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PREOPERATIVE DIAGNOSIS:
History of pulmonic insufficiency with a very large pulmonary artery
aneurysm.
POSTOPERATIVE DIAGNOSIS:
History of pulmonary insufficiency with a very large pulmonary artery
aneurysm, tricuspid regurgitation and right ventricular dilation and
at least mild dysfunction.
PROCEDURE:
Pulmonary artery aneurysm repair with concomitant pulmonic valve
replacement with the use of a pulmonary homograft (CryoLife pulmonary
valve and conduit, serial #, 27 mm size), with concomitant
tricuspid valve repair utilizing a #28 mm Carpentier-Edwards
incomplete tricuspid valve ring (model #, serial #).
PATHOLOGY:
Preoperative TEE demonstrated evidence of severe pulmonic
insufficiency, at least mild pulmonic valve stenosis, very dilated
tricuspid valve anulus with a 3+ tricuspid regurgitation, right
ventricular dilation and at least mild right ventricular dysfunction.
Post repair, well-seated pulmonic valve replacement with no PI, no PS,
trace TR. Preserved left ventricular function. Mild right ventricular
hypokinesis, unchanged from preoperatively. Epicardial scar, none.
Aorta, normal. The tricuspid valve did have evidence of a dilated
tricuspid valve anulus without evidence of specific leaflet
dysfunction. This was amenable to a tricuspid valve annuloplasty
repair. Pulmonic valve did have evidence of significant leaflets with
at least mild pulmonic stenosis and severe pulmonic insufficiency with
a very large, giant pulmonic artery aneurysm. The distal pulmonary
arteries after the bifurcation were ectatic but not aneurysmal. These
were amenable to pulmonic valve replacement with concomitant pulmonic
artery aneurysm repair with pulmonary valve and artery conduit and
homograft.
ESTIMATED BLOOD LOSS:
100 mL.
PROCEDURE IN DETAIL:
After proper identification in the holding area, the patient was
brought to the operating room and placed supine on the operating room
table. Surgical pause was performed according to house regulations.
General endotracheal anesthesia was induced and administered as per
the anesthesiologist. The patient was prepped and draped in the usual
sterile fashion. A midline incision was made. A median sternotomy was
performed. Pericardial well was created. ACT guided heparinization was
instituted. Ascending aorta, SVC and IVC were cannulated with arterial
and venous cannulas respectively. Antegrade and retrograde
cardioplegia catheter was placed. Bypass was begun. The patient was
cooled to 32 degrees Celsius on cardiopulmonary bypass. The SVC and
IVC were carefully dissected free and encircled with umbilical tapes
for snaring. The aorta was cross clamped and 1:4 blood to crystal del
Nido cardioplegia was delivered antegrade and retrograde achieving
satisfactory arrest. Additional cardioplegia was also given down in a
retrograde fashion at intervals. The SVC and IVC were snared.
Attention was turned to the pulmonic valve replacement and pulmonary
artery aneurysm repair. The pulmonary artery was transected just above
the level of the valve. The posterior portion of the pulmonary artery
was carefully dissected free from the posterior structures and
dissected free. All the pulmonary artery aneurysm was resected
distally up to the pulmonary artery bifurcation. All portions of the
resected pulmonary artery aneurysm resected and sent off to pathology
as permanent specimen. The proximal portions of the pulmonary artery
were carefully dissected free down to the level of the valve. The
pulmonary artery valve leaflets were resected. A 27 mm CryoLife
homograft was chosen for the pulmonary artery reconstruction. This
homograft was opened on the back table and thawed and washed
appropriately. Once it was thawed and washed it was passed off and
carefully trimmed proximally. The distal anastomosis was performed
between the distal end of the homograft and the pulmonary artery
bifurcation with a running 4-0 Prolene suture in running fashion. This
was carefully tied down. The proximal anastomosis was performed
between the homograft and the right ventricular outflow tract and the
pulmonic valve anulus with a running 4-0 Prolene suture in running
fashion. Standard de-airing maneuvers were performed and the suture
was tied down.
