screen display audio developer notes section 1 ... · january 11, 2007 script draft 2 surgical...

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Production Company 1 Client January 11, 2007 Script Draft 2 Surgical Procedures – CABG

Screen Display Audio Developer Notes

SECTION 1: INTRODUCTION

1.1 SCREEN TITLE: SURGICAL PROCEDURES TRAINING Shot of the opening screen centered in content area. Surgical Procedures Training:

CABG This course is for Sales Training Only, Do Not Distribute, Disseminate, or Duplicate.

NARRATOR: The Product Surgical Procedures Training program contains six modules. Each module presents a surgical procedure in which Product can play an important role in hemostasis. This course is for Sales Training Only, Do Not Distribute, Disseminate, or Duplicate.

Fade up title center screen: Flash NEXT button

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1.2

SCREEN TITLE: SURGICAL SPECIALTIES • Orthopedic Surgery

• Vascular/Thoracic Surgery

• Neurosurgery

NARRATOR: The specialties include Orthopedic Surgery, Vascular/Thoracic Surgery and Neurosurgery. The procedures are performed by recognized leaders in the specialties. They include commentary by the surgeon and additional information to help you present pertinent information about The Product to medical professionals who use hemostatic agents in their daily practice.

Fade title under and build bulleted list as called Flash NEXT Button

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SECTION 1: INTRODUCTION

1.3

SCREEN TITLE: COURSE STRUCTURE • Introduction

• Program features • Surgical Team

• Pre-Operative

• Meet the patient • Procedure Overview

• Operating Room

• Narrated surgical video • Product applications

NARRATOR: In addition to this Introduction, each module has three content areas, accessible by clicking on the section tabs at the top of the screen. They include:

• Pre-Operative, where you meet the patient and access a high level overview of the procedure;

• Operating Room, where you can

access a narrated video of the procedure with Product applications.

Fade under specialties, fade up section definitions as called and highlight interface. Highlight Pre-Operative Tab Highlight Operating Room Tab Flash NEXT button

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1.4

SCREEN TITLE: ASSESSMENT Shot of Knowledge Check opening screen

NARRATOR: You can access the sections in any order. Each section has a series of self assessment questions at the end so you can check your knowledge of that section. While no exam is required in this program, you will have to pass an exam covering the content of this program in the Client LMS system. If you are unfamiliar with the procedure in this module, It is recommended that you follow the program in order from Pre-Operative, through the Operating Room, taking the self assessment quizzes in each section. This will prepare you for the Client LMS exam.

Fade under section definitions Fade up Knowledge Check title screen Flash NEXT button

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1.5

SCREEN TITLE: ADDITIONAL FEATURES Glossary Definitions Appendix Additional Information Help Assistance with program features Course Return to course

NARRATOR: The four icons at the top right of the screen provide access to additional features of the program including a Glossary with definitions of relevant terms, an Appendix containing further information about selected topics, and a Help section which has information on how to use the features of the program. The “Course” tab returns you to the course from the Glossary, Appendix or Help sections.

Fade under Knowledge Check screen, build list of feature sections as called Flash NEXT button

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1.6

SCREEN TITLE: CONTROLS Highlight control panel Highlight Play, Stop and Progress Meter Highlight Volume slider Highlight Page Counter Highlight BACK and NEXT buttons

NARRATOR: The control panel is on the bottom of the screen. It contains several features that let you control the presentation. The Play Controls have a Start and Stop button and a progress meter that gives you a visual indicator of your progress through the Section. The Volume slider controls the audio level. The Page Counter lists your current page and the total number of pages in the section. The BACK and NEXT buttons allow you to move forward or back one page at a time.

Fade out definitions. Highlight control panel and individual controls as called. Flash NEXT button

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1.7

SCREEN TITLE: SURGICAL TEAM Drawing of Surgical Team in OR (similar to example). Team highlights as called. Supered Titles:

• Surgical Team • Chief Surgeon • OR Nurse (scrub

nurse) • Anesthesiologist • Circulating Nurse

NARRATOR: The core surgical team for the procedures consists of the Chief Surgeon who directs the surgery, an Anesthesiologist who controls administration of the anesthetic, an Operating Room or OR nurse, also referred to as a scrub nurse, who passes instruments to the Surgeon as needed, and a circulating nurse who manages nursing care in the OR and provides additional equipment to the surgical team.

Provide opt out for Surgical Team Fade up drawing of surgical team in OR Highlight team members as called Super titles Flash NEXT button

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1.8

SCREEN TITLE: ASSESSMENT Drawing fades under Titles appear as called:

• Assistant Surgeon(s)

• Certified Nurse Anesthetist

• Specialist(s)

• Technologist(s)

NARRATOR: In some environments the surgical team may also include one or more assistant surgeons who help the Chief Surgeon with the procedure. In some procedures, a Certified Registered Nurse Anesthetist, or CRNA, may administer the anesthetic rather than an Anesthesiologist. In specialized procedures, such as cardiac bypass, the surgical team will include specialists, such as a perfusionist who operates the heart-lung machine. In some cases, unlicensed assistive personnel, such as surgical technologists, may also assist the surgical team.

Fade under drawing Super titles as called Flash NEXT Button

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1.9

SCREEN TITLE: HELP Help tab highlight

NARRATOR: If you have questions about the navigation options or features of the program, click on the Help tab at the top of the screen. If you are ready to begin learning about this surgical procedure, click a section tab above.

Highlight Help tab Drop highlight Flash NEXT button.

