- Position of antegrade stitch on the aorta - CABG alone - As low as possible on the aorta, but not encroaching on right coronary ostium - The action of the vent will keep blood away from the level of the proximals without introducing too much air into the root - Keep planned proximals in mind - If it is possible, avoid the ring of fat encircling the anterior of the aorta as it will obscure the adventitia, making depth of the suture uncertain. This tissue also does not contain hematoma well. If necessary, remove the fat before placing the stitch - Valvular procedures - High on the aorta as possible, providing enough distance from aortic cannula to allow placement of the cross clamp between aortic and antegrade cannula without clamping one or the other - This provides optimal de-airing - Plan for any proximals that may be necessary - U-stitch with pledgeted 2-0 ethibond, double-armed - Both bites of the U will travel in the direction of the aorta - First bite: take one arm, enter the aortic wall in a shallow angle, avoiding entry into the aorta if possible, travel 3-4 mm before emerging, pull needle through, then pass through a pledget mounted on the end of a Kelly clamp that will eventually be used on the Rumel that cinches this cannulation stitch. - Second bite: second arm, mirror image of the first bite, 2 mm apart, pass through the pledget. - Release the pledget - Assistant snares the sutures above the pledget while surgeon closes needle driver towards the needles on the sutures - Assistant cuts needles off - Surgeon announces needles back to the scrub nurse[^a] - Assistant applies Kelly clamp to red rubber Robinson catheter of the Rumel, and lays out to surgeon's left so that the weight of the clamp provides gentle counter traction to the next maneuver - Surgeon asks for the Cooley antegrade catheter[^b], makes sure needle is loosely tightened at the male connector.[^c] - ![[Screen Shot 2021-11-09 at 9.11.25 AM.png]] - Surgeon grasps proximal pledget with regular DeBakey in right hand, and pulls the sutures taught with the pledget enough distance from the aorta to loop the sutures and pledget around the two back horns the Cooley catheter. The DeBakey is laid down, and the Cooley catheter is exchanged to the right hand, keeping the loop in position with tension. The left hand pulls on the Kelly/Rumel, drawing the needle tip of the Cooley catheter towards the surface of the aorta. The surgeon twists the catheter in the right hand to pick up the sutures emerging distally from the aorta with the front horns. The needle enters the aorta and the catheter is handed to the assistant to keep it in place with a finger. - Surgeon cinches up this Rumel - The Rumel does not need to be tied to the antegrade catheter, even though there is a grommet for this purpose. - The surgeon takes back the antegrade catheter, and removes the needle, pinching the catheter closed with the left hand. - The surgeon attaches the Y connector to the antegrade catheter with the right hand. - Surgeon instructs perfusionist "Root vent on" then releases the pinch on the left hand, which clears the antegrade catheter of air. - Surgeon kinks off just below the Y connector before the antegrade catheter and instructs the perfusionist "Flush and suck" - This clears the line of air, and circulates blood cardioplegia in the system so that the first shot will have a good blood/cardioplegia mix. - When the line is full of blood cardioplegia, instruct perfusionist to stop flush. - If retrograde is to be used, turn the cardioplegia switch to the retrograde position while occluding vent and antegrade ports on the switch. Then instruct perfusionist "Flush retro" and hook up to the retrograde catheter, instruct "Off" and release integral clip on retrograde catheter. Switch back to antegrade, and clear line again if air has gotten inside the system. [^a]: By now, you should be noticing that all sharps, needles, knife, etc are announced and handed back to the scrub nurse, not thrown down elsewhere on the field. This prevents injuries, and helps keep the needle count correct. [^b]: Also known as the "pigsticker", a term handed to me by the previously mentioned brilliant surgeon Mark Stout. If I had to guess as to its derivation, I think it must come from the resemblance to a boar hunting spear. This implement has a cross piece, known as the lugs or the wings, close to point to prevent the insertion of the weapon too far into the quarry, preventing the user from dislodging it, and to prevent the enraged animal from traveling up the spear to injure the hunter. Similarly, the Cooley needle has horns that allow it to be secured and that prevent its insertion into the aorta to an ineffective depth. ![[Screen Shot 2021-11-09 at 9.13.09 AM.png]] [^c]: We prefer an antegrade catheter that does not have the vent line integral to it as it brings more tubing and clutter into the immediate field. As seen above, we like a separate Y connector already attached to the vent line and the cardioplegia switch.