[[700 Technical Outline of Repair of Aortic Dissection]] # LV Vent Insertion - A Ferguson vent with an internal stylet is preferred - The stylet has some flexibility, but if the stylet is compressed into the vent with your thumb, it becomes more rigid - Straighten out the vent and stylet, and lay it over the heart, orienting it in such a way that the tip is pointing towards the apex, and the cannula lies over the LV Vent cannulation stitch - You will observe that you usually will not need to insert the LV vent more than two or 3 cm beyond the single line marker, and never up to the double line marker - Bend the tip of the Ferguson vent and stylet to a right angle about 2 cm from the tip - Keep the vent very handy, lay the tip of it close to the cannulation stitch - Ask for a fifteen blade, with a tonsil standing by - Make a hole in the center of the LV vent cannulation into the Left Atrium with a fifteen blade[^a] - It shouldn’t be necessary, but if the hole isn’t big enough, you can spread a little with the tonsil clamp. - Blood will immediately start to emerge from the Left Atrium - Quickly as possible, while preserving the orientation of the tip in your mind and with your hands, insert the LV vent bent tip into the hole - Assistant can provide some suction with cardiotomy sucker, but not enough to allow air to enter left atriium - It is usually not necessary to stiffen the vent with the stylet - The bent LV usually enters with most of the catheter pointing towards the feet - Once the tip is inside, lift the rest of the catheter towards the ceiling, preserving the sense of the orientation of the tip and directing it towards the apex - Slide it in to the LV through the mitral valve, no further than the predetermined extent[^b] - It can often be seen on TEE, but you should develop familiarity with sensation of correct positioning - Assistant cinches down Rumel, clamps it with a Kelly - The catheter is not tied to the Rumel, as sometimes it may need to be repositioned - Hook up the LV vent to the tubing going through a roller pump into the reservoir - Tuck this assembly into the drape side pocket and keep it out of the way - If possible, you only ever want to see blood draining from this line, not air. If you see air, you are applying unnecessary suction that is only entraining air into the heart. [^a]: I have seen overenthusiastic fellows penetrate the back wall of the RSPV with an eleven blade, but not with a fifteen. A fifteen is just a little smaller than the right size for the Ferguson vent. [^b]: Stick it in too far, and it is surprising to see how easily it will poke through LV. Easily repaired with a big needle pledgeted 4-0 Prolene (placed before you pull it back so you don’t lose the hole), but this is easily avoided if you follow the proper method