# Philosophy of Pericardial Well Creation - The capacity of pericardial stitches to help or impair exposure during cardiac surgery is often underestimated. Exposure of the obtuse margin is aided by tension on pericardial stitches on the left, but obscured by tension of stays on the right. A left bottom third pericardial on tension interferes with visualization of the aortic valve. Practitioners of Off-Pump Bypass Grafting rely on this interplay and on deep stitches almost to the level of the pulmonary veins to rotate the heart to facilitate exposure. I was taught an analagous approach to assist in mitral surgery. - To some extent, I think that we are frozen into certain habits by our preference for certain sternal retractors. My institutional and personal preference for non-mitral cases is the Cooley retractor. The Cooley is simple, has no protruding parts to accidentally snag tissue, grips the sternal edges in a stable and reproducible fashion, but there are other choices better designed to harness the full versatility of pericardial stitches. - The Ankeny retractor has two tightly coiled springs attached to the top surface of either sternal arm - This allows pericardial stitches to be pulled into and held with varying degrees of tension by these springs. - The multiple sternal blades are a little tedious, the rest of the retractor feels large, and the springs tend to get banged around with repeated contact with Sterile Processing Departments - The Medtronic Octobase retractor has disposable inserts that slide into each arm that have little pinch clamps in which pericardials can be secured. - It has a discrete profile with two somewhat angular blades that engage the sternal edges. The pinch clamps hold the pericardial stays well. - The disposable inserts are an expense. - In general, the middle pericardials should be created first, as they will help provide exposure for the bottom third, and these two sets of pericardials will expose the pericardial aortic reflection for the top third pericardials. - The pericardium at the aortic reflection is thinner and weaker than the pericardium closer to the diaphragm.[^a] Stay stitches here should go through the pericardium twice, and since they are primarily for exposure, should not be tied tight enough to rip. # CABG Pericardial Well - Number Zero Silk Pop-Off stitches - First pair at latitude of right atrial appendage contact with aorta - Any side from which an in situ mammary will emerge is fastened under tension to a side drape, over the sternal retractor with a Kelly clamp - This allows access to the pleura to fish out mammary and to help visualize phrenic as necessary - Otherwise stitched over sternal retractor to skin - Large bite of skin is less macerating than small bite - Second pair at internal corners of inverted T, stitched directly to skin medial to sternal retractor - Third pair at corners of pericardial reflection over aorta - Double bites of pericardium at this level - Stitch to skin above the sternal retractor - Occasionally, an additional midline stitch is required to retract tissue around innominate vein. This is usually very delicate stuff, and only enough tension is applied to retract this - All knots should be cut as short as possible as they have a tendency to snag other sutures, particularly prolene. # Aortic Valve Pericardial Well - Number Zero Silk Pop-Off stitches - First pair at latitude of right atrial appendage contact with aorta - Stitched over sternal retractor to skin - Large bite of skin is less macerating than small bite - Stitch for right sided corner of the inverted T, stitched directly to skin medial to sternal retractor - No stitch on left corner: it lifts the apex and obscures the view into the aorta. - If one is in place to facilitate maze or left atrial appendage ligation, it can be cut as soon as this is done. - Third pair at corners of pericardial reflection over aorta - Double bites of pericardium at this level - Stitch to skin above the sternal retractor - Occasionally, an additional midline stitch is required to retract tissue around innominate vein. This is usually very delicate stuff, and only enough tension is applied to retract this - All knots should be cut as short as possible as they have a tendency to snag other sutures, particularly prolene. # Mitral Valve Pericardial Well - Number Zero Silk Pop-Off stitches - Place a stitch at the latitude of the right superior pulmonary vein - Temporarily remove sternal retractor - Pass needle through a large bite of skin - Multiple knots, long tail - Re-apply sternal retractor over this pericardial stay - As retractor opens, it will pull increasingly to roll the pericardium towards the right and improve exposure of the mitral - This stitch usually obviates need for right corner of inverted T stay - Stitch at latitude of right atrial appendage contact with aorta on left, and at left corner of inverted T only to facilitate maze or left atrial appendage ligation, then cut to do away with any traction that would interfere with heart rotation to expose mitral valve - Pair at corners of pericardial reflection over aorta - Before performing the stay on the right, finish incision over medial aspect of superior vena cava and mobilization of superior vena cava - Double bites of pericardium at this level - Stitch to skin above the sternal retractor - Occasionally, an additional midline stitch is required to retract tissue around innominate vein. This is usually very delicate stuff, and only enough tension is applied to retract this - All knots should be cut as short as possible as they have a tendency to snag other sutures, particularly prolene. [^a]:For this reason, if autologous pericardium is needed for a patch, it should preferentially be taken from the lower third, closest to the diaphragm.