Myocardial

Revascularization

Anguie Tatiana Herrera Hernandez 01200021060

 ANATOMY
The coronary arteries arise from the root of the ascending aorta. The main divisions of the coronary arteries
usually travel just below the epicardium of the heart. However, its branches can embed deep into the
myocardium as they pass through the cardiac sulci.
Upon entering the coronary sulcus, in the upper portion of the anterior interventricular sulcus, the ICA divides to
give rise to the anterior interventricular artery (still known to clinicians as the left anterior descending artery) and
the left circumflex artery.
Near its origin, the right coronary artery (RCA) gives rise to the branch of the sinoatrial node, which, as its name
implies, supplies the sinoatrial node. On its way down
the coronary sulcus, it gives rise to the right marginal
branch, this is a large-calibre vessel that travels through the
right edge of the heart towards the cardiac apex, without
reaching it. It then turns to the left toward the posterior aspect
of the cross of the heart, where it gives origin to the branch for
the atrioventricular node.
 GRAFTS ANATOMY
Saphenous Vein Mammary Artery
 Clinical Case

Juan, a 58-year-old man, presents to the doctor with complaints

of chest pain that he has been experiencing for several months.
The pain is oppressive, radiating to the left arm, and is
accompanied by sweating and shortness of breath during the
episodes. In addition, you have noticed that these symptoms are
triggered by physical exertion and sometimes also during rest.
Juan has a history of high blood pressure and type 2 diabetes,
and smokes approximately 10 cigarettes a day. The doctor
suspects coronary disease and decides to perform a series of
tests to confirm the diagnosis and plan the necessary
intervention.
 Diagnostic Methods
Stress Test: A treadmill or stationary bike stress test is performed
to assess the heart's response to exercise. During exercise, John
experiences chest pain, ECG changes, and a drop in blood
pressure. These findings indicate an abnormal response to
exertion and suggest significant coronary artery disease.

Electrocardiogram (ECG): An ECG is performed that shows

changes suggestive of myocardial ischemia, such as ST-
segment elevation in specific leads. This supports the
suspicion of acute or previous coronary disease.

Echocardiography: An echocardiography is performed to assess

heart function, the anatomy of the heart chambers, and the mobility
of the heart walls. It can reveal areas of the myocardium that are not
contracting properly due to lack of blood flow, indicating possible
areas of ischemia.
 Diagnostic Methods

Coronary Angiography (Cardiac Catheterization):

Given the high suspicion of coronary disease, a
coronary angiography is performed. During the
procedure, a catheter is inserted through an artery
in the groin or wrist and advanced to the coronary
arteries. Angiography shows significant narrowing
in one of the heart's main arteries, which supplies
blood to the affected area.
CHECK LIST
 SURGICAL TEAM POSITION PATIENT POSITION

Anesthesiologist

Perfusionist
Nurse
Surgeon

Assistant
Surgical
Instrumentation

Supine Position
MAY TABLE ARRANGEMENT
RESERVATION TABLE ARRANGEMENT
 TÉCNICA QUIRÚRGICA
-May table arrangement and reservation
-Patient's dress
-Count of compresses and gauze
-Fixing pipes and lines with straight kellys
-Dress of the surgeon and assistant
THE EXTRACTION OF THE SAPHENAL VEIN GRAFT IS PERFORMED.
STERNAL OPENING TIME:
-To make an incision, go to the surgeon MB# 7 and HB# 15
-Pass to surgeon dissection and electrocautery for deep tissue incision.
-Pass wire cutters and needle holders to remove the surgical steel for reoperation
-For sternotomy pass to surgeon oscillating saw equipment
-For manual separation of the sternum, go to the Farabeuf separator surgeon.
-Pass bone wax, electrocautery in 60 for hemostasis of the sternal periosteum and bone marrow.
-Pass to the surgeon the sternal protectors and the self-retaining retractor for the fixed retraction of the sternum.
-Pass to the surgeon vascular type dissection and electrocautery device in 40 for the opening of the pericardium.
-Pass needle holder with 0 silk suture to repair the pericardium.
 TÉCNICA QUIRÚRGICA

DISSECTION OF THE MAMMARY ARTERY:

