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CLINICAL CASE OF MYOCARDIAL REVASCULARIZATION

DANI SOFÍA BENÍTEZ SÁNCHEZ

HEAR INSTITUTE OF BUCARAMANGA

PRACTICE ROTATION UDES

2024A
 Clinical Case Cardiovascular Surgery
Patient’s Data:
• Name: María de los Ángeles Pérez Ortiz
• ID: 57689774
• Age: 70 años
• Sex: Female
• Birthdate: 02/07/1953
• Civil status: Married
• Blood type: O+
• Address: Cra 5W 53-34
• Occupation:
RECORD
Pathological: (Diseases)

• Coronary heart disease

Pharmacological: (medications)
• Levothyroxine 125mg

Surgical: (Previous surgeries)

• Mastectomy - Inguinal herniorrhaphy - Cholecystectomy
 DIAGNOSTIC EXAMS
Diagnostic Images:
Transthoracic echocardiogram:
• Left ventricle: Normal size and systolic function.
• Right ventricle: Normal structure and systolic function. No tricuspid insufficiency found.
Coronary arteriography with left catheterism:
• Obstruction of the left coronary artery: 90% obstruction is evident in the superior
ascending branch / 100% obstruction is observed in the circumflex branch.
RX of chest:
• The dense and elongated aorta artery is evident.
Doppler ultrasound of venous vessels of the upper limbs:
• Atheromatous plaques are evident in the supralateral arterial segments and at the level
of the knee. There is a moderate amount of atheromas at the infrapatellar arterial
segments bilaterally. Adequate patency is observed bilaterally without hemodynamic
stenosis.
Doppler ultrasound of venous vessels of lower limbs:
• Positive study for acute deep vein thrombosis at the level of the solid muscular veins of
the right leg. The measurements of the arches and the great saphenous veins are
dictated bilaterally. Small-caliber great saphenous veins are observed at the infrapatellar
level, making it difficult to display.
 PARACLINICS: LABORATORIES
• Partial urine
• Red blood cells
• White blood cells
• Hepatitis B
• Ionized Calcium
• Creatinine
• Potassium
• Sodium
• Glycemia
• Ureic nitrogen
• Albumin
• C-reactive protein
• Blood count
• TSH
• Prothrombin time
 SURGICAL FOUNDATION (MYOCARDIAL
REVASCULARIZATION)

A surgical procedure that uses healthy blood vessels from another part of the body (such as arteries in
the arm or chest, or veins in the legs) to create a new blood flow path.

JUSTIFICATION

• These vessels connect to blood vessels proximal and

distal to the blocked artery, thereby bypassing the
blocked or occluded coronary artery in order to
improve blood flow to the heart. It is used to treat or
prevent serious problems, such as a heart attack.
 PATIENT PREPARATION AND TABLES

Type of washing
• Partial wash with alcohol and isopropyl alcohol
Type of anesthesia
• General
Position
• Supine position.
Type of dressed
• Lower sheet, side fields (2 on each side), upper field covering the lectern,
perineal field protecting the patient's intimate area, gaiters on the patient's
feet. Finally, the umbilical field is located, the upper sheet folded in half,
place Ioban and the general field.
 SURGICAL INSTRUMENTATION PROCESS

Surgical Planning:
• Body surface: 1,82
• Flow: 4,55
• Heparin dose: 5,04

Check list: (todo de manera gráfica)

INSTRUMENTAL
 SURGICAL INSTRUMENTATION PROCESS
EQUIPMENT

BASIC DEVICES
 SURGICAL INSTRUMENTATION PROCESS
BASIC DEVICES

SPECIALIZED MEDICAL DEVICES

PERFUSIÓN DEVICES

HEMOSTATS
SUTURES
TABLES (MAY AND RESERV)
 SURGICAL PROCESS
TIME PROCESS

Opening time: We use MB 3 blade 15, electro scalpel, weithlander separator,

1. Skin incision and TCS are performed on farabeuf separator
the left leg
2. The saphenous vein is located and its We use Electro scalpel, Weithlander separator,ligature clips and
respective extraction is performed 200 clips, cystic forceps, Metzembaum scissors, Adson Kelly
forceps withpre-cut silk 4/0, May scissors
3. The previous step is repeated until the We use Electro scalpel, Weithlander separator,ligature clips and
saphenous vein is completely removed 200 clips, cystic forceps,Metzembaum scissors, Adson Kelly
forceps withpre-cut silk 4/0, May scissors
4. Once the saphenous vein has been Bulldog clamp, arteriotomy cannula, 4/0 precutsilk, May scissors,
removed, its is carried out, binding any baby mosquito clamp, 10cc syringe with heparinized solution,
possible leaks. blue fanny pack
Hemostasis of the sternum is performed We use electro scalpel, suction with a Yankee cannula, bone wax

