melissalynnfalkowski
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PRE-OP DIAGNOSIS: Severe mitral regurgitation with patent foramen ovale
POST-OP DIAGNOSIS: Same with severe atherosclerosis and occlusion of the right femoral artery
PROCEDURE: Complex mitral valve repair using Gore-Tex Neo Cordis to the P3 segment of the posterior leaflet with a #28 Physio II annuloplasty ring, closure of PFO, transesophageal echocardiography, right femoral artery endarterectomy, embolectomy of right femoral artery
DICTATION: Patient was taken to the OR and placed on the table in supine position. He was monitored appropriately, prepped and draped in usual sterile manner. A pulmonary artery vent was placed by anesthesiologist. Transesophageal echocardiography was performed. This revealed severe mitral regurgitation with reversal of flow within the pulmonary veins, mitral annulus was dilated. There was a flail segment in the posterior leaflet. The jet of regurgitation was a central jet. Ventricular function was preserved. The aortic valve was competent.
Incision was made in the right chest. The chest was entered in the level fourth intercostal space. The right lung was deflated. Exposure of the heart and pericardium was excellent. Pericardium was opened anterior to the phrenic nerve.
Cut down was made in the right femoral vessels. Patient was systemically heparinized and cannulated via the right femoral vein and the right femoral artery. Transesophageal echocardiography was used to confirm placement of these catheters. During placement of the venous catheter it extended up into the inferior vena cava across the patent foramen ovale and into the left atrium. This was withdrawn back and manual positioning placed within the superior vena cava. This confirmed the evidence of the patent foramen ovale and this was closed during the procedure. Placement of the right femoral arterial cannula was without incident however I could not advance the endo balloon. We were able to get the wire up into the aortic root and visualized it well on echocardiography however there was some knuckling of the catheter somewhere along the line and I could not get the endo balloon upwards. I did not force it and aborted this approach and used a direct cross clamp approach with clamp.
Bypass was instituted and the patient was kept normothermic. An aortic root vent was placed directly in the aorta and this was used for cardioplegia administration as well and aortic cross clamp was applied and intermittent antegrade cold blood cardioplegia was administered with good diastolic arrest of the heart. Pump time was 182 minutes. Clamp time 113 minutes.
Attention was turned towards the left atrium. Waterston's groove was developed. Left atriotomy was performed and exposure to the mitral valve was adequate. Inspecting the valve I found that there was a ruptured cord to the P3 segment of the posterior leaflet. I attached two neo Gore-Tex cords of CV 4 Gore-Tex and resuspended the posterior leaflet. I then placed annular sutures for ring. I chose a #28 Physio II ring. Sutures were placed through the ring and it was secured in place with a core knot device. The valve was tested and found to be completely competent. There was no leak. Carbon dioxide and routine maneuvers were taken to prevent embolization of air and particulate matter and the left atrium was closed with running 4-0 Prolene suture.
Two pacing wires were placed in the right ventricle and right atrium. Patient was then weaned from cardiopulmonary bypass. Pacing was initially needed but was discontinued after patient's intrinsic rhythm recuperated. The usual small dose of pressors was used and the patient separated from the heart/lung machine.
Protamine was administered and all cannulas were removed. The right femoral vein was closed with a running 6-0 Prolene suture and the right femoral artery was closed with a running 5-0 Prolene suture. I found a large amount of plaque within the right femoral artery and during closure it appeared that there was a large amount of plaque present which was not present during initial cannulation. I was concerned that this had embolized from further upstream although there was significant calcification within the vessel wall itself. I checked for pulse distal to the femoral arterial closure and it was weak. Doppler pulses in the right foot were absent and I decided to re-explore this area.
Patient was given an additional 5000 units of heparin. The arteriotomy opened and a large plaque was found within this area and endarterectomy of the common femoral artery was performed extending down past the superficial femoral and profunda. A good endpoint was obtained and the vessel was irrigated out although there was some hard plaque left at the posterior wall, there was good flow from the profunda, superficial femoral with backbleeding, also good antegrade flow. I placed a #5 Fogarty catheter down the superficial femoral artery and I did not get any material out and reclosed the vessel with a running 5-0 Prolene suture. I checked pulses in the right foot and they were presents with a Doppler.
All wounds were then irrigated and two chest tubes were placed in the right chest. The ribs were approximated with #2 intercostal Vicryl sutures, muscle layers with 0 Vicryl, subcutaneous wounds with 2-0 Vicryl and skin with 3-0 Monocryl. A sterile dressing was applied and the patient was taken to the Open Heart Unit in critical condition. He tolerated the procedure well.
