Procedures

Intermediate Format:

Pericardiectomy/Pericardial Window

Objectives• Assess the related terminology and

pathophysiology of the heart.

• Analyze the diagnostic interventions for a patient undergoing a pericardiectomy.

• Plan the intraoperative course for a patient undergoing_____________.

• Assemble supplies, equipment, and instrumentation needed for the procedure.

Objectives

• Choose the appropriate patient position

• Identify the incision used for the procedure

• Analyze the procedural steps for pericardiectomy.

• Describe the care of the specimen

Terms and Definitions

• Pericardium

• Decortication

• Pericardial effusion

• Cardiac tamponade

Definition/Purpose of Procedure

• Partial excision of adhered, thickened fibrotic pericardium to relieve constriction of compressed heart and large blood vessels

• Removal of a segment of pericardium, permitting pericardial fluid to drain into the pleural space for treatment of cardiac tamponade

• Surgical stripping of the pericardium

Pathophysiology

• Chronic pericarditis– Tubular– Rheumatic– Viral– Neoplastic– Constrictive

Pathophysiology

• Signs & Symptoms– Chest pain– Fever– Cough– Dyspnea– Palpitations– Friction Rub

Surgical Intervention:Special Considerations

• Patient Factors– anxiety

• Room Set-up– For heart surgery

• Possibly cardiac bypass on standby

Surgical Intervention: Positioning

• Position during procedure– Supine, arms on armboards at 90 degrees

• Supplies and equipment

• Special considerations: high risk areas

Surgical Intervention: Special Considerations/Incision

• Special considerations

• State/Describe incision– Median sternotomy– # 10, # 15 blades

Surgical Intervention: Supplies

• General: Cardiac pack • Specific

– Suture• 4-0 & 5-0 Prolene, wire for sternum

• Pledgets

– Medications on field (name & purpose)• Heparinized saline solution and other meds as indicated on

preference card (may have protamine on standby)

– Catheters & Drains: Chest Tubes

Surgical Intervention: Instruments

• General: Chest and Heart sets

• Specific– Have all cardiac bypass instrumentation

available if needed

Surgical Intervention: Equipment

• General

• Specific– Cardiac defibrillator on standby with internal

and external paddles– Cardiac bypass on standby

Surgical Intervention: Procedure Steps

• The lungs are displaced laterally, and the right and left phrenic nerves are identified and protected

• The pericardium is incised

• Decortication begins with the left ventricle – To prevent development of pulmonary edema and Rt Side Heart

Failure, which could happen if one starts w/right ventricle

• A plane is developed between parietal & visceral pericardium– Caution must be taken to prevent calcified portions of the parietal

pericardium from penetrating the heart’s chambers, esp the atria.

• The outer, thickened pericardium is removed as indicated– Have cartilage scissors ready

Surgical Intervention: Procedure Steps

• Fibrous portions adhering to the atria and ventricles are carefully dissected w/dry dissectors and scissors– Extreme caution used to prevent perforation of atria and right

ventricle—small areas of adherent pericardium may be retained– STSR is prepared with loaded 4-0 or 5-0 pledgeted Prolene sutures.

• Dissection is continued; large blood vessels are exposed and freed as needed; the Atria, Ventricles, and both Cavae are freed

• Drainage catheters are placed near the heart or through the pleural spaces– STSR has chest tubes ready with closed drainage system

• Sternum is closed w/ stainless steel wire, and remainder of wound closed “usual manner”

Counts

• Initial: Sponges, Sharps, instruments

• First closing

• Final closing– Sponges– Sharps– Instruments

Specimen & Care

• Identified as pericardium

• Handled: routine

Resources

• STST Ch 22 pp. 918, 919

• Taber’s Cyclopedic Medical Dictionary

• Alexanders Ch 27, p. 1143, 1156-1157

• Lemone and Burke pp. 895-897

The surgical incision most likely for open heart surgery is:

a. Anterolateral thoracotomy

b. Posterolateral thoracotomy

c. Median sternotomy

d. supraclavicular

Which medication is commonly given IV about 3-5 min prior to cross-clamping the artery during Arteriotomy?

a. Epinephrine

b. Protamine sulfate

c. Papavarine

d. Heparin

All of the following are sutures used in CV surgery to suture vessels or vascular grafts except:

a. Polytetrafluoroethylene (PTFE or Gore-Tex)

b. Polyporpylene (Prolene)

c. Polyester (Dacron)

d. Surgical gut (chromic)

Which of the following procedures would commonly require the use of extracorporeal circulation (heart-lung bypass)?

A. Abdominal Aortic Aneurysmectomy with Graft

B. Pneumonectomy

C. Coronary Artery Bypass Graft

D. Vena Cava Umbrella insertion

The vessel used to increase the overall blood supply to the heart following CABG is the :

a. Saphenous artery

b. Brachial artery

c. Carotid artery

d. Internal mammary artery

The creation of a commuication between an artery and a vein for hemodialysis access is called a(n)

a. Bypass Graft

b. Aneurysmectomy

c. Vena Cava Umbrella Filter Placement

d. Arteriovenous Fistula Formation

Which of the following bypass grafts would require preclotting?

A. Knitted polyester (Dacron)

B. Saphenous vein

C. Human umbilical cord graft

D. Polytetrafluoroethylene (PTFE)

The procedure in which a Fogerty Catheter is used to remove blockage of a vessel is referred to as:

a. Arteriovenous shunt

b. Endarterectomy

c. Embolectomy

d. Ligation and stripping

The autogenous graft which is left in place after destruction of the internal valves and then sutured into the arterial system is:

a. In-situ saphenous vein graft

b. Human umbilical cord graft

c. PTFE graft

d. ligation and stripping of the saphenous vein

The artery that carries deoxygenated blood in the adult is the:

a. Aorta

b. Carotid artery

c. Pulmonary artery

d. Coronary artery

Common artery bypass procedures include all of the following except:

a. axillo-popliteal

b. Femoro-femorol

c. Axillo-femoral

d. Femoro-popliteal

Specific equipment used during surgery on a pt with a pacemaker in place should include:

a. A magnet

b. Mono-polar ESU with its patient return electrode applied to the patient

c. Mono-polar ESU without its patient return electrode applied to the patient

d. Bi-polar ESU with its patient return electrode applied to the patient

Suture material used to place vascular grafts would include:

a. PDS

b. Vicryl/Dexon

c. Prolene

d. Stainless steel

A Femoro-popliteal Bypass is scheduled. Which self-retaining retractor would be used to facilitate exploration of the femoral artery?

a. Harken

b. Debakey

c. Weitlaner

d. Gelpi