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PREOPERATIVE DIAGNOSES:
1. Type 1 aortic dissection.
2. Ruptured aortic aneurysm.
3. Aorta atrial fistula.
4. Coronary artery disease.
PROCEDURE PERFORMED:
1. Redo replacement of the ascending aorta, aortic root, and hemi arch
with a composite 26 mm Hemashield graft and a 27 mm freestyle
stentless aortic mini root.
2. Reimplantation of left main.
3. Ligation of the right coronary artery.
4. Coronary artery bypass grafting x2 utilizing a saphenous vein graft
placed in sequential fashion to the posterior descending and
posterolateral branch of right coronary, harvesting of left greater
saphenous vein, circulatory arrest, exploration and repair of right
femoral artery, and pericardial patch repair of aorta atrial
fistula. Exploration and repair, right femoral artery.
Operating SURGEON:
J, M.D.
ASSISTANT:
Dr. A, M.D.
The patient was taken to the operating room, placed supine position,
where he was prepped and draped in the usual fashion. The right
femoral artery and vein were dissected free utilizing electrocautery
in order to establish arterial cannulation for the procedure. Of note,
attempt was made to dissect the right axillary artery, although a
guidewire could not be passed into the artery despite utilizing
fluoroscopic guidance. Once the right femoral artery and vein were
exposed, the patient was heparinized and a direct arteriotomy of the
right femoral artery was performed and then the arterial cannula was
inserted as well as a venous cannula. A median sternotomy incision was
performed. The sternal wires were untwisted, transected, and removed.
Thereafter, an oscillating saw was utilized to enter the anterior and
posterior tables of the sternum. The dissection of the adhesions
immediately adherent to the undersurface of the sternum were dissected
free utilizing electrocautery. Thereafter, a sternal retractor was
placed and a very careful dissection of the diaphragmatic surface of
the heart was performed and then the ascending aorta and then upon
entering the right lateral aspect the aorta the posterior rupture was
entered so we instituted a full cardiopulmonary bypass. The full
cardiopulmonary bypass was established and the patient was cooled to
20 degrees centigrade. Of note, pump suctions were placed in the field
to aspirate the blood. Once temperature was dropped to 20 degrees the
pump was stopped and circulatory arrest was instituted. A dissection
of the right superior pulmonary vein was performed, placing a vent in
the right superior pulmonary vein. Of note, the patient had a
retrograde cardioplegia cannula as well and retrograde cardioplegia
was given throughout the case. It was a patent mammary to the LAD;
this was not disturbed, although a bulldog clamp was placed on the
pedicle proximally to avoid rewarming of the heart. Thereafter, the
ascending aorta was entered and then it was noted that the patient had
a dissection which could be considered both chronic and acute, and
extending up to the arch, but not into the arch, and then extending
down towards the aortic root and involving both the left main and the
right coronary artery. Of note, the ostium of the right coronary was
severely calcified, as well as the ascending aorta in this region. A
26 mm Hemashield graft was passed onto the operative field and sutured
in end-to-end fashion with a 4-0 Prolene suture and two layer closure
with a felt strip surrounding the outside of the aortic wall.
Thereafter, BioGlue was placed and then the retrograde arterial
perfusion was then re-established and the Hemashield graft was
clamped. The patient was rewarmed. Of note, every 20 minutes further
doses of cardioplegia were given. Buttons were cut out of the
coronaries for later reanastomosis into the root. Due to the fact that
the ostium of the right coronary was severely calcified, it would be
extremely difficult for this graft to reanastomose onto the aortic
mini root, so a decision was made to harvest a segment of vein on the
left greater saphenous region which was done in a routine fashion.
Thereafter, because the dissection extended down to the root and there
was a significant amount of hematoma surrounding the entire ascending
aorta and aortic root, decision was made to resect the aortic valve
and place 4-0 Tevdek sutures in one linear plane. The anulus was
sized, noted to accommodate a 27 mm freestyle mini root, then the mini
root was passed onto the operative field, washed, and then was seated
in the intra-annular position with a felt strip utilized to tie over
the sutures to maintain hemostasis. Thereafter, openings were cut in
the posterior aspect of the mini root to accommodate the left main.
