TWilliam2019
Guru
Postoperative diagnosis:
#1 ascending aortic dissection
#2 acute ischemic stroke with a right hemi--deficit
#3 moderate pulmonary hypertension
#4 cardiomegaly with left ventricular hypertrophy
33864
33866
*
Procedure:
#1 replacement of ascending aorta with 32 mm hemashield graft
#2 replacement of the aortic arch using a 24 mm Gelweave graft
#3 interposition bypass to the left carotid using a 6 mm Dacron graft
#4 interposition graft to the innominate artery using an 8 mm Dacron graft
#5 deep hypothermic circulatory arrest (69 minutes)
#6 resuspension of the aortic valve
#7 cutdown and exposure of the right axillary artery with placement of 8 mm end-to-side graft
#8 right femoral arterial cutdown with direct cannulation using a 23 mm femoral cannula
#9 primary repair of the right femoral artery
#10 management of coagulopathy (90 minutes)
#11 cardiopulmonary bypass
#12 bilateral cerebral Somanetics
#13 TEE with visualization and interpretation ×2
Indication:
48-year-old African-American male presenting with syncope and right-sided transient neurologic deficits. Patient underwent code stroke evaluation and was ultimately given TPA given his presentation. CTA of the head, neck, chest, abdomen, and pelvis revealed an ascending aortic dissection. I discussed the risk and benefits of surgery extensively with the patient, and they understand the high risks, risk of morbidity and mortality, without definitive guarantee of neurologic improvement. He is being taken to surgery emergently for repair.
*
Intraoperative findings:
The patient had an ascending aortic aneurysm that originated at the level of the sinotubular junction, and measured approximately 4.8 cm in size. The aorta tapered to a normal caliber leading up to the arch. The aortic intimal/media tear likely originated in the aortic arch. Upon placing the patient on cardiopulmonary bypass using right axillary artery cannulation, high pressures were met in a poor index flow of 1.8 resulted in termination of bypass use via the right axillary and the patient was transitioned the femoral cannulation. Upon evaluating the arch under circulatory arrest, the arch vessels had the media completely detached with invagination of the media into the aortic arch. The aortic arch had to be resected up to the level of the left subclavian. The patient had a bovine arch and the left carotid along with the innominate artery had to be individually grafted and implanted into the neo-ascending aortic graft.
*
Pre-bypass TEE:
Pre-bypass TEE showed normal left ventricular function. Ejection fraction was greater than 55%. There were no regional wall motion abnormalities identified. There was moderate left ventricular hypertrophy. There was trace mitral regurgitation with a normal mitral valve apparatus. The left atrial appendage was free of thrombus. There was no echogenic smoke within the left atrium. Right ventricular function was normal. There was trace tricuspid regurgitation. The aortic valve was a trileaflet valve with trace central insufficiency at the zone of coaptation. The dissection was identified extending to the level of the sinotubular junction. Next
*
Post-bypass TEE:
Post-bypass TEE showed preservation of ventricular function. There was no alteration of valvular function. Right ventricular function was normal. The aortic valve was competent with trace central insufficiency at the zone of coaptation, completely unchanged from previous TEE. There was no dissection flap identified within the root.
Procedure in detail:
After consent was obtained from the family, the patient was taken emergently to the operating suite and placed on the operating table. Gen. anesthesia was induced with endotracheal intubation. Monitoring lines were placed by anesthesia. TEE probe was placed by anesthesia. The patient was prepped and draped in usual sterile fashion using DuraPrep solution. Timeout was used confirm patient identity as well as the surgery to be performed. Next
*
Pre-bypass TEE was performed with findings as described. Once this was completed, a right horizontal subclavicular incision was made. The soft tissues were divided. The pectoralis major muscle was released from its clavicular attachments. The underlying pectoralis minor muscle was retracted laterally. Several crossing small venous and arterial branches were clipped and incised. The underlying axillary artery was identified. It was encircled with a vessel loop proximally and distally. The patient was given 5000 units of heparin. Again, should be noted that patient did receive TPA prior to surgery. Proximal distal vascular clamps were placed for hemostatic control. A longitudinal arteriotomy was made. An 8 mm graft was then anastomosed to the subclavian artery in an end to side fashion using 5-0 Prolene. A 23 French arterial cannula was placed within the graft. De-airing of the graft was then performed.
