Tips And Techniques ForTips And Techniques For

Multivessel OPCABMultivessel OPCAB

John D. Puskas, MD, John D. Puskas, MD, John D. Puskas, MD, John D. Puskas, MD,

Emory University, AtlantaEmory University, Atlanta

AATS Adult Cardiac SkillsAATS Adult Cardiac Skills

April 28, 2012April 28, 2012

San Francisco, CASan Francisco, CA

““““““““Beating HeartBeating Heart”””””””” SurgerySurgery

vsvs

““““““““Beat The HeartBeat The Heart”””””””” SurgerySurgery

OPCAB TechniqueOPCAB Technique�� sternotomy, limited skin incision and retractionsternotomy, limited skin incision and retraction

�� LIMA (RIMA) harvest under direct visionLIMA (RIMA) harvest under direct vision

�� wide pericardiotomy, traction sutures; open pleuraewide pericardiotomy, traction sutures; open pleurae

�� epiaortic U/S in every patient (60epiaortic U/S in every patient (60--90 seconds) 90 seconds)

cardiac displacement: Starfish/Urchin + deep traction suturecardiac displacement: Starfish/Urchin + deep traction suture�� cardiac displacement: Starfish/Urchin + deep traction suturecardiac displacement: Starfish/Urchin + deep traction suture

�� mechanical coronary stabilization: Octopus IV/ Acrobatmechanical coronary stabilization: Octopus IV/ Acrobat

�� proximal occlusion of target vessels with silasticproximal occlusion of target vessels with silastic

�� distal distal ““““““““nono--touchtouch””””””””; blower; 8; blower; 8--0 suture; 3.5x loupes0 suture; 3.5x loupes

�� SVG or RA proximals from ascending aorta or IMASVG or RA proximals from ascending aorta or IMA

�� Doppler assessment of graftsDoppler assessment of grafts

Techniques For Multivessel OPCAB In 2001Techniques For Multivessel OPCAB In 2001

““““Heart may be rotated but not compressed””””

�� Divide diaphragmatic muscle which inserts on right Divide diaphragmatic muscle which inserts on right

xiphoid to elevate right sternal borderxiphoid to elevate right sternal border

�� Open both pleural spaces widely; pacingOpen both pleural spaces widely; pacing

�� Bilateral, transverse, diaphragmatic Bilateral, transverse, diaphragmatic pericardiotomiespericardiotomies

towards phrenic nervestowards phrenic nervestowards phrenic nervestowards phrenic nerves

�� Deep pericardial traction suture(s); slingDeep pericardial traction suture(s); sling

�� PLOM, MOM, ALOM, Ramus: let base of heart PLOM, MOM, ALOM, Ramus: let base of heart

descend; rotate apex under right sternal borderdescend; rotate apex under right sternal border

�� PDA, PLV, PLOM: elevate base of heart; apex toward PDA, PLV, PLOM: elevate base of heart; apex toward

the ceiling; traction suture above IVCthe ceiling; traction suture above IVC

�� Third generation stabilizer: Octopus IIIThird generation stabilizer: Octopus III

Multivessel OPCAB Since 2003Multivessel OPCAB Since 2003

““““Heart may be rotated but not compressed””””

�� Divide diaphragmatic muscle which inserts on right Divide diaphragmatic muscle which inserts on right

xiphoid to elevate right sternal borderxiphoid to elevate right sternal border

�� Open right pleural space only for large hearts, low EF, Open right pleural space only for large hearts, low EF,

multiple lateral wall grafts multiple lateral wall grafts

Deep pericardial traction sutureDeep pericardial traction suture�� Deep pericardial traction sutureDeep pericardial traction suture

�� Use Starfish/Urchin for atraumatic cardiac Use Starfish/Urchin for atraumatic cardiac

displacementdisplacement

�� on apex for PDA, LAD, Diagonalon apex for PDA, LAD, Diagonal

�� on lateral wall for RI, ALOM, MOM, PLOMon lateral wall for RI, ALOM, MOM, PLOM

