#10. OPEN HEART SURGICAL PROCEDURES

PREOPERATIVE DIAGNOSIS: Severe coronary artery disease.

POSTOPERATIVE DIAGNOSIS: Severe coronary artery disease.

TITLE OF OPERATION: Coronary artery bypass grafting surgery.

ANESTHESIA: General.

DESCRIPTION OF OPERATIVE PROCEDURE: Under general anesthesia, the patient was prepped and draped in the usual sterile fashion. A midline sternotomy incision was made through the skin, the fascia was divided, and the sternum was divided with the use of the sternal saw.
The left internal mammary artery was harvested simultaneously with the video endoscopic harvesting of the right greater saphenous vein. Clips were placed on the branches.
The pericardium was opened. The patient was heparinized. Pericardial stays were used for retraction. The aortic pursestring was inserted. The atrial pursestring was inserted. The aortic line was inserted. The atrial line was inserted. The patient was placed on cardiopulmonary bypass. Cardioplegia was administered in an antegrade fashion via the aortic root. Crossclamp was applied. A good diastolic arrest was achieved and the clamp was placed on the surface of the right ventricle.
Attention was turned to the distal right coronary artery and origin of the acute marginal branch of the right coronary artery. An arteriotomy incision was made in the acute marginal branch. The saphenous vein was anastomosed to this in a running fashion using 7-0 Prolene. Attention was turned to the obtuse marginal of the circumflex artery. An arteriotomy incision was made and saphenous vein was anastomosed to this in a running fashion using 7-0 Prolene. Cardioplegia was administered at the end of each distal graft down through the graft and down through the aortic root to 250 cc. Attention was then turned to the left anterior descending artery. The left anterior descending artery was buried in the fat. The left internal mammary artery was anastomosed to the left anterior descending artery in a running fashion using 7-0 Prolene. A good flush was noted.
The flow was turned down. The crossclamp was removed. The side biter was applied to the aorta and the two proximals were anastomosed to the aorta, one from the obtuse marginal and one from the acute marginal. Prolene 6-0 was used to perform these anastomoses. Marking rings were placed on each of these. The flow was turned down. The side biter was removed. All grafts were deaired.
Flow was resumed to all grafts. The heart began in a normal spontaneous rhythm. The left chest was aspirated. The lungs were inflated. The patient was weaned from cardiopulmonary without difficulty. Pacing wires were placed on the right ventricle and brought out on the left lateral aspect of the incision. All lines were removed. Protamine was administered. Hemostasis was secured from all sites, including the skin fat, the mammary bed, and all cannulations, all proximal and distal anastomotic sites.
The incision was then closed in layers with #5 stainless steel wires used to approximate the sternum, 0-Vicryl suture used to approximate the muscle, 2-0 Vicryl to approximate the subcutaneous tissue, and 4-0 Vicryl subcuticular closure used to approximate the skin.
The patient tolerated the procedure well and returned to the recovery room in stable condition. All lap, instrument, and needle counts were correct