*
Sternal incision was made. The soft tissues were divided. Sternotomy was performed in standard fashion. The sternal tables were cauterized for hemostasis and bone wax was placed. The anterior mediastinal soft tissue was divided. The pericardium was opened and teed off along the diaphragm. Stay sutures were placed create a pericardial well. Gross observation of the ascending aorta revealed an aortic aneurysm at the level of the sinotubular junction, but it was measuring 4.8 cm by CT scan and this was consistent with gross observation. The aorta had a bright red hue throughout its ascending portion. The patient was fully heparinized and ACT was found be therapeutic for full cannulation and bypass.
*
Dual stage venous cannula was then placed in the right atrium. Reverse autologous priming of the pump was performed. The patient was then placed on full cardiopulmonary bypass. After going on full flow, my perfusionist reported elevated arterial perfusion pressures and can only run at an index of 1.8. Decision was made to reinitiate ventilation and wean the heart off of bypass. Decision was made to perform femoral cannulation to improve flows.
*
Incision was then made in the right inguinal region. Cutdown to the right femoral artery was performed using electrocautery with division of the soft tissues. The femoral sheath was opened. The underlying femoral artery was identified and encircled with a vessel loop. A 5-0 Prolene was then used to create a pursestring on the anterior wall the femoral artery. Needle was inserted into the femoral artery and guidewire was advanced without difficulty. Serial dilation the femoral artery was performed and then finally, the 23 French femoral arterial cannula was placed and secured. The arterial line was de-aired. Again, her pulmonary bypass was initiated with much improvement in the flows. This also allowed for improved cerebral Somanetics, with the cerebral Somanetics improving to the 60 and 70th percentile.
*
The patient was then systemically cooled to 18°C. During this time, retrograde cardioplegia cannula was placed through the free wall the right atrium and positioned in the coronary sinus. Cross-clamp was then placed and cold retrograde cardioplegia was delivered to achieve full diastolic cardiac arrest. Temperature probe was placed in the septum. Ice was placed over the right ventricle.
After ventricular fibrillation was induced, the ascending aorta was opened with Metzenbaum scissors. Dissection flap was clearly visualized and appeared to terminate a millimeter or 2 beyond the commissures of the aortic valve. The aortic root was uninvolved. It was at this point, that resuspension of the aortic valve was performed. A pledgeted 5-0 Prolene was placed along all 3 of the commissure to resuspend the valve. Pledgeted sutures were then placed along the sinotubular junction in order to anchor the intima and media to the adventitia.
*
Once the patient had been at 18 or 19° for approximately 20 minutes, the head was packed in ice. Decision was made to perform circulatory arrest. Once this was performed, the clamp was released and drop sucker was placed within the aorta. The ascending aorta was resected. And submitted to pathology. The aortic arch was evaluated and it was quite evident that the aortic arch was heavily involved. Each had vessel appeared to be completely detached from the media. I suspect, that the tear may have originated in the arch, but this was not definitive. The aortic arch was then resected to the level of the left subclavian artery. This was also submitted to pathology. The left carotid artery at its takeoff had no media. The left carotid artery was resected back until the media was identified. The innominate artery also had no media at the level of the takeoff. It was resected back to the level of the bifurcation between the right subclavian and right carotid.