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SECTION 2: PRE-OPERATIVE

2.1

SCREEN TITLE: CABG General shot of operating room during CABG procedure

NARRATOR: Coronary artery bypass grafting, or CABG, is the most commonly performed open heart surgery, with over 350,000 procedures each year in the US alone1 and over 800,000 worldwide.2 It is performed exclusively by cardiothoracic surgeons and the procedure has been refined and perfected over the last forty years. Most patients now experience excellent outcomes. 3

FADE UP to OR photo Flash NEXT button

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2.2

SCREEN TITLE: CORONARY ARTERY DISEASE

Drawing of heart with arteries prominent Dissolve to cross section of artery with plaque around lining Animate plaque increasing and ARTERY narrowing slowly to total occlusion

NARRATOR: Coronary artery bypass is the surgical treatment for ischemic heart disease, more commonly referred to as coronary artery disease or CAD. Coronary artery disease is the result of atherosclerosis, the buildup of plaque in the coronary arteries. The plaque, composed of cholesterol, fat and other substances, collects in the arteries and forms stenoses, or narrowings of the vessels. The stenoses occlude blood flow to the heart resulting in acute angina and shortness of breath. If they become completely occluded, loss of blood supply to the heart can result in myocardial infarction, or heart attack, in which areas of heart muscle die, causing severe damage or death. 4

FADE UP to drawing of heart Dissolve to cross section of artery with plaque Animate artery closing Flash NEXT button

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2.3

SCREEN TITLE: BENEFITS OF CABG

Shot of OR with surgery in place Photo of older man walking briskly, smiling Super: 5 years 92%

10 years 81%

NARRATOR: Coronary artery bypass uses blood vessels from other parts of the body to redirect the blood flow around stenoses in the coronary arteries and restore adequate blood supply to the heart. 5 For most patients the long term results of the procedure are excellent. Almost all patients experience relief of the symptoms of angina, and although some symptoms may recur, most patients have sustained relief. 6 As a group, patients have a five year survival rte of 92% and a ten year survival rate of 81%. 7

FADE UP to shot of OR

Photo of older man walking briskly, smiling Super: 5 years 92%

10 years 81% Flash NEXT button

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2.4

SCREEN TITLE: ANATOMY OF THE HEART Drawing of the heart with portions of aorta and pulmonary artery Dissolve to cross section Highlight Atrium Super Arrow to indicate blood flow Highlight right ventricle and pulmonary artery Highlight right ventricle and aorta

NARRATOR: The heart is a pump comprised mainly of muscle that is located in the center of the chest. Its sole function is to pump blood through the body. Each side of the heart has an upper and lower chamber. The upper chamber, or atrium, collects blood and pumps it into the lower chamber, or ventricle. The ventricles pump blood out of the heart. The right ventricle pumps blood to the lungs where it is oxygenated, and the left ventricle pumps blood to the rest of the body. A series of valves insure that the blood flow is maintained in the proper direction.8

FADE UP to drawing of heart DISSOLVE to cross section Super arrows Highlight right ventricle and pulmonary artery Highlight right ventricle and aorta Flash NEXT button

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2.5

SCREEN TITLE: CIRCULATION Drawing of heart with venae cavae, aorta, pulmonary arteries and veins Highlight venae cavae as called Highlight arrow to highlight flow from atrium to ventricle to pulmonary arteries Highlight pulmonary veins with arrow to left atrium Highlight left ventricle and aorta with arrow to indicate outflow

NARRATOR: Desaturated blood from the body enters the right atrium from the superior vena cava which carries blood from the upper body and the inferior vena cava which carries blood from the lower body. The atrium pumps the blood into the right ventricle which pumps it to the lungs via the pulmonary arteries. Oxygenated blood from the lungs flows into the left atrium via the pulmonary veins. This circuit is called the pulmonary circulation. The blood is then pumped into the left ventricle, which pumps the blood to the body via the aorta. This is called the systemic circulation. 9

FADE UP to drawing of heart and vessels Highlight vena cavae as called Highlight arrow to highlight flow from atrium to ventricle to pulmonary arteries Highlight pulmonary veins with arrow to left atrium Highlight left ventricle and aorta with arrow to indicate outflow Flash NEXT button

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2.6

SCREEN TITLE: INTERACTIVE HEART Drawing of heart in cross section with vessels from CIRCULATION screen Names as labels in random order including: Left atrium Right atrium Left ventricle Right ventricle Aorta Pulmonary arteries Pulmonary veins Superior vena cava Inferior vena cava

NARRATOR: Using your cursor, accurately label the parts of the heart and major vessels Correct Feedback: Good, that’s correct. Negative Feedback: Sorry, try again

Label heart and vessel procedure - Drag name tags to label heart and vessels - When assembled, click on commit - If correct, get correct feedback - If wrong, name tags fly apart and negative feedback presented - Get second try - If correct, get correct feedback - If wrong, tags correctly attach themselves

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2.7

SCREEN TITLE: THE CORONARY ARTERIES

Drawing of heart with coronary arteries emphasized Label left and right arteries Label circumflex artery and LAD as called Label marginal artery and posterior interventricular artery

NARRATOR: The system of arteries and veins that supply the heart with blood and return it to the lungs is called the coronary circulation. The left and right coronary arteries branch off the aorta as it leaves the heart. The left coronary artery branches into the circumflex artery and the left anterior descending artery or LAD. The right coronary artery branches into the marginal artery and the posterior interventricular artery. These are the arteries that are treated with coronary artery bypass surgery. 10

FADE UP to drawing of heart with arteries emphasized Super labels as called Flash NEXT button

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2.8

SCREEN TITLE: CORONARY ARTERRY EXERCISE Drawing of heart with coronary arteries prominent Names as labels in random order including: Left coronary artery Right coronary artery Circumflex artery Left anterior descending artery Marginal artery Posterior interventricular artery

NARRATOR: Using your cursor, accurately label the coronary arteries Correct Feedback: Good, that’s correct. Negative Feedback: Sorry, try again

Label coronary artery procedure - Drag name tags parts to label heart and vessels - When assembled, click on commit - If correct, get correct feedback - If wrong, name tags fly apart and negative feedback presented - Get second try - If correct, get correct feedback - If wrong, tags correctly attach themselves

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2.9

SCREEN TITLE: PRE-OPERATIVE TESTS General shots of blood testing

NARRATOR: Several screening tests may be performed before surgery to determine if the patient has a bleeding disorder. The CBC or complete blood count is the most common test performed. It determines the number of red and white blood cells and can also include a platelet count. The number of platelets is an important indicator of the blood’s ability to stop bleeding by clotting and a physician may order a separate Platelet Count Test. Two tests are commonly performed to test the overall function of proteins required for normal blood clotting: the prothrombin time test, or PT, and the Activated Partial Thromboplastin Time, or aPTT test. 11

Fade up shot of blood testing SUPER: CBC: Complete Blood Count SUPER: Platelet Count SUPER: PT: Prothrombin Time aPTT: Activated Partial Thromboplastin Time Flash NEXT button.

