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Aortic Stenosis/Replacement with St. Jude Conduit
Oh my. Help again. Thanks again.
PREOPERATIVE DIAGNOSIS
SEVERE AORTIC INSUFFICIENCY, STATUS POST VALVE-SPARING REPLACEMENT
POSTOPERATIVE DIAGNOSIS
SEVERE AORTIC INSUFFICIENCY, STATUS POST VALVE-SPARING REPLACEMENT
OPERATION
REPLACEMENT WITH 27 MM ST. JUDE CONDUIT
EXTRACORPOREAL MEMBRANE OXYGENATION CANNULATION
ANESTHESIA
GENERAL ANESTHESIA
SPECIMENS
None.
IMPLANTS
27 mm St. Jude valve conduit.
CARDIOPULMONARY BYPASS TIME
5 hours and 29 minutes.
CROSS-CLAMP TIME
150 minutes, 22 minutes, and 12 minutes.
OPERATIVE FINDINGS
Extremely dense fibrotic tissue related to valve-sparing replacement of Dacron
graft. Dense fibrotic process made it very difficult to mobilize the coronary
arteries safely, which were retracted. The root was replaced with a 27 mm St.
Jude medical mechanical valve conduit. Coronaries were reimplanted via the
Cabrol procedure with two separate short 8 mm Dacron interposition grafts. We
initially separated from cardiopulmonary bypass without difficulty, however,
there was significant bleeding from the posterior aspect of the anastomosis
requiring me to stop the heart again to repair this. We again separated from
cardiopulmonary bypass and significant bleeding developed from the aortic
cannulation site necessitating the reinstitution of cardiopulmonary bypass. At
this point in time, the RV function seemed to be struggling and the RV
pressures seemed to be somewhat high so we elected to remain on ECMO.
DESCRIPTION OF PROCEDURE
After informed consent was obtained he was brought to the Operating Room and
placed on the table in supine position. Anesthesia monitors were attached and
general anesthesia was obtained. The chest and abdomen were prepped and draped
in usual sterile fashion. Previous incision was entered and dissection was
carried down to the sternal wires which were excised. A redo sternotomy was
performed with the oscillating saw. Immediately once passed into the sternum
it was apparent there was extremely dense and thick adhesions within the
mediastinum primarily related to the previous Dacron graft. I was able to open
the sternum and place a sternal retractor. I then began dissecting to identify
the atrium and identified the aorta. Once I had passed through the dense
fibrotic tissue it was much easier to dissect out the Dacron aorta. The
previous graft had gone very high and I elected to cannulate at this site just
superior to my previous cannulation site. Two 4-0 pledgeted Prolene sutures
were placed at this location and a stitch was placed in the atrium as well. A
full heparinizing dose was given and these vessels were cannulated and
cardiopulmonary bypass was instituted. I then carried out dissection in the
remainder of the atrium to identify the right superior pulmonary vein were a
left ventricular vent was placed. I placed an additional venous cannula into
the superior vena cava as well through a right atrial incision. I dissected
out the lower aspect of the heart in order to place a retrograde cardioplegic
cannula into the coronary sinus. I then dissected circumferentially around the
aorta. The aorta was crossclamped and cardioplegia was administered and the
heart arrested, this was retrograde cardioplegia. I then transected the aorta.