*
Individual interposition grafts were placed to the carotid and innominate artery. A 6 mm Dacron graft was then sewn end-to-end to the left carotid artery. An 8 mm Dacron graft was sewn end-to-end to the innominate artery. Once this was completed, a 24 mm Gelweave graft was sewn to the distal aortic arch, just proximal to the left subclavian takeoff. Pledgeted sutures were used to tack the media to the wall of the left subclavian and create patency. An outer felt strip was used to reinforce this anastomosis. Once this was completed, the 6 mm and 8 mm graft were each sewn to the neo-ascending aorta graft. Once a 6 mm graft was anastomosed to the aortic graft, de-airing was performed and the cross-clamp was placed to allow for antegrade cerebral perfusion via the left carotid artery. During circulatory arrest which lasted 69 minutes, the cerebral Somanetics dip to the high 30th percentile, but quickly improved to greater than 50th percentile with the antegrade cerebral perfusion. The 8 mm graft was then sewn to the aorta. Flows were lowered and the cross-clamp was then removed and positioned more proximally on the aortic graft to allow for bilateral cerebral perfusion. Next, the patient was rewarmed to 32°C.
*
There was a significant discrepancy between the sinotubular junction size and the 24 mm graft which had been placed on the distal arch. A 32 mm Dacron graft was then anastomosed to the sinotubular junction with outer felt strip reinforcement in order to conform sinotubular junction to a size reduction. The grafts were then contoured and then anastomosed together using 4-0 Prolene. A needle vent was placed in the graft and placed on high suction. The patient was then fully rewarmed. The patient was placed in steep Trendelenburg and de-airing maneuvers were performed. After adequate de-airing, the needle vent was placed on high suction and the cross-clamp was removed. Next
*
The heart was defibrillated to establish a sinus rhythm. Pacing wires were placed on the right ventricle brought out the level of the skin. Anastomoses were found to be relatively hemostatic. There were several areas that were oversewn with 4-0 Prolene or 5-0 Prolene. Once this is completed, the lungs were ventilated. After full rewarming, the heart was weaned from cardiopulmonary bypass without difficulty. Final TEE was performed with findings as described.
*
The next 90 minutes were dedicated to reversal of the coagulopathy. Protamine was delivered to reverse the effects of heparin. The patient received 2 rounds of bleeding protocol which included packed red cells, platelets, FFP, as well as cryoprecipitate. After hemostasis was achieved, CoSeal was sprayed over the aortic anastomoses. The mediastinum had been irrigated with saline as well as antibiotic irrigation multiple times to the procedure. A right angle chest tube was placed on the diaphragm as well as in the right pleural cavity. A 32 French straight chest tube was placed in the mediastinum. The sternum was reapproximated with #7 wires. It also had double wires used secondary to the patient's obesity. This. Abdominal fascia was reapproximated with 0 Ethibond. Soft tissues reapproximated with 0 Vicryl. Skin was closed with 4 Monocryl running subcuticular manner. Next
*
The right axillary artery graft was clipped twice proximally to allow for a small residual stump. The remainder of the graft was excised and it was then oversewn with 5-0 Prolene. The soft tissues reapproximated with 2-0 Vicryl. Skin was closed with 4-0 Monocryl.
*
During the time in which coagulopathy was being corrected, the right femoral artery cannula was removed. The pursestring was cinched to achieve partial hemostasis. 2 figure-of-eight's were then placed using 5-0 Prolene to achieve full hemostasis. The femoral artery was palpated distal to the primary repair and found to have a good pulse. The soft tissues reapproximated with 2-0 Vicryl. Skin was closed with 4 Monocryl running subcuticular manner. Next
*
The patient tolerated procedure well and was transferred to CVRU in critical condition.
