A finger placed against the vertebral bodies as temporary occlusion
The sac is captured with a Kelly forceps and the incision is made with a scissor, avoiding the phrenic nerve
It is wiser not to suture the myocardium; instead, put a finger on the wound to prevent blood loss and wait a few minutes until the cardiac rhythm becomes normal
Myocardial Suture
When blood is expelled in every contraction, once the pericardium is opened, a finger must occlude the hole. At this moment it is not important to occlude it completely. A small leak is expected and gentle pressure on the heart will prevent arrythmias or cardiac failure.
Most of the patients are young. and interrupted simple sutures without pledges are well tolerated. Patients older than 50 and/or with previous hypertension have friable myocardium. Hence Teflon or pericardium felt pads are used (Fig. 3.4). In those particular patients, all caution should be taken to avoid myocardium tearing by following the heart movements.
It is important for the surgeon to take a minute to calm down to prevent tremor in the hands. Once the gross blood loss is controlled, there is no hurry. Tachycardia implies the risk of a tear on the heart. More importantly, cardiac frequency slows down, which makes the suturing process easier.
In preparing the suture, note that no more than 2 or 3 stitches are usually necessary. The suture most commonly used is polypropylene. It is better to use two needle-holders, one for the surgeon and the other for the assistant (Fig. 3.5). The surgeon crosses the heart with the needle and the assistant receives it, avoiding a tear, by following the heart movements and the needle curve. A few milliliters of saline on the hands helps with making the knots.
The entire wall is sutured in right ventricular wounds, and in the left part of it. Atrial wounds are clamped with a Satinsky forceps and stitched with a running suture. In the atrium it is better to perform the suture over a Satinsky clamp, because the wall is thin and fragile (Fig. 3.6).
Wounds closer to the coronary artery are sutured running beneath the vessel in order to avoid its closure (Fig. 3.7). Wounds of the coronary vessel can result in significant ischemia, arrhythmias, and death. Most of them, however, produce minimal effects in spite of the elevated ST segment. Accordingly, if the proximal coronary artery is wounded, repair is intended with 6-0 or 7-0 TiCron or polypropylene separated suture. If it is technically impossible and a local cardiovascular team are not available, then the artery is ligated under EKG monitoring. A 10-minute surveillance is recommended for arrhythmias or hemodynamic decompensation. If this is not tolerated, then the suture is removed, and gentle digital compression is made until the bypass is initiated.
