conleyclan
Guru
Hmmmm...... Thanks for any help 
PREOPERATIVE DIAGNOSIS
FREE PULMONARY INSUFFICIENCY
ATRIAL FLUTTER
POSTOPERATIVE DIAGNOSIS
FREE PULMONARY INSUFFICIENCY
ATRIAL FLUTTER
OPERATION
PULMONARY VALVE REPLACEMENT
RIGHT FEMORAL ARTERY RECONSTRUCTION
RIGHT FEMORAL VEIN RECONSTRUCTION
LEFT FEMORAL ARTERY RECONSTRUCTION
ANESTHESIA
GENERAL ANESTHESIA
ESTIMATED BLOOD LOSS
Minimal.
IMPLANTS
29 mm Medtronic Mosaic porcine valve in right ventricular outflow tract.
SPECIMENS
None.
CARDIOPULMONARY BYPASS TIME
131 minutes.
OPERATIVE FINDINGS
1. Stenosis of the right femoral artery.
2. Extensive adhesions of the right ventricular outflow tract to the
posterior table of the sternum.
3. Mesocardia of the heart with a very large ventricular mass.
4. Severely calcified right ventricular outflow tract, 29 mm Medtronic
Mosaic valve placed.
DESCRIPTION OF PROCEDURE
After informed consent was obtained was brought to the Operating Room and
placed on the table in supine position. Anesthesia monitors were attached and
general anesthesia was obtained. Her chest, abdomen, and legs were prepped and
draped in usual sterile fashion. has previously had a CAT scan that
demonstrates that the right ventricular outflow tract is heavily calcified and
this calcification was adherent to the posterior table of the sternum in the
midline. This reason as well was discussed with her. I thought the best is
femoral artery cannulation and vein cannulation and *________________________
pump in the groin first. We made a transverse incision in the right groin and
carried this dissection down until we could identify the femoral artery and
vein. They were both of good size. Proximal and distal control was obtained to
both vessels. The femoral vein was cannulated with a femoral venous cannula
after placing a guidewire. We could easily pass these cannula to 45 cm. I
placed a 5-0 Prolene pursestring in the vein. We then with proximal and distal
control of the femoral artery, I attempted to place first a 16-French arterial
cannula and subsequently a 14-French arterial cannula. Both had passed about 3
cm, but no further and it was obvious that there was some obstruction in her
femoral artery. For this reason I reconstructed the right femoral artery with
interrupted 6-0 Prolene sutures. I should also note that we had given a full
heparinizing dose prior to cannulating these vessels. We then turned our
attention to the left groin where a transverse incision was again made and the
dissection was carried down until the femoral artery and vein were identified.
Interestingly these were more lateral than on the right groin. I obtained
proximal and distal control of the artery as well as control of the profunda
femoris artery and I was able to insert a 14-French arterial cannula without
difficulty. We then commenced cardiopulmonary bypass. The cannulas were
secured in place. I then reentered the previous midline incision and carried
the dissection down until the deeply seated sternal wires were identified and
these were removed. A redo sternotomy was performed with an oscillating saw
and I was able to enter the mediastinum, however, the right ventricular
outflow tract was extremely adherent to the posterior table of the sternum and
in fact even with sharp dissection I was unable to dissect this free. For this
reason and because I wanted to change my cannulation to the aorta because
saturations have been dropping on the left leg with the NIRS saturation I
placed two 4-0 French pledgeted pursestrings in the aorta and I cannulated the
aorta with an 18-French cannula. I then dissected out the superior vena cava
and I placed an additional cannula in the superior vena cava. This nicely
decompressed the heart. I returned to the left groin, the arterial line was
removed and the femoral artery was again reconstructed with 6-0 interrupted
Prolene sutures. The flow was restored in the NIRS on the thigh quickly went
back to baseline. I now turned my attention to fully dissecting out the right
ventricular outflow tract. It was necessary to use curved Mayo sutures to
force the right ventricular tract off the sternum almost as if using a
crowbar. Once this was completed, I turned my attention to attempting the maze
procedure. I dissected out the right heart, however, the right ventricular
mass was so large and the heart was rotated in such a fashion that the atria
is very difficult to reach and in fact I did not feel that I could safely
reach the atrium to perform a maze without arresting the heart. Concerned
about arresting the heart for a few reasons, one is that her right ventricular
function is very bad at this point in time, and additionally the right
coronary passing through the between the aorta and pulmonary artery makes
crossclamp somewhat more difficult. For this reason, I felt it is not safe to
proceed with the maze procedure. I then turned attention to the right
ventricular outflow tract, which was opened. All calcified tissue was removed.