*
Specimens: Ascending aorta
estimated blood loss: 650 mL
blood replaced: 2 rounds of transfusion protocol, please see official records
drains: Chest tubes as described
implants: 24 mm Gelweave graft to the ascending aorta, 32 mm Dacron graft for the proximal ascending aorta, 6 and 8 mm Dacron graft for interposition grafts
condition at completion of procedure: Critical
#1 ascending aortic dissection
#2 acute ischemic stroke with a right hemi--deficit
#3 moderate pulmonary hypertension
#4 cardiomegaly with left ventricular hypertrophy
33864
33866
*
Procedure:
#1 replacement of ascending aorta with 32 mm hemashield graft
#2 replacement of the aortic arch using a 24 mm Gelweave graft
#3 interposition bypass to the left carotid using a 6 mm Dacron graft
#4 interposition graft to the innominate artery using an 8 mm Dacron graft
#5 deep hypothermic circulatory arrest (69 minutes)
#6 resuspension of the aortic valve
#7 cutdown and exposure of the right axillary artery with placement of 8 mm end-to-side graft
#8 right femoral arterial cutdown with direct cannulation using a 23 mm femoral cannula
#9 primary repair of the right femoral artery
#10 management of coagulopathy (90 minutes)
#11 cardiopulmonary bypass
#12 bilateral cerebral Somanetics
#13 TEE with visualization and interpretation ×2
Indication:
48-year-old African-American male presenting with syncope and right-sided transient neurologic deficits. Patient underwent code stroke evaluation and was ultimately given TPA given his presentation. CTA of the head, neck, chest, abdomen, and pelvis revealed an ascending aortic dissection. I discussed the risk and benefits of surgery extensively with the patient, and they understand the high risks, risk of morbidity and mortality, without definitive guarantee of neurologic improvement. He is being taken to surgery emergently for repair.
*
Intraoperative findings:
The patient had an ascending aortic aneurysm that originated at the level of the sinotubular junction, and measured approximately 4.8 cm in size. The aorta tapered to a normal caliber leading up to the arch. The aortic intimal/media tear likely originated in the aortic arch. Upon placing the patient on cardiopulmonary bypass using right axillary artery cannulation, high pressures were met in a poor index flow of 1.8 resulted in termination of bypass use via the right axillary and the patient was transitioned the femoral cannulation. Upon evaluating the arch under circulatory arrest, the arch vessels had the media completely detached with invagination of the media into the aortic arch. The aortic arch had to be resected up to the level of the left subclavian. The patient had a bovine arch and the left carotid along with the innominate artery had to be individually grafted and implanted into the neo-ascending aortic graft.
*
Pre-bypass TEE:
Pre-bypass TEE showed normal left ventricular function. Ejection fraction was greater than 55%. There were no regional wall motion abnormalities identified. There was moderate left ventricular hypertrophy. There was trace mitral regurgitation with a normal mitral valve apparatus. The left atrial appendage was free of thrombus. There was no echogenic smoke within the left atrium. Right ventricular function was normal. There was trace tricuspid regurgitation. The aortic valve was a trileaflet valve with trace central insufficiency at the zone of coaptation. The dissection was identified extending to the level of the sinotubular junction. Next
*
Post-bypass TEE:
Post-bypass TEE showed preservation of ventricular function. There was no alteration of valvular function. Right ventricular function was normal. The aortic valve was competent with trace central insufficiency at the zone of coaptation, completely unchanged from previous TEE. There was no dissection flap identified within the root.
Procedure in detail:
After consent was obtained from the family, the patient was taken emergently to the operating suite and placed on the operating table. Gen. anesthesia was induced with endotracheal intubation. Monitoring lines were placed by anesthesia. TEE probe was placed by anesthesia. The patient was prepped and draped in usual sterile fashion using DuraPrep solution. Timeout was used confirm patient identity as well as the surgery to be performed. Next
*
Pre-bypass TEE was performed with findings as described. Once this was completed, a right horizontal subclavicular incision was made. The soft tissues were divided. The pectoralis major muscle was released from its clavicular attachments. The underlying pectoralis minor muscle was retracted laterally. Several crossing small venous and arterial branches were clipped and incised. The underlying axillary artery was identified. It was encircled with a vessel loop proximally and distally. The patient was given 5000 units of heparin. Again, should be noted that patient did receive TPA prior to surgery. Proximal distal vascular clamps were placed for hemostatic control. A longitudinal arteriotomy was made. An 8 mm graft was then anastomosed to the subclavian artery in an end to side fashion using 5-0 Prolene. A 23 French arterial cannula was placed within the graft. De-airing of the graft was then performed.