�� on acute margin for RCAon acute margin for RCA

�� Latest generation coronary stabilizerLatest generation coronary stabilizer

Manipulate the Heart:Manipulate the Heart:

SlowlySlowly

GentlyGentlyGentlyGently

IncrementallyIncrementally

PersistentlyPersistently

Manipulate the Heart With:Manipulate the Heart With:

““““““““ApicalApical”””””””” Suction DevicesSuction Devices

Traction SuturesTraction Sutures

Table Rotation/TiltTable Rotation/TiltTable Rotation/TiltTable Rotation/Tilt

GravityGravity

Not your hands!Not your hands!

Pericardial Suture(s)

OPCABOPCAB

Left Circumflex GraftsLeft Circumflex Grafts�� deep traction suture(s) and suction positioner in combinationdeep traction suture(s) and suction positioner in combination

�� bilateral transverse diaphragmatic pericardiotomybilateral transverse diaphragmatic pericardiotomy

�� rotate heart to right; avoid compression against sternal borderrotate heart to right; avoid compression against sternal border

�� excise right pericardial fat padexcise right pericardial fat pad�� excise right pericardial fat padexcise right pericardial fat pad

�� atrial pacing for large heartsatrial pacing for large hearts

�� open right pleural cavity for large hearts, low EF, multiple OMsopen right pleural cavity for large hearts, low EF, multiple OMs

�� latest generation stabilizers latest generation stabilizers

�� learning curve, patience and judicious persistencelearning curve, patience and judicious persistence

Using The Cardiac PositionerUsing The Cardiac Positioner

�� The Starfish (or Urchin) can be used on ANY surface The Starfish (or Urchin) can be used on ANY surface

of the heart and is most helpful when moved around of the heart and is most helpful when moved around

for different grafts:for different grafts:

�� On apex for LAD, Diagonal, PDAOn apex for LAD, Diagonal, PDA

�� On lateral wall for Ramus and Obtuse MarginalsOn lateral wall for Ramus and Obtuse Marginals�� On lateral wall for Ramus and Obtuse MarginalsOn lateral wall for Ramus and Obtuse Marginals

�� On acute margin for RCA, some PDAsOn acute margin for RCA, some PDAs

�� Place it near the target artery, but not too nearPlace it near the target artery, but not too near

�� Use minimum suction necessaryUse minimum suction necessary

�� Avoid cracks in epicardial fat that break suctionAvoid cracks in epicardial fat that break suction

Using the Coronary StabilizerUsing the Coronary Stabilizer

�� The Coronary Stabilizer may be used to both present and The Coronary Stabilizer may be used to both present and

to stabilize coronary artery targets, but it works best to to stabilize coronary artery targets, but it works best to

stabilize.stabilize.

�� The Octopus or Acrobat is a suction device, not a The Octopus or Acrobat is a suction device, not a

compression device. compression device. Apply it at the mechanical median Apply it at the mechanical median compression device. compression device. Apply it at the mechanical median Apply it at the mechanical median

of the cardiac cycle.of the cardiac cycle.

�� If hemodynamics are compromised, try easing off the If hemodynamics are compromised, try easing off the

degree of compression (do not turn off suction).degree of compression (do not turn off suction).

�� Take advantage of the malleable pods.Take advantage of the malleable pods.

Using the Coronary StabilizerUsing the Coronary Stabilizer

�� The malleable pods may be:The malleable pods may be:

��bent up or down or bent into a curvebent up or down or bent into a curve

��bent together or apartbent together or apart

��rotatedrotated��rotatedrotated

��bent independent of each otherbent independent of each other

�� Especially useful for irregular epicardial fat to Especially useful for irregular epicardial fat to

optimize optimize ““““““““tissue capturetissue capture”””””””” and stabilization.and stabilization.