This was sutured in end-to-side fashion with a 5-0 Prolene suture in a
continuous over and over fashion. Thereafter, the Hemashield graft was
measured to the mini root and then sutured in end-to-end fashion with
a 5-0 Prolene suture in two-layer closure. Thereafter, because of the
fact that the right coronary could not be anastomosis, this was
ligated with a 3-0 Prolene suture in two different locations, and then
the posterior descending and posterolateral branch of right coronary
was identified. An arteriotomy was made; this also had a 1.5 mm
intraluminal diameter. A segment of vein was anastomosed end-to-side
fashion utilizing a 7-0 Prolene suture. Thereafter, the posterior
descending artery of the right coronary artery was identified. This
also had a 1.5 mm intraluminal diameter. A lateral venotomy was made
and a side-to-side anastomosis was performed with a 7-0 Prolene
suture. Thereafter, an opening was made in the Hemashield graft; this
was anastomosed end-to-side fashion utilizing 6-0 Prolene suture.
Further dissection upon filling the heart at this point it was noted
blood extravasated from the dome of the right atrium and after careful
dissection it was noted that there was a an opening in the right
atrium which did communicate with the ruptured portion of the aorta,
which was evident on angiogram in retrospect. So, the edges of the
opening were fashioned and then a pericardial patch was brought onto
the operative field and sutured in a continuous over and over fashion
with a 4-0 Prolene suture. Thereafter, the patient was placed in
Trendelenburg position. Then the cross-clamp was removed and multiple
de-airing maneuvers were performed utilizing a vent in the Hemashield
graft. Multiple attempts were made to wean the patient from
cardiopulmonary bypass. So, a decision was made to implant an
intraaortic balloon pump, and then we tried weaning the patient again.
After multiple attempts, the patient could not be weaned from
cardiopulmonary bypass, so a decision was made to place the patient on
ECMO. This was performed by my partner, Dr. R, and will be
dictated in a separate note. After a very extensive and lengthy
intraoperative procedure, the chest tubes were placed. The patient was
on ECMO as well as atrial and ventricular pacing wires. Then,
hemostasis was obtained and number 5 steel sternal wires were placed
to approximate the sternum. Then the muscle, subcutaneous tissue, and
skin were all closed in routine fashion. Of note, the patient was
transferred from the operating room in extremely critical condition.
Family was aware.
Hi!
Can someone please help me with this Operative Report, my codes is 33863, 33511, 33530 and 33641
1. Type 1 aortic dissection.
2. Ruptured aortic aneurysm.
3. Aorta atrial fistula.
4. Coronary artery disease.
PROCEDURE PERFORMED:
1. Redo replacement of the ascending aorta, aortic root, and hemi arch
with a composite 26 mm Hemashield graft and a 27 mm freestyle
stentless aortic mini root.
2. Reimplantation of left main.
3. Ligation of the right coronary artery.
4. Coronary artery bypass grafting x2 utilizing a saphenous vein graft
placed in sequential fashion to the posterior descending and
posterolateral branch of right coronary, harvesting of left greater
saphenous vein, circulatory arrest, exploration and repair of right
femoral artery, and pericardial patch repair of aorta atrial
fistula. Exploration and repair, right femoral artery.
Operating SURGEON:
J, M.D.
ASSISTANT:
Dr. A, M.D.
The patient was taken to the operating room, placed supine position,
where he was prepped and draped in the usual fashion. The right
femoral artery and vein were dissected free utilizing electrocautery
in order to establish arterial cannulation for the procedure. Of note,
attempt was made to dissect the right axillary artery, although a
guidewire could not be passed into the artery despite utilizing
fluoroscopic guidance. Once the right femoral artery and vein were
exposed, the patient was heparinized and a direct arteriotomy of the
right femoral artery was performed and then the arterial cannula was
inserted as well as a venous cannula. A median sternotomy incision was
performed. The sternal wires were untwisted, transected, and removed.