*
Sternal incision was made. The soft tissues were divided. Sternotomy was performed in standard fashion. The sternal tables were cauterized for hemostasis and bone wax was placed. The anterior mediastinal soft tissue was divided. The pericardium was opened and teed off along the diaphragm. Stay sutures were placed create a pericardial well. Gross observation of the ascending aorta revealed an aortic aneurysm at the level of the sinotubular junction, but it was measuring 4.8 cm by CT scan and this was consistent with gross observation. The aorta had a bright red hue throughout its ascending portion. The patient was fully heparinized and ACT was found be therapeutic for full cannulation and bypass.
*
Dual stage venous cannula was then placed in the right atrium. Reverse autologous priming of the pump was performed. The patient was then placed on full cardiopulmonary bypass. After going on full flow, my perfusionist reported elevated arterial perfusion pressures and can only run at an index of 1.8. Decision was made to reinitiate ventilation and wean the heart off of bypass. Decision was made to perform femoral cannulation to improve flows.
*
Incision was then made in the right inguinal region. Cutdown to the right femoral artery was performed using electrocautery with division of the soft tissues. The femoral sheath was opened. The underlying femoral artery was identified and encircled with a vessel loop. A 5-0 Prolene was then used to create a pursestring on the anterior wall the femoral artery. Needle was inserted into the femoral artery and guidewire was advanced without difficulty. Serial dilation the femoral artery was performed and then finally, the 23 French femoral arterial cannula was placed and secured. The arterial line was de-aired. Again, her pulmonary bypass was initiated with much improvement in the flows. This also allowed for improved cerebral Somanetics, with the cerebral Somanetics improving to the 60 and 70th percentile.
*
The patient was then systemically cooled to 18°C. During this time, retrograde cardioplegia cannula was placed through the free wall the right atrium and positioned in the coronary sinus. Cross-clamp was then placed and cold retrograde cardioplegia was delivered to achieve full diastolic cardiac arrest. Temperature probe was placed in the septum. Ice was placed over the right ventricle.
After ventricular fibrillation was induced, the ascending aorta was opened with Metzenbaum scissors. Dissection flap was clearly visualized and appeared to terminate a millimeter or 2 beyond the commissures of the aortic valve. The aortic root was uninvolved. It was at this point, that resuspension of the aortic valve was performed. A pledgeted 5-0 Prolene was placed along all 3 of the commissure to resuspend the valve. Pledgeted sutures were then placed along the sinotubular junction in order to anchor the intima and media to the adventitia.
*
Once the patient had been at 18 or 19° for approximately 20 minutes, the head was packed in ice. Decision was made to perform circulatory arrest. Once this was performed, the clamp was released and drop sucker was placed within the aorta. The ascending aorta was resected. And submitted to pathology. The aortic arch was evaluated and it was quite evident that the aortic arch was heavily involved. Each had vessel appeared to be completely detached from the media. I suspect, that the tear may have originated in the arch, but this was not definitive. The aortic arch was then resected to the level of the left subclavian artery. This was also submitted to pathology. The left carotid artery at its takeoff had no media. The left carotid artery was resected back until the media was identified. The innominate artery also had no media at the level of the takeoff. It was resected back to the level of the bifurcation between the right subclavian and right carotid.
