49-year-old female who presented with dizziness.
MRI showed infarcts to the right occipitoparietal area. In
addition, she embolized to her index finger. CT of the chest
revealed filling defect anteromedially in the ascending aorta above
the aortic valve. Previous echo performed noting no abnormalities
with the aortic valve or mitral valve. However, there appeared to
be some clot in the left atrial appendage. Neurology was consulted.
A safe period of time was allowed for the patient to lessen the risk
of converting an ischemic stroke to a hemorrhagic stroke. Certainly
she is still at risk, however, she is certainly at risk for further
embolization as well.
OPERATION IN DETAIL:
After informed consent, patient brought to the operating suite and
placed in supine position. Induction of anesthesia had been
established. The TEE probe had been placed and there were no
abnormalities of the aortic valve. Ventricular function appeared
normal. The left femoral artery was palpated preoperatively and
noted to have an excellent and bounding pulse. Dissection utilizing
a small incision to expose the femoral artery was clearly performed.
The sternotomy had been performed in its midline. The pericardium
was opened and reflected laterally. Externally visualizing the
aorta I did not see any pathology. There was no evidence of any
extending intramural hematoma. Dissection was taken as high up to
the level of the innominate. A retrograde cannula was utilized for
retrograde cardioplegia. Antegrade was also placed on the lateral
segment of the aorta away from the clot itself. The patient was
placed on cardiopulmonary bypass with femoral cannulation of right
atrial appendage. At this point in time, the cross-clamp was
applied. Antegrade, as well as retrograde was administered. The
retrograde had a poor waveform and appeared not to have good flow
emanating from the ostium once we opened the aorta. Once we opened
the aorta, the clot was clearly within the center of the opening.
The antegrade catheter was visualized and this was away from the
thrombus, as we had hoped. The cross-clamp did not involve any
further thrombus.
At this point in time, there was a focal thrombus approximately 2.5
cm. This was sent for a stat Gram stain and revealed negative for
organisms. The aorta itself appeared abnormal in this particular
anteromedial segment. It almost appeared as if there was a focal
ulcerated plaque with thrombus on the inside. I did not see any
intramural hematoma, but this area was a little calcific and then
excised a segment of about 3 cm. A Dacron graft was then matched
and placed. The posterior wall of the aorta was not transected,
only the anteromedial segment in tier form fashion. I did not see
anymore abnormalities in the aorta itself. The head was in a down
position. The flow was down. Cross-clamp was removed slightly to
allow any further clot to be thrown toward me in that direction.
Again, I did not visualize any clot whatsoever after excising the
initial clot formation. Patient tolerated the procedure well with
no complications. Assistance with deairing was noted with the TEE.
Several maneuvers were utilized for assistance of deairing, as well
as CO2 and a vent. Patient tolerated the procedure well with no
complications and was separated from cardiopulmonary bypass without
event. Pump time was 58 minutes. Cross-clamp was 41 minutes.
Sternotomy was closed. Two pleural tubes, 2 mediastinal tubes, 1 B
wire.