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2.9

SCREEN TITLE: PRE-OPERATIVE TESTS

General shots of blood testing Super as called:

● BUN ● Serum Chloride ● CO2 ● Creatinine ● Glucose ● Serum Potassium ● Serum Sodium

Cath film showing angiogram

NARRATOR: Some surgeons also order a Chem 7 test which is a series of seven chemical tests on the serum. They include: blood urea nitrogen, serum chloride, carbon dioxide, creatinine, glucose, serum potassium and serum sodium. 12

The patient may have a number of diagnostic tests to determine the extent of occlusion in the affected arteries. However, all surgeons will order a cardiac catheterization with angiography because this is the best available technology to provide a view of the stenoses. 13

SUPER titles as called:

● BUN ● Serum Chloride ● CO2 ● Creatinine ● Glucose ● Serum Potassium ● Serum Sodium

Dissolve to angiogram

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2.10

SCREEN TITLE: SURGICAL PROCEDURE

MS general OR shot with surgery in progress Drawing of patient on operating table Show the location and length of the sternotomy Dissolve to ribcage open

NARRATOR: The following narration is a description of coronary artery bypass grafting utilizing cardiopulmonary bypass that was synthesized from several sources.14 The techniques and outcomes of the procedure may vary somewhat by the performing surgeon. The procedure is performed under general anesthesia. A coronary artery bypass is performed in stages. In the first stage, the chest is opened with a median sternotomy. The surgeon makes an incision approximately ten inches long down the center of the sternum then separates it with a bone saw. The ribcage is opened to provide access to the heart and careful hemostasis is achieved.

FADE UP to OR shot DISSOLVE to drawing of patient on operating table Dissolve to drawing showing sternotomy Dissolve to drawing with ribcage open Flash NEXT button

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2.11


Drawing of body outline with IMA and great saphenous vein highlighted Photo of perfusionist and heart-lung machine

NARRATOR: The conduits are then harvested. About 95% of procedures use the internal mammary artery as the primary conduit due to its superior patency over time. The great saphenous vein in the leg is commonly used if additional grafts are required. The next step in the procedure is to achieve cardiopulmonary bypass in which the patient’s breathing and blood circulation are switched to a heart-lung perfusion machine often referred to as the pump. The perfusionist is responsible for maintaining the patient in a physiologic state while in bypass.

FADE UP to drawing with IMA and saphenous vein highlighted DISSOLVE to photo of perfusionist and heart-lung machine Flash NEXT button

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2.12


Drawing of heart with major vessels Dissolve in line to aorta above heart and line to right atrium Dissolve to photo of OR with patient connected to pump

NARRATOR: The aorta is clamped and cannulated above the heart to provide blood flow to the body and the right atrium is cannulated to provide blood flow to the lungs. As the patients breathing and circulation are transferred to the pump, the lungs stop moving and a potassium based cardioplegia solution is applied to the heart to stop it from beating and to cool it. This provides the surgeon a bloodless, motionless field. The heart may be further cooled with a saline slush.

FADE UP to drawing of heart and major vessels Dissolve in line to aorta above heart and line to right atrium Dissolve to photo of OR with patient connected to pump Flash NEXT button

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2.13


Drawing of heart with coronary arteries prominent Dissolve to drawing of veins attached to circumflex artery, lower part of right coronary artery Dissolve in IMA attached to LAD Dissolve to drawing of veins grafted to aorta

NARRATOR: The surgeon first makes the distal anastomoses to the arteries receiving grafts in a manner that connects the end of the vein to the side of the artery. The arteries remain in place and continue to provide blood to other sections of the heart. Next, the surgeon makes the distal anastomosis of the internal mammary artery to the left anterior descending artery. This artery is connected to the subclavian artery so no proximal anastomosis is required and once this is done blood flow is effectively restored. Circular segments of the aortic wall are removed with an aortic punch and the proximal anastomoses to the aorta are performed.

FADE UP to drawing of heart with coronary arteries prominent Dissolve to drawing of veins attached to circumflex artery, lower part of right coronary artery Dissolve in IMA attached to LAD

Dissolve to drawing of veins

grafted to aorta Flash NEXT button

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2.14


Drawing of patient with open chest Dissolve in chest tubes and pacing wires Animate wound closing

General shot of OR with heart surgery in progress

NARRATOR: The patient is then gradually weaned from bypass while the surgeon carefully checks to insure hemostasis in the entire field. Chest tubes are placed in the mediastinum and thoracic cavity, pacing wires are attached to the heart, and the heart is restarted. The sternum is closed with steel sutures and the skin incision is closed. The entire procedure can take from two to four hours to complete depending on how many grafts are made. The patient will be transferred to an ICU for recovery and will require monitoring for one to two days. The average hospital stay is five to seven days.

FADE UP to drawing of patient with open chest Dissolve in chest tubes and pacing wires

Animate wound closing DISSOLVE to OR shot Flash NEXT button

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2.15

SCREEN TITLE: SURGICAL TEAM General OR shot with heart surgery in progress Stock photo representing patient

NARRATOR: Most CABG procedures are performed using a heart/lung machine. In the procedure we will observe, the surgeon will perform the bypass without the heart/lung machine. This is referred to as off pump or beating heart surgery. The patient is a seventy-five year old male who presented with acute myocardial infarction. He is overweight and diabetic. He suffers from chronic atrial fibrillation and has an AV sequence pacemaker. The patient was taking aspirin and Coumadin prior to the surgery. Coumadin was discontinued five days before surgery.