It was necessary to place an additional clamp as one clamp was not sufficient
to fully occlude the Dacron graft that was previously placed. With the aorta
transected I identified the coronary arteries again as of last time there was
a leftward rotation of the coronary arteries such that the right coronary
artery is leftward in the chest and the left coronary artery is rightward in
the chest. I evaluated the valves and there was basically complete central
insufficiency. I did not feel that it would be possible to place an
adequate-sized valve through the existing conduit. For this reason, I then
dissected out the coronary buttons and dissected down to the previous valve. I
then placed interrupted 2-0 Tycron sutures circumferentially around the site
to see if we have valve conduit. This was sized to a 27 mm valve conduit and
this was brought to the field. The sutures were placed through the valve
conduit, 14 sutures were used in all and the sutures were tied being sure that
the valve seated properly. There were such dense fibrotic adhesions around the
coronary arteries. It was impossible to mobilize these adequately to
approximate them back to the graft. For this reason I elected to place short
interposition grafts of 8 mm Dacron in the fashion of Cabrol. I first
completed anastomosis to the left coronary artery. I then beveled this
anastomosis and using an eye cautery opened the aortic wall and anastomosis
completed with a running 5-0 Prolene suture. This Dacron conduit is very short
in length perhaps no more than 5 mm. In similar fashion I sewed the Dacron
conduit to the right coronary artery. Again using the eye cautery I opened the
aortic conduit and I completed this anastomosis with a 4-0 Prolene suture.
Again, this conduit is very short approximately 4 mm. I tested the valve and
it closed and opened nicely. I then completed my distal anastomosis with a
running 4-0 Prolene suture. This was somewhat difficult because of where the
clamps that had been placed. I should note that we administered cardioplegia
every 20 minutes throughout this time. This was all in a retrograde fashion. I
then placed in a head down position and deaired the left ventricle and
then removed the cross clamp. We continued to deair through the ventricular
vent as well as through an aortic root vent. We had cooled to 28 degrees
Celsius and it took a significant period of time to rewarm. Once we were fully
rewarmed we began weaning from cardiopulmonary bypass, however, there was
significant bleeding from the posterior aspect of the aorta where the new
conduit was anastomosed to the previously placed conduit. I attempted to place
repairing sutures, but it was obvious that this was significant bleeding. For
this reason, I elected to rearrest the heart. The heart was recross-clamped
and the heart was arrested again and I opened the conduit. I then placed
several reinforcing sutures posteriorly although no specific bleeding site
could be identified. I then recompleted the conduit anastomosis and again
deaired the left ventricle and removed the cross-clamp. It was immediately
obvious, however, there was a tension of this anastomosis from the repair
suture. For this reason, I again arrested the heart and I again removed to my
sutures to visualize the anastomosis. The repair suture that was causing the
tension was removed. I again completed the conduit to conduit anastomosis with
a running 4-0 Prolene suture. This cross-clamp time was 12 minutes. I again
placed Tim in a head down position, deaired the left ventricle and removed the
cross-clamp. It again took his heart a period of time to recover, but once
ventricular function recovered we had weaned from cardiopulmonary bypass and
the atrial cannula was removed. The pursestring was tied and the aortic
cannula was removed. In the process of tying the pursestring of the aortic
cannula one of the pursestrings probe and the other was not sufficient to
fully occlude. We placed the cannula back in to control bleeding. However at
this time I noted the blood pressure was 190 mmHg and there was significant
bleeding. Medicine was given to lower the blood pressure in order to repair
the aorta. However, this dropped the blood pressure precipitously
necessitating us to go back on cardiopulmonary bypass. This was done by
placing the 20 mm cannula back through the previous site and the atrial
cannula as well. Cardiopulmonary bypass was reinstituted and cardiac function
appeared to recover. However, on observing echocardiogram although there was
good left ventricular function the right ventricular function seemed to be
down. Puzzling was that the RV pressure was elevated to approximately
two-thirds of systemic. Because of this I elected to leave on ECMO and
ECMO was prepared and brought to the field. We weaned down from
cardiopulmonary bypass and connected to the ECMO circuit ensuring that there
was no air. ECMO flow was instituted. Half a dose of protamine was
administered and the wound was observed for hemostasis. We had good ECMO flows
and there was some ejection from the ventricle and the bleeding seemed to be
well controlled and therefore no protamine was given. Two 19-French Blake
drains and a 24 Blake drain was brought separate stab incisions. A Silastic
patch was sewn in place and the wound was covered with Ioban dressing.
left the Operating Room with good urine output and excellent mixed venous
saturations with the plan for recovery of his right ventricle on weaning from
ECMO. The second cardiopulmonary bypass run was 53 minutes.