�� Useful for curved areas of the heart, grafting vessels Useful for curved areas of the heart, grafting vessels

close to each other.close to each other.

�� Pods together for max stabilization.Pods together for max stabilization.

Using the MisterUsing the Mister--BlowerBlower

�� Use warm, humidified, pHUse warm, humidified, pH--balanced fluid.balanced fluid.

�� Minimize force of COMinimize force of CO2 2 at all times.at all times.

Blow on target ONLY when driving the needle. Blow on target ONLY when driving the needle. �� Blow on target ONLY when driving the needle. Blow on target ONLY when driving the needle.

Otherwise, direct jet outside field.Otherwise, direct jet outside field.

�� Beware of endothelial injury or vessel wall dissection Beware of endothelial injury or vessel wall dissection

which are possible with excessive use of the blower.which are possible with excessive use of the blower.

OPCAB Suture TechniqueOPCAB Suture Technique

�� Proximal occlusion with silastic vessel loopProximal occlusion with silastic vessel loop

�� Direct silastic loop with pericardial sutureDirect silastic loop with pericardial suture

�� ““““““““No touchNo touch”””””””” distally distally

�� Shunts used sparingly: Shunts used sparingly:

�� large RCAs (alternative to pacing)large RCAs (alternative to pacing)

�� intramyocardial vesselsintramyocardial vessels�� intramyocardial vesselsintramyocardial vessels

�� critical anatomycritical anatomy

�� Good visualization is Good visualization is sine quo non sine quo non of precise anastomoses; of precise anastomoses;

humidified CO2 mister/blower humidified CO2 mister/blower

�� ““““““““SecondSecond”””””””” assistant is your best friendassistant is your best friend

�� Head light, 3.5x loupes, Castros, 8Head light, 3.5x loupes, Castros, 8--0 suture0 suture

�� See intima on both sides, every stitchSee intima on both sides, every stitch

OPCAB Techniques:OPCAB Techniques:

Intramyocardial VesselsIntramyocardial Vessels

�� Use Use ““““““““usualusual”””””””” tricks to find vessel:tricks to find vessel:

�� refer to angiorefer to angio

�� dissect back from visible branchdissect back from visible branch

�� ““““““““seesee”””””””” or feel the vesselor feel the vessel

�� use topographic clues, crevices/creases in epicardial fatuse topographic clues, crevices/creases in epicardial fat�� use topographic clues, crevices/creases in epicardial fatuse topographic clues, crevices/creases in epicardial fat

�� Optimize use of malleable pods of stabilizer. Optimize use of malleable pods of stabilizer.

�� Achieve tissue capture, then (progressively) spread Achieve tissue capture, then (progressively) spread

pods apart to expose IM vessel(s).pods apart to expose IM vessel(s).

�� Blower is key to visualization.Blower is key to visualization.

�� May use shunt rather than snare.May use shunt rather than snare.

““““““““RulesRules”””””””” For Graft Sequencing For Graft Sequencing

In Multivessel OPCAB (1)In Multivessel OPCAB (1)

�� Graft the collateralized vessel(s) first, then reperfuse Graft the collateralized vessel(s) first, then reperfuse

the collateralized vessel(s)the collateralized vessel(s)

�� Finally, graft the collateralizing vessels last.Finally, graft the collateralizing vessels last.