It appeared that she had previously had some Dacron patch at this location as
well. I sized the outflow tract to a 29 mm. I then placed pledgeted Tycron
sutures posteriorly. The valve had been prepared at the back table and was
brought to the field. These sutures were placed in the sewing ring and the
valve was seated. I then reconstructed the entire right ventricular outflow
tract with a Gore-Tex patch sewn in place with a running 4-0 Prolene suture.
Once this was completed, I applied CoSeal glue. We then reconfirmed and there
was no air in the left heart and we began to let the heart eject again. I
returned my attention to the right groin and I removed the femoral venous
cannula. We reconstructed the right femoral artery with a pursestring of
interrupted 6-0 Prolene suture. We then weaned from cardiopulmonary bypass
without difficulty. The echocardiogram demonstrated function that was
equivalent to preoperative and no gradient in the right ventricular outflow
tract. The SVC cannula was then removed. There was a tear of the SVC
cannulation site and this was repaired with interrupted 5-0 Prolene sutures.
The arterial cannula was removed. Both pursestring sutures were tied and an
additional reinforcing suture was placed as well. It took a significant period
of time to obtain hemostasis probably had been on Coumadin preoperatively and
the INR at the time of surgery was 16.5. We did close both groins in three
layers with the last layer being interrupted nylon sutures. This was after
confirming hemostasis. Once good hemostasis confirmed on the chest a single
ventricular pacing wire placed as well as a 19-French Blake drain and a
24-French Blake drain. I did place a lateral weave on the right side of the
sternum to reinforce it and the chest was then closed with stainless steel
wires. The skin was closed in three layers and a Dermabond dressing was
applied. ..... appeared to tolerate the procedure very well and was
transported to the ICU in stable condition.
PREOPERATIVE DIAGNOSIS
FREE PULMONARY INSUFFICIENCY
ATRIAL FLUTTER
POSTOPERATIVE DIAGNOSIS
FREE PULMONARY INSUFFICIENCY
ATRIAL FLUTTER
OPERATION
PULMONARY VALVE REPLACEMENT
RIGHT FEMORAL ARTERY RECONSTRUCTION
RIGHT FEMORAL VEIN RECONSTRUCTION
LEFT FEMORAL ARTERY RECONSTRUCTION
ANESTHESIA
GENERAL ANESTHESIA
ESTIMATED BLOOD LOSS
Minimal.
IMPLANTS
29 mm Medtronic Mosaic porcine valve in right ventricular outflow tract.
SPECIMENS
None.
CARDIOPULMONARY BYPASS TIME
131 minutes.
OPERATIVE FINDINGS
1. Stenosis of the right femoral artery.
2. Extensive adhesions of the right ventricular outflow tract to the
posterior table of the sternum.
3. Mesocardia of the heart with a very large ventricular mass.
4. Severely calcified right ventricular outflow tract, 29 mm Medtronic
Mosaic valve placed.
DESCRIPTION OF PROCEDURE
After informed consent was obtained was brought to the Operating Room and
placed on the table in supine position. Anesthesia monitors were attached and
general anesthesia was obtained. Her chest, abdomen, and legs were prepped and
draped in usual sterile fashion. has previously had a CAT scan that
demonstrates that the right ventricular outflow tract is heavily calcified and
this calcification was adherent to the posterior table of the sternum in the
midline. This reason as well was discussed with her. I thought the best is
femoral artery cannulation and vein cannulation and *________________________
pump in the groin first. We made a transverse incision in the right groin and
carried this dissection down until we could identify the femoral artery and
vein. They were both of good size. Proximal and distal control was obtained to
both vessels. The femoral vein was cannulated with a femoral venous cannula
after placing a guidewire. We could easily pass these cannula to 45 cm. I
placed a 5-0 Prolene pursestring in the vein. We then with proximal and distal
control of the femoral artery, I attempted to place first a 16-French arterial
cannula and subsequently a 14-French arterial cannula. Both had passed about 3
cm, but no further and it was obvious that there was some obstruction in her
femoral artery. For this reason I reconstructed the right femoral artery with
interrupted 6-0 Prolene sutures. I should also note that we had given a full
heparinizing dose prior to cannulating these vessels. We then turned our
attention to the left groin where a transverse incision was again made and the
dissection was carried down until the femoral artery and vein were identified.
