Heart procedures: pericardiocentesis, sternotomy and bypass grafts

1. Pericardiocentesis: the subxiphoid route

Under echo guidance, the needle enters at the left xiphocostal angle, angled about 30° to the skin and aimed at the left shoulder, passing under the costal margin into the pericardial space in front of the right ventricle. With echo, an apical or parasternal entry is often chosen where the fluid is deepest and closest to the skin.

Surgeon’s corner: Tamponade: hypotension, raised jugular venous pressure and muffled heart sounds, with pulsus paradoxus; echo shows diastolic collapse of the right heart. Drain under ultrasound with ECG and pressure monitoring; in trauma, type A aortic dissection or free-wall rupture the treatment is emergency surgery — needle drainage there is only a temporising step in extremis, removing small volumes.

2. Median sternotomy

Most heart operations go through the sternum: a midline incision from the suprasternal notch to below the xiphoid, then the bone is divided with a saw and spread. The pericardium is opened in front of the heart, the right ventricle and the aorta immediately below.

Surgeon’s corner: At redo sternotomy the right ventricle or a previous graft may be stuck to the back of the sternum: imaging before reopening and careful oscillating-saw technique prevent catastrophic bleeding.

3. Coronary bypass: LIMA to LAD

The left internal mammary (thoracic) artery is freed from the back of the chest wall, left attached to the subclavian artery and sewn to the LAD beyond the narrowing. It is the most durable graft — more than nine in ten are open after ten years — and improves survival.

Surgeon’s corner: Bypass rather than stents is favoured in three-vessel disease (especially with diabetes or a low ejection fraction) and in complex left main disease (intermediate–high SYNTAX score); in low-complexity left main disease PCI is a reasonable alternative. The heart team decides.

4. Vein grafts to the right and circumflex arteries

For the other territories, segments of great saphenous vein (or the radial artery) are sewn from the ascending aorta to the right coronary artery and to obtuse marginal branches of the circumflex.

Surgeon’s corner: Vein grafts degenerate: about half are diseased or blocked at ten years. A patient with recurrent angina years after bypass often has a failing vein graft while the LIMA is still open.