Attention was then turned to the tricuspid valve repair. Right
atriotomy was created and stay sutures were placed providing very good
visualization of the tricuspid valve anulus. Two Ethibond tricuspid
valve annular sutures were placed circumferentially around the
tricuspid valve anulus being sure to avoid the conduction system. The
anulus was sized with sizers. These annular sutures were passed
through the sewing ring of a #28 mm Carpentier-Edwards incomplete
tricuspid valve ring. The ring was seated in the subvalvular space and
inspected carefully. After ensuring that no suture was trapped, the
tricuspid valve anular sutures were secured in position with the use
of the COR-KNOT device. The patient was fully rewarmed at this point.
The right atriotomy was run closed with running 4-0 Prolene suture in
running fashion in 2 layers in an imbricating fashion and carefully
tied down. The patient was placed in deep Trendelenburg. Warm blood
was given retrograde to flush out the coronary ostia and aortic cross-
clamp was released. Organized rhythm was restored. Epicardial pacing
wires were placed in the inferior surface of the right ventricle and
tunneled through the skin. Twenty-French chest tubes were placed in
the anterior and inferior mediastinum. These channel drains were
secured to the skin with interrupted 2-0 silk sutures. Standard de-
airing maneuvers were performed. The aortic root vent was removed and
oversewn with 4-0 Prolene suture. The patient was gradually weaned
from cardiopulmonary bypass. The total aortic cross-clamp time was 123
minutes. The patient was decannulated. Each cannulation site was
oversewn with 4-0 Prolene suture. Protamine was administered and
hemostasis was achieved which was quite satisfactory at the conclusion
of the case. The patient's epicardial fat was reapproximated loosely
over the patient's aorta with multiple interrupted 2-0 silk sutures.
Patient's sternum was reapproximated with stainless steel wires. The
fascia and subcutaneous layers were run closed with running Vicryl
sutures in layers in the usual fashion. Running Monocryl suture was
used for the skin. All sponge, needle and instrument counts at the end
of the case were correct. The patient was transported intubated in
satisfactory condition to the 5 Blum ICU.
History of pulmonic insufficiency with a very large pulmonary artery
aneurysm.
POSTOPERATIVE DIAGNOSIS:
History of pulmonary insufficiency with a very large pulmonary artery
aneurysm, tricuspid regurgitation and right ventricular dilation and
at least mild dysfunction.
PROCEDURE:
Pulmonary artery aneurysm repair with concomitant pulmonic valve
replacement with the use of a pulmonary homograft (CryoLife pulmonary
valve and conduit, serial #, 27 mm size), with concomitant
tricuspid valve repair utilizing a #28 mm Carpentier-Edwards
incomplete tricuspid valve ring (model #, serial #).
PATHOLOGY:
Preoperative TEE demonstrated evidence of severe pulmonic
insufficiency, at least mild pulmonic valve stenosis, very dilated
tricuspid valve anulus with a 3+ tricuspid regurgitation, right
ventricular dilation and at least mild right ventricular dysfunction.
Post repair, well-seated pulmonic valve replacement with no PI, no PS,
trace TR. Preserved left ventricular function. Mild right ventricular
hypokinesis, unchanged from preoperatively. Epicardial scar, none.
Aorta, normal. The tricuspid valve did have evidence of a dilated
tricuspid valve anulus without evidence of specific leaflet
dysfunction. This was amenable to a tricuspid valve annuloplasty
repair. Pulmonic valve did have evidence of significant leaflets with
at least mild pulmonic stenosis and severe pulmonic insufficiency with
a very large, giant pulmonic artery aneurysm. The distal pulmonary
arteries after the bifurcation were ectatic but not aneurysmal. These
were amenable to pulmonic valve replacement with concomitant pulmonic
artery aneurysm repair with pulmonary valve and artery conduit and
homograft.
ESTIMATED BLOOD LOSS:
100 mL.
PROCEDURE IN DETAIL:
After proper identification in the holding area, the patient was
brought to the operating room and placed supine on the operating room
table. Surgical pause was performed according to house regulations.