FADE UP to general OR shot with heart surgery in progress DISSOLVE to Stock photo representing patient Flash NEXT button

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2.15

SCREEN TITLE: SURGICAL TEAM

Stock OR photo with bypass team

NARRATOR: The surgeon ordered several blood tests prior to surgery including a CBC, platelet count, PT, aPTT, hematocrit and hemoglobin, type and cross, Chem 7 and a total metabolic package. He also ordered a pre-albumen to determine if the patient would need extra nourishment after surgery. In this procedure the lead surgeon will direct the surgery and perform the primary steps in the procedure. He will be assisted by an assistant surgeon and a scrub nurse who will hand him the instruments he needs in sequence as required in the procedure. An anesthesiologist will administer the anesthesia and a circulating nurse will supervise the overall nursing care during the operation.

DISSOLVE to stock OR photo with bypass team

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2.17

SCREEN TITLE: ASSESSMENT 1. The right ventricle pumps blood to: a. The lungs b. The brain c. The upper body d. The lower body 2. Desaturated blood enters the right atrium from the venae cava. The atrium pumps the blood into the right ventricle which pumps it into the lungs. Oxygenated blood flows into the left atrium via the pulmonary veins. This is called the: a. Coronary circulation b. Systemic circulation c. Pulmonary circulation d. Primary circulation

NARRATOR:

Correct answer: a Correct answer: c

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2.17

SCREEN TITLE: ASSESSMENT 3. Which of these arteries are treated with CABG? a. Internal mammary artery b. Circumflex artery c. Marginal artery d. Inferior descending artery 4. Which of these are the most common conduits for CABG? a. Internal mammary artery b. Small saphenous vein c. Great saphenous vein d. Radial artery

NARRATOR:

Correct Answer: b, c Correct answer: a, c

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2.17

SCREEN TITLE: ASSESSMENT 5. What is the primary active ingredient in cardioplegia solution? a. Saline b. Heparin c. Calcium d. Potassium

NARRATOR:

Correct answer: d

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3.1

SCREEN TITLE: MEET THE SURGEON The following video of a cardiac artery bypass graft is real-life and represents the technique of the specified vascular surgeon. The audio portion of this program has been edited for content. Changes do not affect the outcome or conclusions of this program. Photo of Dr. Vascular Surgeon

NARRATOR: The following video of a cardiac artery bypass graft is real-life and represents the technique of the specified vascular surgeon. The audio portion of this program has been edited for content. Changes do not affect the outcome or conclusions of this program. We will observe a beating heart cardiac artery bypass graft performed by Dr. Vascular Surgeon. Dr Surgeon is a Doctor of Osteopathic Medicine and a Fellow of the American College or Surgeons. He is Chief of Cardiac Surgery at Hospital in Anytown, USA. He is also a Clinical Associate Professor of Surgery at the Medical College of The University.

FADE UP to disclaimer text DISSOLVE to photo of Dr. Vascular Surgeon

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3.2

SCREEN TITLE: PREPARATION FOR SURGERY

NARRATOR: The procedure is performed under general anesthesia. When the video opens, the anesthetic has been administered and the patient has been draped. He was received heparin and antibiotics in the operating room. He is on aspirin and a beta blocker. We join the video as Dr. Surgeon is making the initial incision above the sternum

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3.3

SCREEN TITLE: PROCEDURE VIDEO

SURGEON: You can see us opening the chest and for orientation purposes the top of the chest is at the bottom of the screen. And this incision is directly over the sternum. After the skin has been cut down to the sternum with a knife blade we use a cautery to hemostase the entirety of the wound. Hemostasis is so important because most of the bleeding that one gets during cardiac surgery is either from the sternum or from the soft tissue. It is very important to be directly in the middle of the sternum. When we cut down the middle of the sternum if the saw is off to either side you can end up having not very good closure at the end because the sternum will not have enough bone for the wires to hold.

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3.3


SURGEON: Here you can see us putting in a right common femoral arterial line. We always put in a right radial arterial line to monitor the blood pressure. But in some cases, particularly very long operations, we like to be sure that the arterial tracing is accurate. NARRATOR Some of the drugs used to maintain blood pressure can constrict the arteries peripherally and prevent an accurate blood pressure measurement. That’s why surgeons frequently put in a femoral arterial line.15

PAUSE video if necessary for narrator. Re-start video

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3.3


SURGEON: You can see the chest open with the saw and you can see how we really make an effort to keep the saw at the midline so that we have an equal amount of bone on either side. The periosteum, or the tissue on either side of the bone, has a tendency to bleed in addition to the bleeding from the bone itself. Probably the major source of blood loss is from the sternum. Because it’s just like a leaky faucet: the sternum will drip the entire operation if you don’t get good hemostasis. Traditionally we use bone wax to stuff in the sternum but most of the patients who have heart surgery have very soft bone and you put in a ton of bone wax which acts as what we call a foreign body and all you need is one bacteria in this foreign body and the combination ends up to a severe infection. So it’s better to use something that will go away easily such as Product. And even putting Product on the Gelfoam sometimes works well to prevent the bleeding.

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3.3


SURGEON: After the initial opening of the chest cavity I’ve selected to apply Product to an absorbable gelatin sponge and wipe it along the sternum to aid in hemostasis. Hemostasis at this point will help keep the surgical field clear as I progress through the remainder of the CABG procedure. Because of the large area of this patient’s sternum, I have chosen to use two applications. So once again it is very important to have accurate hemostasis because you can lose an incredible amount of blood during the operation if there is any bleeding. So I spend a lot of time on the sternum.

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3.3

SCREEN TITLE: PROCEDURE VIDEO Pop Up: Photo/drawing of skyhook

SURGEON: Once we have sternal hemostasis, we put in a gadget that we call the sky hook. We put it off to the left side of the chest and we pull up on the breast bone, on the left side of the breast bone. And there’s an artery just on the other side of the chest wall laying on the breast bone on the inside of the chest that we take down for use of the bypass graft. So we are in the process of taking this down. Frequently there are arterial bleeders and we use clips for these arterial bleeders.