�� Be flexible with timing of IMABe flexible with timing of IMA--LAD anastomosis:LAD anastomosis:

��First:First:��First:First:

�� LAD is collateralizedLAD is collateralized

�� tight LMtight LM

��Last:Last:

�� LAD is least diseased (collateralizing) LAD is least diseased (collateralizing)

�� Routine case, completely stableRoutine case, completely stable

““““““““RulesRules”””””””” For Graft Sequencing For Graft Sequencing

In Multivessel OPCAB (2)In Multivessel OPCAB (2)

�� Be flexible with timing of proximals:Be flexible with timing of proximals:

��first, for critical ischemia, early reperfusion is desiredfirst, for critical ischemia, early reperfusion is desired

��early, after distals of critical collateralized targetsearly, after distals of critical collateralized targets

allows perfusion during occlusion of the allows perfusion during occlusion of the �� allows perfusion during occlusion of the allows perfusion during occlusion of the

collateralizing vessel and minimizes overall collateralizing vessel and minimizes overall

ischemiaischemia

��early, before in situ RIMA distalearly, before in situ RIMA distal

��last, after LAD distal, in routine cases last, after LAD distal, in routine cases

�� facilitates estimation of graft lengthfacilitates estimation of graft length

““““““““RulesRules”””””””” For Graft Sequencing For Graft Sequencing

In Multivessel OPCAB (3)In Multivessel OPCAB (3)

�� Beware occlusion of the large RCA, especially if it is not Beware occlusion of the large RCA, especially if it is not

very tightly stenosed: BRADYCARDIAvery tightly stenosed: BRADYCARDIA

��Epicardial pacingEpicardial pacing

��Intracoronary shuntIntracoronary shunt

��reperfuse other collateralizing vessels firstreperfuse other collateralizing vessels first

�� Beware mitral regurgitation in OPCABBeware mitral regurgitation in OPCAB

��cardiac displacement + MR = HD instabilitycardiac displacement + MR = HD instability

��Ischemic MR: graft culprit vessel to papillary muscle Ischemic MR: graft culprit vessel to papillary muscle

early early

““““““““RulesRules”””””””” For Graft Sequencing For Graft Sequencing

In Multivessel OPCAB (4)In Multivessel OPCAB (4)

�� Graft sequence in OPCAB should be INDIVIDUALIZED Graft sequence in OPCAB should be INDIVIDUALIZED

FOR EACH PATIENT:FOR EACH PATIENT:

��Coronary anatomy, pattern of stenosesCoronary anatomy, pattern of stenoses

��Patterns of collateralizationPatterns of collateralization��Patterns of collateralizationPatterns of collateralization

��Myocardial contractilityMyocardial contractility

��Ascending aortic atherosclerosisAscending aortic atherosclerosis

��Conduit availabilityConduit availability

��Graft geometryGraft geometry

OPCABOPCAB

Heparin ProtocolHeparin Protocol

�� Half dose (1.5 mg/kg) Heparin IV given 3 min before Half dose (1.5 mg/kg) Heparin IV given 3 min before

IMA is divided from chest wallIMA is divided from chest wall

�� Supplemented with 3000 units every 30 minutesSupplemented with 3000 units every 30 minutes

�� ACT monitored, kept > 300 secACT monitored, kept > 300 sec

�� Half dose (typically 0.75 Half dose (typically 0.75 --1.0 mg/kg) Protamine after 1.0 mg/kg) Protamine after

last anastomosis; ACT 130last anastomosis; ACT 130--150 150

OPCAB Platelet InhibitionOPCAB Platelet Inhibition

�� Aspirin not stopped preopAspirin not stopped preop

�� Aspirin 325 mg po night before OPCABAspirin 325 mg po night before OPCAB

�� Aspirin 325 mg per rectum as foley catheter is insertedAspirin 325 mg per rectum as foley catheter is inserted�� Aspirin 325 mg per rectum as foley catheter is insertedAspirin 325 mg per rectum as foley catheter is inserted

�� Plavix routinely given postoperatively (since 2003 at Plavix routinely given postoperatively (since 2003 at

Emory) , starting with 150 mg Emory) , starting with 150 mg ““““““““loadload”””””””” 44--12 hours postop 12 hours postop

and then 75 mg qd for 6and then 75 mg qd for 6--12 months12 months

�� Aspirin 162 mg qd beginning 4Aspirin 162 mg qd beginning 4--12 hr postop; life12 hr postop; life