-Pass to the surgeon microvascular dissection

and electrocautery in 20 for dissection of the
mammary artery.
-For ligation and hemostasis of this, use Ligaclip
forceps and the corresponding clip cartridge
according to the caliber of the vessel and
Metzembaum scissors.
-Prepare moist gauze with nitroglycerin-
impregnated solution for arterial vasodilation of
the mammary artery.
VASCULAR TIME:

-Pass vascular dissection, T. Mayo and 2/0 polyester and 4/0 polypropylene
suture for the surgeon to make the tobacco pouches in:
o Ascending Aorta
o right atrium
o root of the aorta
-Prepare pass threads (tourniquet) and Kelly to refer the tobacco bags made
by the surgeon.
-Prepare the appropriate cannula for the patient's infusion as appropriate.
-Go to the surgeon HS# 7 SB# 11 to perform the arteriotomy to perform the corresponding cannulation.
-Prepare pre-cut silk 1 for fixing the placed cannulas by passing them through the surgeon's hand.
-Prepare tube clamp and gauze for purging the arterial cannula.
-Pass to surgeon HS#7 SB#11 to make the incision in the right atrium.
-Pass the long Metzembaum scissors to the surgeon to widen the incision and perform the corresponding cannulation.
-Prepare pre-cut silk 1 for fixing the placed cannulas by passing them through the surgeon's hand.
-Prepare suitable connectors for the connection of the cannula to the extracorporeal circuit.
-Go to surgeon HS#7 SB#11 to make the incision in the right upper pulmonary vein.
-Go to the surgeon P. Kelly Adson to widen the incision and perform the corresponding cannulation.
-Prepare total occlusion vascular clamp for the surgeon to perform aortic clamping.
CORRECTION TIME:

-Give the surgeon compresses and gauze in order to position the heart and
achieve exposure of the arteries to be revascularized.
-Transfer to the microvascular dissection surgeon to perform the coronary
arteriotomy and its prolongation.
-Prepare the 7/0 gauge polypropylene synthesis and suture instruments for the
surgeon to perform the distal anastomoses of the vein graft to the coronary
artery.
-For better exposure of the surgical field at the anastomosis site, prepare CO2
aeration with aspiration line and cannula.
-For the test of the effectiveness of the coronary vessel prepare syringe with
saline solution.
-Prepare instruments for diaeresis, elastic vascular grasping, and bulldog clamp,
for cutting the free saphenous graft and preparing the vessel for proximal
anastomosis.
-For proximal anastomoses, prepare umlaut instruments mb#7 hb#11 and
punch to prepare the aorta at the anastomosis site of the new coronary vessel.
-Prepare the 6/0 gauge polypropylene synthesis and suture instruments for the
surgeon to perform the proximal anastomoses of the graft to the aorta.
CLOSING TIME:

-Prepare warm saline solution, to speed up patient warming.

-Prepare for aortic unclamping and removal of the patient from extracorporeal circulation.
-Pass Mayo scissors, vascular dissection and assist the surgeon at the time of removal
of the cardiovascular cannulas, anticipating partial occlusion clamp and reinforcing
sutures with and without supportfrom pledget.
-Pass pacemaker wire so that the surgeon can position them as
he sees fit in the atrium and ventricle.
-Pass HS#3 SB#15, vascular dissection, suture and Long Metzenbaum Scissors and chest tubes
so that the surgeon can position them as he sees fit in the pleurae and mediastinum respectively.
-Nelaton 14 probe is inserted for chest tube aspiration
-Assist the surgeon in general hemostasis with electrocautery of the surgical area, providing suture material, gauze,
compresses and hemostasis elements.
-Verification of counts
-Prepare number 6 surgical wire, Rochester, needle holder, and wire cutters for the surgeon to face the sternum.
-Prepare 2/0 or 3/0 polypropylene to face the muscles and subcutaneous tissue with needle holder, claw
dissection, and Mayo scissors.
-Prepare poliglecaprone to face the skin with needle puller, adson dissection with claw and mayo scissors.
-Make the patient heal by cleaning and covering the wound with dressings and/or adhesive tapes.
 BIBLIOGRAPHY
https://cardiovascularpractice2023.weebly.com/