POST-OP DIAGNOSIS: Same with severe atherosclerosis and occlusion of the right femoral artery
PROCEDURE: Complex mitral valve repair using Gore-Tex Neo Cordis to the P3 segment of the posterior leaflet with a #28 Physio II annuloplasty ring, closure of PFO, transesophageal echocardiography, right femoral artery endarterectomy, embolectomy of right femoral artery
DICTATION: Patient was taken to the OR and placed on the table in supine position. He was monitored appropriately, prepped and draped in usual sterile manner. A pulmonary artery vent was placed by anesthesiologist. Transesophageal echocardiography was performed. This revealed severe mitral regurgitation with reversal of flow within the pulmonary veins, mitral annulus was dilated. There was a flail segment in the posterior leaflet. The jet of regurgitation was a central jet. Ventricular function was preserved. The aortic valve was competent.
Incision was made in the right chest. The chest was entered in the level fourth intercostal space. The right lung was deflated. Exposure of the heart and pericardium was excellent. Pericardium was opened anterior to the phrenic nerve.
Cut down was made in the right femoral vessels. Patient was systemically heparinized and cannulated via the right femoral vein and the right femoral artery. Transesophageal echocardiography was used to confirm placement of these catheters. During placement of the venous catheter it extended up into the inferior vena cava across the patent foramen ovale and into the left atrium. This was withdrawn back and manual positioning placed within the superior vena cava. This confirmed the evidence of the patent foramen ovale and this was closed during the procedure. Placement of the right femoral arterial cannula was without incident however I could not advance the endo balloon. We were able to get the wire up into the aortic root and visualized it well on echocardiography however there was some knuckling of the catheter somewhere along the line and I could not get the endo balloon upwards. I did not force it and aborted this approach and used a direct cross clamp approach with clamp.
Bypass was instituted and the patient was kept normothermic. An aortic root vent was placed directly in the aorta and this was used for cardioplegia administration as well and aortic cross clamp was applied and intermittent antegrade cold blood cardioplegia was administered with good diastolic arrest of the heart. Pump time was 182 minutes. Clamp time 113 minutes.
Attention was turned towards the left atrium. Waterston's groove was developed. Left atriotomy was performed and exposure to the mitral valve was adequate. Inspecting the valve I found that there was a ruptured cord to the P3 segment of the posterior leaflet. I attached two neo Gore-Tex cords of CV 4 Gore-Tex and resuspended the posterior leaflet. I then placed annular sutures for ring. I chose a #28 Physio II ring. Sutures were placed through the ring and it was secured in place with a core knot device. The valve was tested and found to be completely competent. There was no leak. Carbon dioxide and routine maneuvers were taken to prevent embolization of air and particulate matter and the left atrium was closed with running 4-0 Prolene suture.
Two pacing wires were placed in the right ventricle and right atrium. Patient was then weaned from cardiopulmonary bypass. Pacing was initially needed but was discontinued after patient's intrinsic rhythm recuperated. The usual small dose of pressors was used and the patient separated from the heart/lung machine.
Protamine was administered and all cannulas were removed. The right femoral vein was closed with a running 6-0 Prolene suture and the right femoral artery was closed with a running 5-0 Prolene suture. I found a large amount of plaque within the right femoral artery and during closure it appeared that there was a large amount of plaque present which was not present during initial cannulation. I was concerned that this had embolized from further upstream although there was significant calcification within the vessel wall itself. I checked for pulse distal to the femoral arterial closure and it was weak. Doppler pulses in the right foot were absent and I decided to re-explore this area.
Patient was given an additional 5000 units of heparin. The arteriotomy opened and a large plaque was found within this area and endarterectomy of the common femoral artery was performed extending down past the superficial femoral and profunda. A good endpoint was obtained and the vessel was irrigated out although there was some hard plaque left at the posterior wall, there was good flow from the profunda, superficial femoral with backbleeding, also good antegrade flow. I placed a #5 Fogarty catheter down the superficial femoral artery and I did not get any material out and reclosed the vessel with a running 5-0 Prolene suture. I checked pulses in the right foot and they were presents with a Doppler.
All wounds were then irrigated and two chest tubes were placed in the right chest. The ribs were approximated with #2 intercostal Vicryl sutures, muscle layers with 0 Vicryl, subcutaneous wounds with 2-0 Vicryl and skin with 3-0 Monocryl. A sterile dressing was applied and the patient was taken to the Open Heart Unit in critical condition. He tolerated the procedure well.
