1.2 Mechanism of a brachial plexus injury.