Suturing of a heart wound

General principles and surgical access

Cardiac wound closure is always an emergency procedure. The intervention is performed exclusively under endotracheal anesthesia. In modern clinical practice, cardiopulmonary bypass (CPB) is routinely used for extensive reconstructions on the "open" heart, pericardium, and great vessels (aorta, pulmonary trunk, superior vena cava); however, in emergency injuries, surgeons act immediately.

The choice of surgical access depends directly on the localization of the wound tract and X-ray findings.

In surgery, the following access options are distinguished:

• Universal accesses: median sternotomy or transpleural access. They provide maximum visualization of all parts.
• Frequently used accesses: standard lateral thoracotomy (performed on the left or right depending on the projection of the injury).

Pericardiotomy and temporary hemostasis

Access to the myocardium begins with working on the pericardial sac. The pericardial incision must correspond to the operated area.

The main topographical rule: the incision is made wide, strictly anterior to the phrenic nerve (n. phrenicus) to avoid iatrogenic injury.

For convenience, the edges of the pericardial incision are sutured with special traction sutures — this allows tissues to be easily pulled into the wound. Hemostasis of the pericardial edges themselves is achieved using electrosurgery or oversewing bleeding vessels.

As soon as the surgeon gains access to the source of bleeding, temporary hemostasis is performed. To do this, the heart wound is tightly closed with the index finger of the left hand. At this stage, traction sutures are placed on the pericardium and the damaged chamber itself (e.g., the left ventricle). The edges of the wound are gently approximated using U-shaped traction sutures.

Heart suturing technique

Only atraumatic needles are used for suturing cardiac tissues. Continuous locking, interrupted, or U-shaped sutures are placed directly onto the wound compressed by the finger.

The suturing technique strictly depends on the wall thickness of the damaged chamber:

1. Atrial wall: mattress or continuous sutures are applied. The most important task here is precise approximation of the endocardial edges.
2. Ventricular wall: requires greater reliability due to high pressure, therefore a double-row suture (continuous or U-shaped) is used. The threads must be tightened extremely carefully so as not to cut through the fragile myocardium.

Special situation: if cardiac arrest occurred before the pericardium was opened, surgical sutures are placed in short intervals between direct cardiac massage compressions.

Intraoperative resuscitation

During surgery, emergency open-heart resuscitation measures may be required.

Direct cardiac massage consists of rhythmic and periodic compression of the ventricles by the surgeon's hand. There is a critically important biomechanical rule: the fingers must compress the ventricles strictly perpendicular to the interventricular septum. Compressing the heart along the septum is categorically unacceptable, as it carries a huge risk of its rupture and irreversible damage.

If ventricular fibrillation occurs, defibrillation is indicated. The device electrodes must fit the myocardium as tightly as possible. The optimal discharge voltage of the defibrillator is 2–3 kV.

Completion of surgery

After final hemostasis and rhythm stabilization, the final stage begins. The pericardial cavity is thoroughly cleared of accumulated blood and clots, followed by generous washing with isotonic sodium chloride solution.

The pericardium is closed with interrupted sutures to prevent fluid accumulation. A mandatory condition is drainage of the pericardial cavity. For this, a soft plastic tube is installed. Drainage ensures the evacuation of residual blood or effusion, which is the main measure for preventing postoperative cardiac tamponade.

Briefly: answers to topical questions

Class and exam questions

What else to study on this topic

• Topographical anatomy of the great heart vessels (aorta, pulmonary trunk, venae cavae)
• Principles and equipment for cardiopulmonary bypass (CPB)
• Pathophysiology and clinical presentation of cardiac tamponade
• Comparative characteristics of sternotomy and lateral thoracotomy

Other topics in the section "Operations on the Chest Wall and Thoracic Organs"

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