Interestingly these were more lateral than on the right groin. I obtained
proximal and distal control of the artery as well as control of the profunda
femoris artery and I was able to insert a 14-French arterial cannula without
difficulty. We then commenced cardiopulmonary bypass. The cannulas were
secured in place. I then reentered the previous midline incision and carried
the dissection down until the deeply seated sternal wires were identified and
these were removed. A redo sternotomy was performed with an oscillating saw
and I was able to enter the mediastinum, however, the right ventricular
outflow tract was extremely adherent to the posterior table of the sternum and
in fact even with sharp dissection I was unable to dissect this free. For this
reason and because I wanted to change my cannulation to the aorta because
saturations have been dropping on the left leg with the NIRS saturation I
placed two 4-0 French pledgeted pursestrings in the aorta and I cannulated the
aorta with an 18-French cannula. I then dissected out the superior vena cava
and I placed an additional cannula in the superior vena cava. This nicely
decompressed the heart. I returned to the left groin, the arterial line was
removed and the femoral artery was again reconstructed with 6-0 interrupted
Prolene sutures. The flow was restored in the NIRS on the thigh quickly went
back to baseline. I now turned my attention to fully dissecting out the right
ventricular outflow tract. It was necessary to use curved Mayo sutures to
force the right ventricular tract off the sternum almost as if using a
crowbar. Once this was completed, I turned my attention to attempting the maze
procedure. I dissected out the right heart, however, the right ventricular
mass was so large and the heart was rotated in such a fashion that the atria
is very difficult to reach and in fact I did not feel that I could safely
reach the atrium to perform a maze without arresting the heart. Concerned
about arresting the heart for a few reasons, one is that her right ventricular
function is very bad at this point in time, and additionally the right
coronary passing through the between the aorta and pulmonary artery makes
crossclamp somewhat more difficult. For this reason, I felt it is not safe to
proceed with the maze procedure. I then turned attention to the right
ventricular outflow tract, which was opened. All calcified tissue was removed.
It appeared that she had previously had some Dacron patch at this location as
well. I sized the outflow tract to a 29 mm. I then placed pledgeted Tycron
sutures posteriorly. The valve had been prepared at the back table and was
brought to the field. These sutures were placed in the sewing ring and the
valve was seated. I then reconstructed the entire right ventricular outflow
tract with a Gore-Tex patch sewn in place with a running 4-0 Prolene suture.
Once this was completed, I applied CoSeal glue. We then reconfirmed and there
was no air in the left heart and we began to let the heart eject again. I
returned my attention to the right groin and I removed the femoral venous
cannula. We reconstructed the right femoral artery with a pursestring of
interrupted 6-0 Prolene suture. We then weaned from cardiopulmonary bypass
without difficulty. The echocardiogram demonstrated function that was
equivalent to preoperative and no gradient in the right ventricular outflow
tract. The SVC cannula was then removed. There was a tear of the SVC
cannulation site and this was repaired with interrupted 5-0 Prolene sutures.
The arterial cannula was removed. Both pursestring sutures were tied and an
additional reinforcing suture was placed as well. It took a significant period
of time to obtain hemostasis probably had been on Coumadin preoperatively and
the INR at the time of surgery was 16.5. We did close both groins in three
layers with the last layer being interrupted nylon sutures. This was after
confirming hemostasis. Once good hemostasis confirmed on the chest a single
ventricular pacing wire placed as well as a 19-French Blake drain and a
24-French Blake drain. I did place a lateral weave on the right side of the
sternum to reinforce it and the chest was then closed with stainless steel
wires. The skin was closed in three layers and a Dermabond dressing was
applied. ..... appeared to tolerate the procedure very well and was
transported to the ICU in stable condition.