sandy06
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POSTOPERATIVE DIAGNOSIS:
Severe aortic insufficiency, aortic root abscess, severe mitral
regurgitation, aortic and mitral valve endocarditis, congestive heart
failure,respiratory failure, cardiomyopathy, ection fraction 30
percent and an aortic to left atrial fistula.
PROCEDURE PERFORMED:
Replacement of the aortic valve and ascending aorta
utilizing a 25 mm Cadaveric aortic root homograft. Debridement of
aortic in mitral valve. Reimplantation of the coronaries, complex
mitral valve repair utilizing a Cadaveric antral leaflet mitral valve
patch to repair a large defect in the native anterior leaflet mitral
valve, and exploration repair of left femoral artery.
OPERATING SURGEON:
ASSISTANT:
PROCEDURE:
The patient was taken to the OR, intubated from the intensive care
unit and prepped and draped in the usual fashion. A two team approach
was utilized, one team exposing a left femoral artery and vein in a
Seldinger technique was utilized to cannulate the left femoral
artery. The patient was heparinized and a median sternotomy incision
was performed. The incision was taken down through skin and
subcutaneous tissues, down to the midportion of sternum. Electrical
saw was utilized for median sternotomy. Thereafter, a sternal
retractor was placed. The pericardium was opened in midline tacked
the skin. Of note, at least a liter and a half of pleural fluid was
aspirated from each pleural cavity. The venous and retrograde
cardioplegia cannulations were performed in routine fashion. We then
instituted full cardiopulmonary bypass. The aorta was cross-clamped
and a and retrograde cardioplegia was given, as well as the antegrade
cardioplegia and this was repeated every 15 minutes throughout the
operation as well as given cardioplegia directed down the coronary
ostia. The aorta was transected and it was immediately noted that
then not coronary leaflet was totally destroyed by the by the
vegetation and the noncoronary leaflet was resected and sent off to
pathology for culture. Then the left and right coronary leaflets were
also resected down to the anulus. The decision was made to place
Cadaveric aortic homograft. The anulus was sized. It was sized at a
27 so therefore a 25 mm, Cadaveric homograft was thawed and probably
prepared for implantation. During the thawing process the aortic
anulus was debrided a large cavity was evident and there was also a
large perforation into the anterior leaflet of the mitral valve and
this was extensively debrided as well. A noted left lateral atriotomy
was also performed exposing the mitral valve was performed and there
was noted that the dome of the atrial wall was intact and and the
destruction over the anulus extended to the antral leaflet mitral
valve on to its midportion, as well as onto the anulus its self. Once
the Cadaveric homograft was thawed out the anterior leaflet was
resected and this was used as a patch to repair the defect in the
anterior leaflet of the mitral valve. This was sutured to the edges
with a 6-0 Prolene suture in a continuous over and over fashion.
Thereafter 4-0 Tevdek sutures were placed circumferentially in one
linear plane, and the sutures were placed on the newly formed anulus
and then the homograft was prepared with the muscle barbae debrided
and then in 2 3 mm of muscle from the anulus was left intact.
Thereafter, the sutures were placed through the inflow aspect of the
of the homograft each the sutures were tied over a pericardial strip
thereafter openings were cut in the anterior portion and the
homograft buttons were transected and then the native buttons were
fashioned to accommodate these openings in the homograft and sutured
in an end-to-side fashion with 6-0 Prolene suture in a continuous
over-and-over fashion. Thereafter, the homograft will was sized to
the aorta and then sutured in end-to-end fashion with a 5-0 Prolene
suture in a continuous over-and-over fashion. Thereafter the left
atrium was closed with 4-0 Prolene suture two layer closure. The
patient placed in Trendelenburg position. The aortic cross-clamp was
removed. The multiple de-airing maneuvers were performed utilizing a
Venti needle in the root of the aorta. Only trace mitral
insufficiency was evident after in this the de-airing process and two
ventricular and one atrial pacing wire was placed well as substernal
chest tube and bilateral pleural chest tube. The patient was then
weaned from bypass. The venous cannula was removed. The purse suture
tied down. The patient protamine which he tolerated well. Then the
arterial cannula was removed from the femoral artery and direct
repair left femoral artery was performed, approximating intima and
adventitia in two-layer closure. Thereafter, number 5 steel sternal
wires were placed to approximate the sternum. Then muscles
subcutaneous tissue and skin were all closed in routine fashion.