Pause video if necessary. Pop on photo/drawing of skyhook

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3.3


SURGEON: We still really do not see the heart or the lung yet because we haven’t opened up the pericardium, the sack around the heart. And the lung is staying in the left chest even though that cavity is open. Once again it is very important to have hemostasis in the beginning of the operation because any drip, drip, drip for the rest of the three hours of the operation can be a problem.

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3.3


SURGEON: Here I am clipping the end of the internal mammary artery on the left side of the chest. And after it’s clipped on both sides I’ll transect it and bring it into the field with the scissors that’s in my left hand. The artery actually has a little bit of tissue on either side of it because it’s a very fragile artery. Sometimes if you tear a branch it ruins the artery. We are putting on a spray called papaverine which dilates the artery; it’s a smooth muscle relaxant to make the artery larger. This artery is very spastic. It’s not good to use bypass graft: it has a lot of spasm in it so we constantly spray it with papaverine while we’re manipulating it. The spasm is from the manipulation. And here I’m just clipping branches on the artery.

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3.3


SURGEON: This left internal mammary artery comes off the artery that goes to the left arm, and the best thing about this left internal mammary artery is it has a tendency to have no atherosclerosis so it doesn’t get disease. Now we are preparing for the bypass surgery by putting in a retractor and spreading the chest a little bit wider. Simultaneous with this my team is taking out the vein in the leg for other bypass grafts.

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3.3


SURGEON: Now we’re going to open up the pericardium which is the sack around the heart so you can see the heart beating beneath. Most of what you see on the heart there is right ventricle. Now we are coming up over the aorta. It’s very important to have the pericardium opened widely for when we do beating heart surgery so that the heart can be moved in different positions without any constriction. In order to keep the right lung out of the way we put traction sutures on the pericardium, on this sack that has been opened so we can see everything. You can just see my assistant taking the vein out of the leg. And here we have the internal mammary artery getting further prepared for use of bypass graft. You really have a good view of the artery there.

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3.3


SURGEON: Once again I try to do all the manipulation well ahead of when I’m going to use this internal mammary artery because it will spasm with the manipulation. Now the pericardium’s been opened now I’m going to have to take the heart out. I put a suction device on the end of the heart or on the apex as we call it, and pull the heart out of the chest. And directly down from the suction device you can see the most important artery on the heart which is called the anterior descending artery which goes between the right and left ventricle. So because that’s the most important we use the very best graft we have and we also do it as the first bypass because once this artery is bypassed usually the rest of the bypasses will go very well because at least this part of the heart has been revascularized or bypassed.

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3.3

SCREEN TITLE: PROCEDURE VIDEO Pop On: Stabilizer

SURGEON: So we have just placed the coronary stabilizer. You can see the area around the heart isn’t moving and this makes beating heart surgery not so hard to do. Now I’m making sure the internal mammary artery is straight. It’s not good if it has a twist, it won’t work as well. Now we use a fine blade to take the covering off the artery beneath the tissue on the heart so that we isolate the artery. Now a big artery, which this is a big artery, is usually about 2 mm in size. A little one is about 1 mm. When I open the artery up obviously the blood will squirt out so we put a little tourniquet tape to prevent the blood from squirting out while we put in something called a shunt. You‘ll see how that shunt works in a moment.

Pause video if necessary. Pop on photo/drawing of stabilizer

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3.3

SCREEN TITLE: PROCEDURE VIDEO Bulldog Clamp

SURGEON: So this tape is silastic so it doesn’t injure the artery. So now we’re poking the artery open. There’s blood coming out. You can see the gadget that shoots CO2 to clear the field of blood. Now we’re putting in a shunt which is basically just a tube with flanged ends so that we’ll have blood flow from one end of the artery to the other end and there won’t be too much blood coming out. However this is a fair amount of blood. You don’t want the shunt to be too tight because then you can’t put the sutures in. I’ve opened the artery but you don’t see there’s what we call a bull dog, clamp on the artery. So that’s why it’s not bleeding.

Pause Video if necessary. Super photo/drawing of bulldog clamp. Restart video

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3.3


SURGEON: Now we’re ready to start stitching the left internal mammary artery, which is the bypass graft, to the heart artery, which is the anterior descending artery. We use very fine suture, so fine you can barely see it. You can see how the CO2 keeps the blood out of the field. The reason we use CO2 is because it’s easily dissolved in the blood versus if we use straight oxygen to blow then the nitrogen and the oxygen get mixed into the blood and bubbles can form. With the CO2 the bubbles don’t form. So we use CO2 with a slight mist to keep tissues from drying out.

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3.3


SURGEON: And now we’re putting the sutures in, sewing up the artery. We don’t ever tie the artery shut with the shunt in. we take the shunt out at the last minute. So I was just making sure there that the internal mammary artery, the bypass graft, was flowing well. So that little gush of blood was from the internal mammary artery, or the bypass graft. Now I’m pulling the stitches up tight so that hopefully there’s no leaks. And then before I tie it, I’ll pull the shunt out. Now the shunt’s out. Sutures tied up. Now to keep this from getting twisted I suture it to the surface of the heart. Sometimes when we are doing the surgery, this bypass graft can get pulled upon and if it’s sutured to the surface the anastomosis is not pulled. It’s where these traction sutures are placed so you don’t disrupt the anastomosis.

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3.3


SURGEON: It’s amazing that the blood pressure can be maintained with all these positions. It might drop a little but generally it’s not a problem. Because I didn’t like that one position I’m putting the suction device on a different area of the heart. I’m trying to find the optimal place to do the bypass. Many times, particularly the right coronary artery has severe calcification and it’s so severe you can’t even sew. The artery needs to be large enough to take the bypass graft because sometimes if you go to a tiny area, a tiny artery, then the bypass graft won’t stay open. It’s like trying to funnel a river into a tiny stream. The bypass graft, usually being the size of a pencil and the artery that you bypass being like the pencil tip. If you don’t have what we call a large arterial tree the graft doesn’t stay open. So there’s a lot of clinical considerations to picking the place you want to bypass.

