PREOPERATIVE DIAGNOSIS:
Chronic medically refractory angina.
POSTOPERATIVE DIAGNOSIS:
Chronic medically refractory angina.
PROCEDURE PERFORMED:
Minimally invasive sole therapy laser transmyocardial revascularization.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal.
COMPLICATIONS: None.
DRAINS: One 19 French Blake drain.
DESCRIPTION OF PROCEDURE: The patient was identified and placed on the operative table in the supine position. General endotracheal anesthesia was induced. The left chest and groin were prepped and draped in the normal sterile fashion. The patient was given IV antibiotics prior to start of the case.
A standard 2 inch incision was made below the left breast and dissection was carried down through the fifth interspace. Once we entered the chest, we amputated the pericardial fat pad and identified the pericardium. We made a window in the pericardium and used stay sutures to make a well around the pericardium. Scarred ends of the lung were scarred down and we pushed this out of the way. Once we had a pericardial stay suture in place, we then meticulously took down all the adhesions around the left ventricle, freeing up the left ventricle all the way over to the great cardiac vein on the inferior wall, anteriorly to the level around the apex, anteriorly to the level of the LAD and then laterally out to the level of the vein graft. We then proceeded to place 35 laser TMR channels, doing 5 at a time and using a 2 to 3 minute rest period in between each set of 5 channels. Each channel was placed about 1 cm apart from each other to cover the entire ischemic area along the left ventricle. We did do most of the channels in the area of the right coronary distribution and in the LV apex, 35 channels were done in all.
Once this was done, we then checked for bleeding. After several minutes pressure, there was no evidence of any bleeding. We coated the heart with Tisseel and loosely closed the pericardium over the top of the heart. We then placed a 19 French Blake drain along the pericardium and then we injected the wound with 0.25% Marcaine. We then placed a PainBuster pain device within the subpleural space along the incision, and we then closed the incision using one interrupted #2 Vicryl stitch. We then closed the pectoral muscle over the top of this in one layer using running 0-Vicryl and then subcutaneous tissue and the skin. The wounds were cleaned and dried. Sterile bandages were placed. All needle, sponge and instrument counts were correct at the end of the case. The patient tolerated the procedure well.
