Surgery of the heart, pericardium and great vessels

image of Surgery of the heart, pericardium and great vessels
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There are a wide variety of acquired and congenital conditions that affect the heart, pericardium or great vessels for which there are either proven or potential surgical treatments. This chapter covers optimizing safety when dissecting near the heart and great vessels, pericardial diseases, patent ductus arteriosus and vascular ring anomalies.

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15.1 (a) In this dog with cor triatriatum dexter, thick (3.5 metric (0 USP)) silk has been placed around the cranial vena cava (CrC), azygos vein (Az) and caudal vena cava (CdC) via a right fifth intercostal approach. Each silk suture passes through a length of rubber tubing (R) to make a Rummel snare in preparation for total venous inflow occlusion. Pericardial basket sutures keep the lung out of the surgical field. (b) The snares are tightened and held in place by clamps on the silk suture as it exits the rubber tubing (out of photograph), to arrest venous inflow and allow intracardiac manipulations. The fibromuscular band dividing the right atrium, which is to be resected, can be seen (B). (c) Once the atrium is sealed by the vascular (Satinsky) clamp, the snares are released and the circulation of blood resumes. The atrial incision is closed ‘inside’ the clamp.
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15.2 (a) The view of the heart and pericardium via a left fourth intercostal thoracotomy in a 1.4 kg dog with patent ductus arteriosus. An incision has been made in the pericardium ventral to the phrenic nerve (P), revealing the pulmonary artery trunk (PA). The vagus nerve (V) and aorta (Ao) are also visible. (b) The closed Potts forceps (F) are passing across the transverse pericardial sinus (TPS), isolating the aortic and pulmonary artery roots, which lie cranially. If bleeding occurs during dissection, a straight vascular clamp with the caudal jaw passing across the TPS and the cranial jaw cranial to the aorta allows total cardiac outflow occlusion to be achieved. Along with traction on the aorta, this manoeuvre should allow time to place a haemostatic vascular clamp across the bleeding ductus.
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15.3 (a) The view from a right fifth intercostal thoracotomy in a dog undergoing ‘open’ subtotal pericardectomy. Pericardial fluid is seen gushing from a small incision in the pericardium made almost immediately on entry to the thorax to relieve any tamponade. The phrenic nerve (P) can also be seen. (b) The phrenic nerve (P) has been dissected free of the pericardium and is gently held dorsally using a silicone vessel loop. Silk stay sutures are holding the pericardium open after a vertical incision has been made from the base to the apex of the pericardial sac. (c) Elevation of the phrenic nerve allows the T-shaped incision to be made close to the dorsal pericardial reflection. If the left phrenic nerve can be isolated in a similar way, the incision in the pericardium is continued at this level all the way around the base of the heart. (d) Once removed, the pericardium is inspected and a sample of tissue submitted for microbiological analysis with the remainder submitted for histopathological analysis. It is good practice to submit pleural biopsy specimens and sternal lymph node samples from dogs with presumed idiopathic disease.
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15.4 (a) The view of the heart and pericardium via a left fourth intercostal thoracotomy in a 1.4 kg dog with patent ductus arteriosus. With a vessel loop around the vagus nerve (V) and one around the aorta (Ao), the ductus arteriosus (D) is apparent. With gentle dorsal traction on the aorta, the dissection plane caudal to the ductus is made obvious (arrowed). PA = pulmonary artery trunk. (b) This dissection can be developed gently using a Mixter (M) or Halsted mosquito forceps, as appropriate. (c) The dissection plane between the cranial ductus and the aorta is identified by a ‘crease’ in the overlying mediastinum. This plane is gently developed using Mixter (M) or Halsted mosquito forceps, as appropriate. (d) The dissection around the ductus was completed using mosquito forceps in this small dog. (e, f) Two sutures of surgical silk and one fine polypropylene suture are passed around the ductus and tied.
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15.5 In a dog with persistent right aortic arch, the aortic root (Ao) can be seen to the right of the trachea, causing an abrupt deviation in the airway that can be seen on good-quality dorsoventral thoracic radiographs exposed (or digitally post-processed) to visualize the mediastinum. The deviated right tracheal wall and the oesophagus are delineated by arrows.
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15.6 Barium oesophagogram with liquid barium mixed with food in a dog with persistent right aortic arch. The oesophagus cranial to the heart base is dilatated and there is a narrowing of the oesophagus at the base of the heart. Barium and food are also in the caudal oesophagus and the stomach. Fluoroscopy can help evaluate motility in the caudal oesophagus.
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15.7 (a) A left fourth intercostal thoracotomy in a dog with persistent right aortic arch. The trachea (T) is visible in the cranial thorax, along with thymus (Th) ventrally. The aorta is not immediately visible but the pulmonary artery (PA) can be seen through the pericardium just ventral to the phrenic nerve (P). (b) In this dog, the ligamentum arteriosum joins the left main pulmonary artery (LMPA) to an aberrant left subclavian artery (LSA). (c) With silk ligatures tied around the ligamentum, it is divided and a large-bore stomach tube is passed through the narrowed oesophagus (O). Any restricting fibrous bands are sectioned. The course of the LSA should also be examined and if it causes narrowing of the oesophagus in the cranial thorax, it too can be divided between ligatures.
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15.8 Although most dogs are significantly improved after surgery, some may need to be fed from an elevated position, and will need to remain in that position for several minutes in order to allow gravity to assist with the passage of food through the oesophagus, throughout their lives.
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15.9 (a) Via a median sternotomy, a Satinsky clamp has been placed across the right atrial appendage (RAA) so that the tumour and its associated thrombus can be resected. The right ventricle (RV) is seen above the right atrium in this photograph. There is sufficient tissue left in the clamp to allow suturing to be done before the clamp is removed. (b) Appearance of the right atrium (RA) after removal of the Satinsky clamp. The atrial wall was closed using 1.5 metric (4/0 USP) polypropylene in a continuous horizontal mattress suture pattern that was oversewn with a simple interrupted pattern.
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