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3.3

SCREEN TITLE: PROCEDURE VIDEO Photo/drawing of coronary shunt

SURGEON: Doing beating heart surgery frequently is like using an erector set: trying all sorts of different positions so that you can make something really work. Once again we put our tourniquet around the artery so that when we open it we can pull up on it to reduce the amount of bleeding. There’s the vein with our mark on it to keep it straight. Now we are going to cut it sharply with a knife and prepare it for use as a bypass graft. We are sticking the artery here to open it and once there’s a little bit of a hole we put some scissors in to open it further. Someone’s gently pulling on the tourniquet to reduce the amount of blood coming out and now we are putting a shunt in again. It’s a tube with flanged ends and you can see this big white thing and that’s a radio p…marker so that if it falls out into the chest we’ll be able to see it on an X-ray.

PAUSE video if necessary: Super drawing/photo of shunt

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SURGEON: We’re going to put our sutures in and sew the vein onto the heart. Now this area is moving a little bit more than the standard anastomosis would move. A lot of surgeons don’t do beating heart surgery because of this. Once you get used to sewing on the beating heart, it’s almost second nature. Once again the anastomosis is almost completed. You see the shunt still hanging out: that little string there. We’re ready to pull out the shunt and tie the anastomosis. So there the bypass has been placed to what we call the posterior descending artery which is that part of the heart that lays up against the diaphragm. It’s always rewarding when you see blood come back out of the graft knowing that even though the artery is severely narrowed there’s still blood that always goes through all these arteries and you know that you didn’t pinch off the heart artery itself during the sewing which sometimes occurs.

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SURGEON: You just saw an ultrasound device where we looked at the aorta to make sure there wasn’t severe atherosclerosis because sometimes when you put a clamp or any gadget on the aorta to do what we call the proximal anastomosis. This atherosclerosis breaks off and when it breaks off the worst place for it to go is the brain where it can cause a stroke. We did the far end of the bypass graft. Now we have to do what we call the proximal end. We sew the bypass graft on the aorta to give the bypass graft the blood supply to take to the heart.

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SCREEN TITLE: PROCEDURE VIDEO Photo/drawing of aortal punch.

SURGEON: I try to stay away from using clamps although most heart surgeons once again use a clamp but we have what we call proximal devices that serve as a microclamp on the aorta where you don’t pinch off a large portion of aorta to do the proximal anastomosis. This just squeezes down on a small area of aorta to do the beginning part of the anastomosis so that the graft that we just put on the artery, the posterior descending artery, will have a blood flow. The aorta is pinched a bit with this gadget. We’re going to make a hole in the aorta but because of the sophistication of the gadget you aren’t going to see a lot of blood squirt out although it leaks a little bit. So that’s a hole in the aorta and now we’re going to sew the vein glass on the aorta.

PAUSE video if necessary. SUPER photo/drawing of aortal punch

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SURGEON: The aorta is the single most frequent cause of strokes with bypass surgery so the less that you do to the aorta the better it is. You can see we are putting our bull dog so that there is no flow coming back in our graft. We open up the graft and now we’re going to sew it to the aorta. You want to make sure you sew this well to the aorta and you don’t have any breaks in your sutures. Because when you take off this device there will be a lot of blood coming out. So now were going to loosen the device and the will be blood flowing into the graft. We select another spot on the aorta for another bypass graft.

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SURGEON: Frequently there’s air so you just saw me needling the vein graft to get all the air out of it because you don’t want put air in the heart artery because it clogs up the artery. The air will go away after awhile but not after it’s caused some sort of event because it jams up the arteries. The blood won’t flow if there’s a big air bubble. Once again, placing a hole in the aorta for the next graft. And once again we are going to make sure all the valves are gone in the vein because instead of putting it on the standard way where the valves don’t make a difference, we’re going to turn it around and have the blood flow the opposite way and if there’s any valves then the blood flow wont occur very well. Now the reason I’m doing this is because it’s bigger at one end than the other

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SURGEON: .Now obviously you like to have the big end be the input end which is this beginning part, the proximal part. Because then it will taper as it goes to the heart and then it will taper even more when it goes into the heart arteries because the heart arteries are generally so small, usually anywhere from 11/2 to 2 mm in size. So now I am going to release the gadget after I sew this up here and tie the knot. You will be able to see the vein graft fill up suddenly as we let blood into it. We’ll pull out this gadget. The red thing there is what we call a snare where I tighten up this purse string suture around this hole in the aorta but then when I’m done with it I can just tie a knot.

PAUSE video if necessary. Super drawing of purse string suture.

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SURGEON: So here I’m tying a knot. Sewing up the hole in the aorta where the gadget went in. Then I reinforce this suture with another suture just to be extra sure this hole doesn’t come open. We use this white thing which is a piece of Dacron and we call it a pledget just to bolster the suture. Sometimes the tissue is not so good and the suture, because it is so fine, will pull through the tissue and you end up having a worse situation. So here the bypasses are on. We just measured the flow in the bypass graft. I like to measure all the flow.

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SCREEN TITLE: PROCEDURE VIDEO Photo/drawing of ultrasonic probe

SURGEON: That gadget that was just in the field, the one with the white handle, is an ultrasonic probe that can tell us how much flow is in each graft. And here we are dissecting out a portion of what we call the pedicle of the internal mammary artery, the bypass graft that we started with first. You have a good shot of the artery there but that probe doesn’t go around the tissue very well: it needs to go directly around the artery itself. So I’m just cleaning it off. And there are various expectations for how much flow: a big artery will have lots of flow, a tiny artery will have little flow. You really need to look at the patient, look at the heart and decide. So we have some ultrasonic gel, and now this goes to a transducer which will tell me how much flow is in the artery. And if there’s little flow then I would expect that there was a problem with the graft.

PAUSE video if necessary. Super drawing/photo of ultrasonic probe Re-start video

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SURGEON: Now the heart is up in the air and we are doing the left lateral wall of the heart, doing a bypass graft. We put our tourniquet around the artery so when we open it, it doesn’t bleed. This artery is very well stabilized by the coronary stabilizer. My assistant is pulling up on the tourniquet so we can open up the artery without a lot of blood loss. Now we are measuring the right length of the graft because it can’t be too long and can’t be too short: it needs to be just right. If you look at the area where the artery is open you can see it’s fairly stable compared to the rest of the heart. In that way, the beating heart surgery gets accomplished. It’s still moving but it’s not moving much compared to the other areas around it. You can see there is no blood in the graft so that when we open this graft up, we always have to get the air out.