General endotracheal anesthesia was induced and administered as per
the anesthesiologist. The patient was prepped and draped in the usual
sterile fashion. A midline incision was made. A median sternotomy was
performed. Pericardial well was created. ACT guided heparinization was
instituted. Ascending aorta, SVC and IVC were cannulated with arterial
and venous cannulas respectively. Antegrade and retrograde
cardioplegia catheter was placed. Bypass was begun. The patient was
cooled to 32 degrees Celsius on cardiopulmonary bypass. The SVC and
IVC were carefully dissected free and encircled with umbilical tapes
for snaring. The aorta was cross clamped and 1:4 blood to crystal del
Nido cardioplegia was delivered antegrade and retrograde achieving
satisfactory arrest. Additional cardioplegia was also given down in a
retrograde fashion at intervals. The SVC and IVC were snared.
Attention was turned to the pulmonic valve replacement and pulmonary
artery aneurysm repair. The pulmonary artery was transected just above
the level of the valve. The posterior portion of the pulmonary artery
was carefully dissected free from the posterior structures and
dissected free. All the pulmonary artery aneurysm was resected
distally up to the pulmonary artery bifurcation. All portions of the
resected pulmonary artery aneurysm resected and sent off to pathology
as permanent specimen. The proximal portions of the pulmonary artery
were carefully dissected free down to the level of the valve. The
pulmonary artery valve leaflets were resected. A 27 mm CryoLife
homograft was chosen for the pulmonary artery reconstruction. This
homograft was opened on the back table and thawed and washed
appropriately. Once it was thawed and washed it was passed off and
carefully trimmed proximally. The distal anastomosis was performed
between the distal end of the homograft and the pulmonary artery
bifurcation with a running 4-0 Prolene suture in running fashion. This
was carefully tied down. The proximal anastomosis was performed
between the homograft and the right ventricular outflow tract and the
pulmonic valve anulus with a running 4-0 Prolene suture in running
fashion. Standard de-airing maneuvers were performed and the suture
was tied down.
Attention was then turned to the tricuspid valve repair. Right
atriotomy was created and stay sutures were placed providing very good
visualization of the tricuspid valve anulus. Two Ethibond tricuspid
valve annular sutures were placed circumferentially around the
tricuspid valve anulus being sure to avoid the conduction system. The
anulus was sized with sizers. These annular sutures were passed
through the sewing ring of a #28 mm Carpentier-Edwards incomplete
tricuspid valve ring. The ring was seated in the subvalvular space and
inspected carefully. After ensuring that no suture was trapped, the
tricuspid valve anular sutures were secured in position with the use
of the COR-KNOT device. The patient was fully rewarmed at this point.
The right atriotomy was run closed with running 4-0 Prolene suture in
running fashion in 2 layers in an imbricating fashion and carefully
tied down. The patient was placed in deep Trendelenburg. Warm blood
was given retrograde to flush out the coronary ostia and aortic cross-
clamp was released. Organized rhythm was restored. Epicardial pacing
wires were placed in the inferior surface of the right ventricle and
tunneled through the skin. Twenty-French chest tubes were placed in
the anterior and inferior mediastinum. These channel drains were
secured to the skin with interrupted 2-0 silk sutures. Standard de-
airing maneuvers were performed. The aortic root vent was removed and
oversewn with 4-0 Prolene suture. The patient was gradually weaned
from cardiopulmonary bypass. The total aortic cross-clamp time was 123
minutes. The patient was decannulated. Each cannulation site was
oversewn with 4-0 Prolene suture. Protamine was administered and
hemostasis was achieved which was quite satisfactory at the conclusion
of the case. The patient's epicardial fat was reapproximated loosely
over the patient's aorta with multiple interrupted 2-0 silk sutures.
Patient's sternum was reapproximated with stainless steel wires. The
fascia and subcutaneous layers were run closed with running Vicryl
sutures in layers in the usual fashion. Running Monocryl suture was
used for the skin. All sponge, needle and instrument counts at the end
of the case were correct. The patient was transported intubated in
satisfactory condition to the 5 Blum ICU.