Sternal separation is performed to look for We use sternum protector (optional) and breast separator
the internal mammary artery
The search, extraction and preparation of Electro scalpel, liga clip clamp 100, clips 100 (2 in a row),
the internal mammary artery is carried out, Metzembaum scissors, clips 200 at the end, Metzembaum
making it permeable scissors, wet gauze, clip 100 at the end of the mammary artery,
fine vascular dissections, antegrade Potts microvascular scissors
The mammary separator is changed to We use two sternal protectors, sternal separator, electros calpel,
the sternal separator, incision and elevation dissecting forceps, suction with a Yankee cannula, silk or normal
of the pericardium is performed. needle holder, May scissors
Heparin administration
Dose: 5,04
Vascular time canulation) With 2/0 polyester without plush, tomiquettes, mayo scissors,
The purse string is performed in the aorta curved Kelly tweezers, metzembaum scissors
artery
The purse-string is performed in the right With 2/0 polyester without plush, tourniquet, May scissors,
atrium curved Kelly clamp

The position of the aortic cannula is made We use MB 7 blade 11, EOPA 20 cannula, tube clamp, tourniquet
and it is connected to the arterial perfusion kit, pre-cut silk 1, May scissors, rigid pericardial suction, arterial
line. perfusion line
The single venous cannula is positioned We use vascular dissection forceps, MB 7 blade 11, single 34/46
and connected to the venous perfusion line venous cannula with 1/2-1/2 connector, tomiquette presser, 1 pre-
cut silk, May scissors, venous perfusion line
During the surgical procedure, before Changing from #18 cannula to a #20 cannula
entering the pump, the perfusionist informs
the surgeon that there is no venous return.
The perfusion machine is checked to see if
something was failing and everything was
fine. The surgeon informs that the Aorta is
very tense and swollen
Entry in C.E.C: It goes into bomb With 2/0 polyester without plush, tourniquet, May
scissors, curved Kelly clamp
Clamping of the aorta artery is performed With satinsky total occlusion clamp

A bag of tobacco for cardioplegia is made, the For this we use 4/0 polypropylene, tomiquete, May
cardioplegia cannula is positioned and connected to the scissors,curved Kelly clamp, cannula for antegrade
perfusion line for cardioplegia. cardioplegia, protected mosquito clamp, perfusion
line for cardioplegia with cousine connector and
three-way stopcock
Cardioplegia is applied Perfusion line for cardioplegia

Correction time steps are performed

Retraction of the heart is performed to look for It is performed manually with radiopaque gauze.
the right coronary artery
Surgical time:
An incision is made in the right coronary artery to
perform the respective anastomosis to the saphenous vein
as a free graft
Proximal anastomosis of the free saphenous vein graft to
the right coronary artery is performed.
Before making an incision in the aorta, the vein graft We use breast dissection forceps, antegrade scissors
is cut to the necessary length
An incision is made in the aorta artery to perform the
distal anastomosis of the right coronary artery graft
A distal anastomosis is performed of the graft previously
anastomosed to the right coronary artery and now in its
distal part to the aorta artery.
We use MB 7 blade 15, potts anterograde microvascular
scissors, saphenous graft in blue coca, vascular
dissection forceps, dennis dissection
Prolene 7/0, vascular needle holder, dennis
dissection, protected Kelly clamp, mayo scissors,
dennis dissection, solution in 20ccsyringe
We use HB # 11, MB #7, punch, wet compress (twice)
We use Prolene 6/0, vascular needle holder, dissection,
protected Kelly clamp, mayo scissors, demnis
dissection, solution in 20cc syringe
Patency of the internal mammary artery is performed by
removing the clip placed at its end anteriorly and testing
patency, the anterior descending artery is located and an
incision is made to perform the respective anastomosis to
the internal mammary artery
Distal anastomosis of the pedicle graft is performed, from We used Prolene 7/0, vascular needle holder, dissection,
the internal mammary artery to the anterior descending
artery
Remove clamp:
It comes out of the pump, it is unclamped and DE
cannulated, tying the tobacco bags
Pacemaker wire position and chest tube incision are
made.
The sternal separator is removed and final hemostasis
of the sternum is performed.
We use Dennis dissection forceps, antegrade Potts
scissors, syringe with solution, bulldog clamp, MB 7
blade 15, antegrade Potts scissors, vascular dissection
forceps, Dennis dissection
mayo scissors, Dennis dissection, 20 cc syringe with
warm saline solution
Renoval of total occlusion clamp, vascular dissection
clamp, salina mayo scissors
Pacemaker thread 2/0, piece of perfusion line, needle
holder, polyester 2/0, MB 7 blade 15, electro scalpel,
May scissors
Electro scalpel, bone wax, farabeuf separators and
surgiccel power
The clean sternal separator is repositioned, the chest
tube is positioned, the pleurovac is prepared and the
compresses are performed and counted
The separator is finally removed, and the sternum is
sutured.
Washing and infiltration
TCS and skin are sutured
Once the procedure is completed and the patient has been
cured, the expense sheet is created in the system and the
checklist in the counts is completed
We use Kocher clamp, chest tube, polyester knot,
Nelaton14probe, suction rubber
Compress, surgical steel 5, wire holder, wire cutter,
Rochester forceps
Asepto Syringe, dry compress, 20cc syringe with
bupivacaine +hypodermic needle
Vicryl0, monocryl3/0, mayo scissors
Always do things with love and with your heart
GRACIAS