*
Individual interposition grafts were placed to the carotid and innominate artery. A 6 mm Dacron graft was then sewn end-to-end to the left carotid artery. An 8 mm Dacron graft was sewn end-to-end to the innominate artery. Once this was completed, a 24 mm Gelweave graft was sewn to the distal aortic arch, just proximal to the left subclavian takeoff. Pledgeted sutures were used to tack the media to the wall of the left subclavian and create patency. An outer felt strip was used to reinforce this anastomosis. Once this was completed, the 6 mm and 8 mm graft were each sewn to the neo-ascending aorta graft. Once a 6 mm graft was anastomosed to the aortic graft, de-airing was performed and the cross-clamp was placed to allow for antegrade cerebral perfusion via the left carotid artery. During circulatory arrest which lasted 69 minutes, the cerebral Somanetics dip to the high 30th percentile, but quickly improved to greater than 50th percentile with the antegrade cerebral perfusion. The 8 mm graft was then sewn to the aorta. Flows were lowered and the cross-clamp was then removed and positioned more proximally on the aortic graft to allow for bilateral cerebral perfusion. Next, the patient was rewarmed to 32°C.
*
There was a significant discrepancy between the sinotubular junction size and the 24 mm graft which had been placed on the distal arch. A 32 mm Dacron graft was then anastomosed to the sinotubular junction with outer felt strip reinforcement in order to conform sinotubular junction to a size reduction. The grafts were then contoured and then anastomosed together using 4-0 Prolene. A needle vent was placed in the graft and placed on high suction. The patient was then fully rewarmed. The patient was placed in steep Trendelenburg and de-airing maneuvers were performed. After adequate de-airing, the needle vent was placed on high suction and the cross-clamp was removed. Next
*
The heart was defibrillated to establish a sinus rhythm. Pacing wires were placed on the right ventricle brought out the level of the skin. Anastomoses were found to be relatively hemostatic. There were several areas that were oversewn with 4-0 Prolene or 5-0 Prolene. Once this is completed, the lungs were ventilated. After full rewarming, the heart was weaned from cardiopulmonary bypass without difficulty. Final TEE was performed with findings as described.
*
The next 90 minutes were dedicated to reversal of the coagulopathy. Protamine was delivered to reverse the effects of heparin. The patient received 2 rounds of bleeding protocol which included packed red cells, platelets, FFP, as well as cryoprecipitate. After hemostasis was achieved, CoSeal was sprayed over the aortic anastomoses. The mediastinum had been irrigated with saline as well as antibiotic irrigation multiple times to the procedure. A right angle chest tube was placed on the diaphragm as well as in the right pleural cavity. A 32 French straight chest tube was placed in the mediastinum. The sternum was reapproximated with #7 wires. It also had double wires used secondary to the patient's obesity. This. Abdominal fascia was reapproximated with 0 Ethibond. Soft tissues reapproximated with 0 Vicryl. Skin was closed with 4 Monocryl running subcuticular manner. Next
*
The right axillary artery graft was clipped twice proximally to allow for a small residual stump. The remainder of the graft was excised and it was then oversewn with 5-0 Prolene. The soft tissues reapproximated with 2-0 Vicryl. Skin was closed with 4-0 Monocryl.
*
During the time in which coagulopathy was being corrected, the right femoral artery cannula was removed. The pursestring was cinched to achieve partial hemostasis. 2 figure-of-eight's were then placed using 5-0 Prolene to achieve full hemostasis. The femoral artery was palpated distal to the primary repair and found to have a good pulse. The soft tissues reapproximated with 2-0 Vicryl. Skin was closed with 4 Monocryl running subcuticular manner. Next
*
The patient tolerated procedure well and was transferred to CVRU in critical condition.
*
Specimens: Ascending aorta
estimated blood loss: 650 mL
blood replaced: 2 rounds of transfusion protocol, please see official records
drains: Chest tubes as described
implants: 24 mm Gelweave graft to the ascending aorta, 32 mm Dacron graft for the proximal ascending aorta, 6 and 8 mm Dacron graft for interposition grafts
condition at completion of procedure: Critical