Thereafter, an oscillating saw was utilized to enter the anterior and
posterior tables of the sternum. The dissection of the adhesions
immediately adherent to the undersurface of the sternum were dissected
free utilizing electrocautery. Thereafter, a sternal retractor was
placed and a very careful dissection of the diaphragmatic surface of
the heart was performed and then the ascending aorta and then upon
entering the right lateral aspect the aorta the posterior rupture was
entered so we instituted a full cardiopulmonary bypass. The full
cardiopulmonary bypass was established and the patient was cooled to
20 degrees centigrade. Of note, pump suctions were placed in the field
to aspirate the blood. Once temperature was dropped to 20 degrees the
pump was stopped and circulatory arrest was instituted. A dissection
of the right superior pulmonary vein was performed, placing a vent in
the right superior pulmonary vein. Of note, the patient had a
retrograde cardioplegia cannula as well and retrograde cardioplegia
was given throughout the case. It was a patent mammary to the LAD;
this was not disturbed, although a bulldog clamp was placed on the
pedicle proximally to avoid rewarming of the heart. Thereafter, the
ascending aorta was entered and then it was noted that the patient had
a dissection which could be considered both chronic and acute, and
extending up to the arch, but not into the arch, and then extending
down towards the aortic root and involving both the left main and the
right coronary artery. Of note, the ostium of the right coronary was
severely calcified, as well as the ascending aorta in this region. A
26 mm Hemashield graft was passed onto the operative field and sutured
in end-to-end fashion with a 4-0 Prolene suture and two layer closure
with a felt strip surrounding the outside of the aortic wall.
Thereafter, BioGlue was placed and then the retrograde arterial
perfusion was then re-established and the Hemashield graft was
clamped. The patient was rewarmed. Of note, every 20 minutes further
doses of cardioplegia were given. Buttons were cut out of the
coronaries for later reanastomosis into the root. Due to the fact that
the ostium of the right coronary was severely calcified, it would be
extremely difficult for this graft to reanastomose onto the aortic
mini root, so a decision was made to harvest a segment of vein on the
left greater saphenous region which was done in a routine fashion.
Thereafter, because the dissection extended down to the root and there
was a significant amount of hematoma surrounding the entire ascending
aorta and aortic root, decision was made to resect the aortic valve
and place 4-0 Tevdek sutures in one linear plane. The anulus was
sized, noted to accommodate a 27 mm freestyle mini root, then the mini
root was passed onto the operative field, washed, and then was seated
in the intra-annular position with a felt strip utilized to tie over
the sutures to maintain hemostasis. Thereafter, openings were cut in
the posterior aspect of the mini root to accommodate the left main.
This was sutured in end-to-side fashion with a 5-0 Prolene suture in a
continuous over and over fashion. Thereafter, the Hemashield graft was
measured to the mini root and then sutured in end-to-end fashion with
a 5-0 Prolene suture in two-layer closure. Thereafter, because of the
fact that the right coronary could not be anastomosis, this was
ligated with a 3-0 Prolene suture in two different locations, and then
the posterior descending and posterolateral branch of right coronary
was identified. An arteriotomy was made; this also had a 1.5 mm
intraluminal diameter. A segment of vein was anastomosed end-to-side
fashion utilizing a 7-0 Prolene suture. Thereafter, the posterior
descending artery of the right coronary artery was identified. This
also had a 1.5 mm intraluminal diameter. A lateral venotomy was made
and a side-to-side anastomosis was performed with a 7-0 Prolene
suture. Thereafter, an opening was made in the Hemashield graft; this
was anastomosed end-to-side fashion utilizing 6-0 Prolene suture.
Further dissection upon filling the heart at this point it was noted
blood extravasated from the dome of the right atrium and after careful
dissection it was noted that there was a an opening in the right
atrium which did communicate with the ruptured portion of the aorta,
which was evident on angiogram in retrospect. So, the edges of the
opening were fashioned and then a pericardial patch was brought onto
the operative field and sutured in a continuous over and over fashion
with a 4-0 Prolene suture. Thereafter, the patient was placed in
Trendelenburg position. Then the cross-clamp was removed and multiple
de-airing maneuvers were performed utilizing a vent in the Hemashield
graft. Multiple attempts were made to wean the patient from
cardiopulmonary bypass. So, a decision was made to implant an
intraaortic balloon pump, and then we tried weaning the patient again.
After multiple attempts, the patient could not be weaned from
cardiopulmonary bypass, so a decision was made to place the patient on
ECMO. This was performed by my partner, Dr. R, and will be
dictated in a separate note. After a very extensive and lengthy
intraoperative procedure, the chest tubes were placed. The patient was
on ECMO as well as atrial and ventricular pacing wires. Then,
hemostasis was obtained and number 5 steel sternal wires were placed
to approximate the sternum. Then the muscle, subcutaneous tissue, and
skin were all closed in routine fashion. Of note, the patient was
transferred from the operating room in extremely critical condition.
Family was aware.
Hi!
Can someone please help me with this Operative Report, my codes is 33863, 33511, 33530 and 33641