The first barrier to overcome with cardiac manipulation is fear
of the unknown. Fear can be eliminated by trusting in the knowledge
and experience of other beating heart surgeons. New skills, techniques,
and tricks are required to manipulate a beating heart in order
to obtain good coronary artery exposure while maintaining stable
Manipulation of a beating heart requires patience and slow, gentle
maneuvers. Do not occlude coronary arteries until there is sufficient
exposure and stabilization of the target area. The comfort level
required to confidently perform the anastomosis, and indeed the
success of the procedure, are directly related to good exposure
The following procedures illustrate techniques for exposing
the vessels on the posterior wall of the heart. For clarity, assume
the use of a median sternotomy for access.
Vessel Exposure Using Deep Pericardial Retraction
Traction placed on deep pericardial retraction sutures (DPRSs)
is used to rotate and vertically displace the apex of the heart.
The importance of the DPRSs, used in combination with the Trendelenburg
position and table rotation, for cardiac manipulation and vessel
exposure cannot be overstated. However, traction placed on the
DPRSs and pressure placed on the ventricle by sponges or other
packing material can cause significant drops in blood pressure
if they are not instituted gradually. DPRSs are placed in the
following locations (Figure 2):
- The first DPRS is placed posterior to the phrenic nerve at
the level of the left superior pulmonary vein (LSPV).
- The second DPRS is placed posterior to the phrenic nerve,
about two-thirds of the distance toward the diaphragm.
- The third DPRS is placed in the posterior pericardium between
the IVC and the LSPV.
- Traction on the first and second DPRSs will allow rotation
of the heart and expose the LAD, diagonal, and high marginal
- Traction on the first and third DPRSs will vertically displace
the apex of the heart and expose the OMs, PLB, and PDA.
Suturing the diaphragmatic pericardial edge
to the skin will create additional room and exposure for easier
grafting of the posterior vessels.