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 hemodynamics.

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 and stabilization.

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 Sutures

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 arteries.
  • 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.

Figure 2. Posterior pericardium with heart removed: Placement of DPRSs
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