OM - PDA Exposure Techniques by
Ted Spooner, M.D.
A pericardial-based retraction system effectively supports the
heart while allowing access to coronary arteries on the inferior
and lateral walls of the heart (Figure 5). A mechanical stabilizer
can then be used to immobilize the target area.
The retraction system is composed of stockinet material (2cm
x 30cm) and a 36-inch braided suture. To
set up the retraction system:
1. Expose the posterior pericardium by manually retracting the
heart to the patient's right.
2. Pass the suture through the pericardium at a point just behind
the coronary sinus and directly beneath the origin of the most
distal coronary artery (usually halfway between the left inferior
pulmonary vein and the IVC).
3. Pass the suture through the midpoint of the stockinet.
4. Have an assistant gently retract the inferior portion of the
5. Draw the stockinet into the pericardium and tie the suture.
The middle of the stockinet is now attached to the posterior
pericardium, and the two free ends of the stockinet are lying
outside the chest. As traction is applied to the two free ends,
the point of fixation moves in an anterior (not lateral) direction.
The following techniques provide good vessel access:
- Inferior surface of the heart (PDA and RCA)-Spread
the free ends of the stockinet to the right and left sides of
the incision. Pull the ends in a cranial direction.
- Circumflex marginal arteries-Move the free ends of
the stockinet to the left lateral side of the heart. Pull the
ends toward the patient's right shoulder (the marginal artery
should be oriented between each end of the stockinet). Attach
the free ends to the drapes with a clamp.
To enhance exposure, rotate the table to the right and use the