Department of Cardiovascular Surgery
University Medical Center
Zaloska 7, 1000 Ljubljana
Slovenia

Anesthesiology: Maja Sostaric, MD

The preparation of the patient starts already at the department with patients' premedication prior the transport to the operating theatre (OR). After admission to the OR monitoring devices (ECG, spO2, non-invasive blood pressure measurement) are placed. ECG electrodes are put precordially in such a manner not to occupy the part over the anterior or right lateral side of the thorax, actually, rather at the dorsal side. External defibrillating electrodes are placed in the same way. Two i.v. cannula G14-16 are inserted into peripheral veins. Arterial catheters are inserted into the left and right radial artery to measure arterial blood pressure directly.
The general anaesthesia is induced using the standard medication. The double-lumen endobronchial tube (Carlens or Portex) is used to enable single lung ventilation during the operation. The transesophageal echo (TEE) probe is inserted passing by the endobronchial tube and acquiring the position to expose the right atrium well. The four-lumen central venous catheter is inserted through the left internal jugular (Figure 1) vein, which is needed to measure the central venous pressure, and for delivering of vasoactive drugs. The position of the tip is checked by the TEE. The pulmonary artery catheter is inserted also through the left internal jugular vein when needed.
TEE screening is performed to inspect valves and to confirm/ or in addition to pre-op patient screening to check if there is excessive atherosclerosis of the aorta, to check if the aortic valve is competent ( if not competent- antegrade cardioplegia cannot be delivered sufficiently via endoclamp cathether) and to measure aortic diameter ( if above 4 cm endoclamp catheter should not be used). Transcutaneous echo may be used to determine the position and status of the femoral vessels.
The 17-Fr venous cannula is inserted through the right internal jugular vein using Seldinger technique, having administerd 5000 IE of Heparin.
The guide wire is inserted always on the right side of the neck (Figure 2 a, b), in the level of thyroid cartilage, and not lower to it (Figure 3), to prevent tearing of the subclavian vein or junction between jugular and sublavian vein due to stiff dilator use.
The position of the guide wire and later the position of the cannula are carefully monitored by the TEE until they reach the final position at the junction of superior vena cava and the right atrium as seen as the very tip at the cranial pole of right atrium by the TEE (Figure 4). The Foley urinary catheter is inserted and connected to the temperature probe to measure temperature. The temperature is also measured in the pharynx. The oxygen saturation is monitored continuously by the fingertip pletismography and repetitive blood gas analyses. The anaesthesiologist performs all the procedures up to now whilst the patient is lying on the table in the standard supine position.
Meanwhile, the scrub nurse prepares everything necessary to prepare the instruments and the video presterilized cables for the operation. Special attention is paid on the flushing and rechecking of the endoclamp aortic balloon catheter. The balloon is inflated and deaired carefully (Figure 5). Additionally, the tubing for the upper venous cannula is prepared and primed with the solution. Afterwards, the surgeon-assistant sets the camera holder to the right of the patient so that the vertical arm position coincides with the very tip of the patients' head (Figure 6). Accordingly, the patient is mostly moved some centimetres down along the table to acquire the desired position with respect to the camera. Finally, the patient is further inclined to the left, the right hemithorax is lifted up by some 15-20 degrees with respect to the table axis (Figure 7). We make sure the right arm is retroflexed in the shoulder maximally in other to expose the right lateral hemithorax better.
Then, the skin incision sites are occasionally marked, especially in women the inframammary groove is determined, the operative sites are prepped and draped. The tubing for the upper venous cannula is put between the first and the second layer. The cautery cable, the cell saver and the camera videocables are set in place and are connected. The rest of the cardiopulmonary bypass (CPB) tubing is delivered at the table and clamped one/one, and the vent line is interrupted to insert the return valve, directed toward the pump. Atrium retractor holder is fixed to the left side of the table at the level of the submammary groove or pectoralis muscle border, respectively.

Advancing further, femoral incision is made first to prepare for the CPB.