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SURGEON: You can see the heart’s pulled way up in the air. You get to see the left ventricle which is on your left side. And you can see how the heart just falls into the chest where you just see only the right ventricle. I’m checking all the anastomosis to be sure there is no significant bleeding. There’s a little bit of bleeding here from the proximal anastomosis, here using the Product solution on some Gelfoam to hold it in place and just a little bit of pressure really does wonders. Many of the other hemostatic agents goo up the anastomosis so that you end up putting in a stitch you can’t see because you can’t get the goo off. The good thing about the Product is that it really works well: it just stays, does its job, and goes. Frequently I put it on the Gelfoam just to hold it in place.

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SURGEON: Now with all the bypasses completed and all the flows checked, you have to go around and hemostase everything. The patients get heparinized in order to do the surgery and then we reverse the heparin with protamine. But while the patient is heparinized, there is not much clot. In fact some of the areas that were clotted bleed. So you have to look at everything you did from start to finish after the protamine is in. All patients bleed a little bit after heart surgery so we always put in many drains. It’s not unusual to put at least a thousand CCs out after the surgery, half of its blood and half of its straight tissue. If we didn’t put the drains in, then this fluid would accumulate in the heart and press on the heart and cause something called tamponade. Where it puts so much pressure the heart can’t fill, the blood pressure goes down, and the patient does poorly.

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SURGEON: So we’d rather have the blood go out than stay in the chest. And we use these tiny drains so that they are more comfortable to the patient. They don’t look so comfortable right now putting them in but ultimately they are more comfortable than the big tubes we used to. Because both plural cavities, that is where the lung is on each sides, are open, we put a drain in each plural cavity and one in the middle. And that way all the blood or fluid is evacuated well after the surgery. Once again, the less bleeding the better.

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SURGEON: When we are done with the drains, we just pull them out and we sew the holes shut. That’s why we put a lot of wraps around each drain so that we can tie it and close the skin when the drain comes out. Now we continue to go around looking at everything we touched, everything that we cut to make sure that there’s perfect hemostasis. The less blood loss there with a heart surgery, the better the patient does. So now we’re going to stick the drain into the left side of the chest. I frequently like to stick it all the way down far onto his back as possible and as low as I can on the diaphragm just so it can collect all the fluid and blood that is possible.

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SURGEON: Here I am putting in a high tech Novocain into the chest. The idea being that this high tech Novocain will numb the nerves that go around the ribs and most of the nerves emanate from the spinal cord and follow the ribs, track around the ribs, to the front. So this ht Novocain hopefully numbs the nerves a little bit. These are pacer wires. As a rule, I do not put in pacer wires for a normal coronary bypass graft, but in this patient he became severely bradycardic in the beginning of the operation and I was concerned that his electrical conduction in his heart was not optimal. And I didn’t want to take a chance that his heart all of a sudden was going to stop on us.

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SURGEON: Now we fixed the plumbing by doing the bypass graft but what makes the heart beat frequently are the electrical wires within the heart and sometimes they’re very old. And the heart can stop, so that’s why we like to have these temporary pacer wires in there. Here we can see some bleeding around the anastomosis. The Product has already been put on the Gelfoam and now usually I’ll put some on the Gelfoam and then add some more onto the top. And just put some gentle pressure. If it’s just a very simple ooze, I’ll just spray the Product and it works great.

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SURGEON: Once again, we frequently irrigate the bone because a sternal wound infection is awful. So we try to wash out all the debris around the sternum, wipe it clean because any dead tissue is a nidus for infection so we wipe off this stuff. We’ve been operating for a few hours and we wipe off everything. Sometimes that causes some bleeding. Right before we close the chest, I routinely check the flows in all the grafts to make sure they’re working because sometimes closing the chest, the graft can kink or get stuck on something and the flow will go down. And the worst scenario is we’ve just closed the chest and kinked the graft where the heart all of a sudden doesn’t work so well.

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SURGEON: We close the bone together with sterna and basically we put multiple wires in and we tie the sternum together like a bale of hay. Once again we don’t want any bleeding from the sternal edges. The Product reduces this bleeding significantly. Generally, when you push the sternum together it wont bleed because the edges are pushed together and it sort of tamponades it. But sometimes it does bleed. Frequently it bleeds in the middle of the night and we have to go back and see what’s oozing. Most of the time, 5 % of the time in all heart surgery, you have to go back for bleeding. Most of the time it’s from sternum or one of these wires so you like to have it as dry as possible when you shut. So we just twist the wires, we cut them, and twist them some more to make sure the sternum is very tight.

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SURGEON: While closing, I’ll put more Novocain into the tissue in front of the sternum to reduce the pain for when the patient wakes up. By putting all this Novocain in and around all the tubes and into the sternum, most patients when they wake up they hardly have any pain whatsoever. And that allows us to take the breathing tube out on the OR table which is also a very nice thing. So now that all the Novocain is put in, we sew up the soft tissues in multiple layers to cover the bone. Once again, the bone is so important to prevent any infection. A bone infection is the worst, more than a tissue infection, not that it’s good but it is not as big a problem as a bone infection.

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SURGEON: We bring the soft tissue together and after that’s done I put more Novocain in and then we sew the skin edges with what we call a subcuticular suture which is just underneath so the patient doesn’t have any stitches to be removed. All these stitches are absorbable. Once the wound is closed, we take off this protective layer of cellophane that has some antibiotic impregnated into it. And to further protect against infection, we glue the edges together.

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NARRATOR: The procedure took approximately four hours from the initial incision to closing the wound. The Product was used at various points with different applicators throughout the procedure to provide hemostasis.

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SCREEN TITLE: ASSESSMENT 1. What is the main source of blood loss in the CABG procedure? a. Sternum b. Pericardium c. Periosteum d. Soft tissue 2. What device is used to expose the internal mammary artery so it can be resected and dissected from the chest wall? a. Chest retractor b. Bulldog clamp c. Skyhook d. Rake

NARRATOR:

Correct answer: a Correct answer: c

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SCREEN TITLE: ASSESSMENT 3. What is used to prevent the internal mammary artery from spasming? a. Protamine b. Papaverine c. Heparin d. CO2 4. What is the single most frequent cause of stroke with bypass surgery? a. Left anterior descending artery b. Pulmonary artery c. Right anterior descending artery d. Aorta

NARRATOR:

Correct answer: b Correct answer: d

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SCREEN TITLE: ASSESSMENT 5. What is the name of the Dacron material used to strengthen aortal sutures? a. Pledget b. Gadget c. Ratchet d. Gelfoam

NARRATOR:

Correct answer: a

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CABG Cited References 1. Sabiston Textbook of Surgery, p. 1276. 2. Coronary Artery Bypass Surgery - St. Jude Medical, p.1. 3. What is Coronary Artery Bypass Grafting - STS, pp. 1, 3. 4. Medline Plus Medical Encyclopedia, p.1. Bypass Surgery, Coronary Bypass - AHA, p.1. What is Coronary Artery Bypass Grafting - STS 5. Bypass Surgery, Coronary Bypass - AHA, p.1. Coronary Artery Bypass - BUPA, p.1 Merck Manual – Heart and Bypass, pp. 209-210. 6. What is Coronary Artery Bypass Grafting - STS, p.3 7. The Heart Acquired Diseases - Current Surgical Diagnosis and Treatment, p.414. 8. Merck Manual – Heart and Bypass, pp. 114-115. 9. Merck Manual – Heart and Bypass, pp. 115-116 10. Merck Manual – Heart and Bypass, pp. 115-116. 11 Merck Manual – Blood Testing, pp. 115-116. 12. Chem 7, Medline Plus Medical Encyclopedia 13. What is Coronary Artery Bypass Grafting - STS, p. 1. Coronary Artery Bypass Procedure – Medline Plus/OR Live, pp. 8, 12. What ic coronary artery bypass graft surgery – MedicineNet, p.2

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14. American Heart Association Coronary Artery Bypass - BUPA The Heart Acquired Diseases - Current Surgical Diagnosis and Treatment Cardiopulmonary Bypass - Heart Health Center Encyclopedia What is coronary artery bypass graft surgery – MedicineNet Medline Plus Medical Encyclopedia Coronary Artery Bypass Procedure – Medline Plus/OR Liv Merck Manual – Heart and Bypass, Sabiston Textbook of Surgery What is Coronary Artery Bypass Grafting - STS Coronary Artery Bypass - The Surgery Book CABG - Vesalius.com 15. From “Brief commentary for CABG”, a portion of the physician’s narrative provided by Synergy that was not included on the tape.

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CABG Bibliography Anatomica Global Book Publishing Pty Ltd Willoughby, NSW Australia Reprinted by Barnes and Noble 2003 Bypass Surgery, Coronary Artery American Heart Association Dallas, TX http://www.americanheart.org/presenter.jhtml?identifier=4484 Cardiopulmonary Bypass The Heart Center Encyclopedia Cincinnati Children's Heart Center Cincinnati, OH http://www.cincinnatichildrens.org/health/heart- encyclopedia/treat/surg/bypass.htm Coronary Artery Bypass Graft (CABG BUPA Reviewed by Dr James Quekett, Bsc.MB Ch.B MRCGP DRCOG DFFP http://hcd2.bupa.co.uk/fact_sheets/html/con_art_bypass.html Coronary Artery Bypass Graft Vesalius.com © Lion Reef Software, Inc., 1996 - 2006. http://www.vesalius.com/graphics/archive/archtn.asp?VID=355&nrVID=191 Coronary Artery Bypass Procedure Morristown Memorial Hospital MedlinePlus/ORLive October 29, 2004 http://www.nlm.nih.gov/medlineplus/surgeryvideos.html

http://www.vesalius.com/graphics/archive/archtn.asp?VID=355&nrVID=191

http://www.nlm.nih.gov/medlineplus/surgeryvideos.html

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Coronary Artery Bypass Surgery St. Jude Medical, Inc Saint Paul, MN http://www.sjm.com/conditions/condition.aspx?name=Coronary+Artery+Disease Current Surgical Diagnosis & Treatment 11th Edition Way, Lawrence, MD and Doherty, Gerard M, MD, Editors Lange Medical Books/McGraw Hill 2003 Medline Plus Medical Encyclopedia Najafian, Nader, M.D., Associate Physician, Renal Division, Brigham & Women's Hospital, Instructor of Medicine, Harvard Medical School. Reviewed by VeriMed Healthcare Network. Updated 6/13/2005 http://www.nlm.nih.gov/medlineplus/ency/article/003462.htm The Merck Manual of Medical Information Second Home Edition Merck & Co., Inc. 2003 Sabiston Textbook of Surgery 16th Edition Courtney M., Jr., M.D. Townsend (Editor); Beauchamp, Daniel R., M.D. (Editor): Evers, B. Mark M.D. (Editor): Mattox, Kenneth L. (Editor); David C. Sabiston (Editor): W.B. Saunders Co. 2001 The Surgery Book Youngson, Robert M., MD; The Diagram Group St. Martin’s Griffin New York 1993

http://www.nlm.nih.gov/medlineplus/ency/article/003462.htm

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What is Coronary Artery Bypass Graft (CABG) Ssurgery MedicineNet.com Last Editorial Review: 4/15/2002 © 1996-2005 MedicineNet, Inc. http://www.medicinenet.com/coronary_artery_bypass_graft/article.htm What is Coronary Artery Bypass Grafting (CABG)? Society of Thoracic Surgeons Author: Thoralf M. Sundt, MD Medical Illustrator: Jill Rhead, MA http://www.sts.org/sections/patientinformation/adultcardiacsurgery/cabg/index.html

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