"I understand that section 1842 (b) (7) (D) of the Social Security Act
generally prohibits Medicare physician fee schedule payment for the services
of assistants at surgery in teaching hospitals when qualified residents are
available to furnish such services. I certify that the services for which
payment is claimed were medically necessary and that no qualified resident was
available to perform the services. I further understand that these services
are subject to post payment review by the Medicare carrier."
Oh my. Help again. Thanks again.
PREOPERATIVE DIAGNOSIS
SEVERE AORTIC INSUFFICIENCY, STATUS POST VALVE-SPARING REPLACEMENT
POSTOPERATIVE DIAGNOSIS
SEVERE AORTIC INSUFFICIENCY, STATUS POST VALVE-SPARING REPLACEMENT
OPERATION
REPLACEMENT WITH 27 MM ST. JUDE CONDUIT
EXTRACORPOREAL MEMBRANE OXYGENATION CANNULATION
ANESTHESIA
GENERAL ANESTHESIA
SPECIMENS
None.
IMPLANTS
27 mm St. Jude valve conduit.
CARDIOPULMONARY BYPASS TIME
5 hours and 29 minutes.
CROSS-CLAMP TIME
150 minutes, 22 minutes, and 12 minutes.
OPERATIVE FINDINGS
Extremely dense fibrotic tissue related to valve-sparing replacement of Dacron
graft. Dense fibrotic process made it very difficult to mobilize the coronary
arteries safely, which were retracted. The root was replaced with a 27 mm St.
Jude medical mechanical valve conduit. Coronaries were reimplanted via the
Cabrol procedure with two separate short 8 mm Dacron interposition grafts. We
initially separated from cardiopulmonary bypass without difficulty, however,
there was significant bleeding from the posterior aspect of the anastomosis
requiring me to stop the heart again to repair this. We again separated from
cardiopulmonary bypass and significant bleeding developed from the aortic
cannulation site necessitating the reinstitution of cardiopulmonary bypass. At
this point in time, the RV function seemed to be struggling and the RV
pressures seemed to be somewhat high so we elected to remain on ECMO.
DESCRIPTION OF PROCEDURE
After informed consent was obtained he was brought to the Operating Room and
placed on the table in supine position. Anesthesia monitors were attached and
general anesthesia was obtained. The chest and abdomen were prepped and draped
in usual sterile fashion. Previous incision was entered and dissection was
carried down to the sternal wires which were excised. A redo sternotomy was
performed with the oscillating saw. Immediately once passed into the sternum
it was apparent there was extremely dense and thick adhesions within the
mediastinum primarily related to the previous Dacron graft. I was able to open
the sternum and place a sternal retractor. I then began dissecting to identify
the atrium and identified the aorta. Once I had passed through the dense
fibrotic tissue it was much easier to dissect out the Dacron aorta. The
previous graft had gone very high and I elected to cannulate at this site just
superior to my previous cannulation site. Two 4-0 pledgeted Prolene sutures
were placed at this location and a stitch was placed in the atrium as well. A
full heparinizing dose was given and these vessels were cannulated and
cardiopulmonary bypass was instituted. I then carried out dissection in the
remainder of the atrium to identify the right superior pulmonary vein were a
left ventricular vent was placed. I placed an additional venous cannula into
the superior vena cava as well through a right atrial incision. I dissected
out the lower aspect of the heart in order to place a retrograde cardioplegic
cannula into the coronary sinus. I then dissected circumferentially around the
aorta. The aorta was crossclamped and cardioplegia was administered and the
heart arrested, this was retrograde cardioplegia. I then transected the aorta.
It was necessary to place an additional clamp as one clamp was not sufficient
to fully occlude the Dacron graft that was previously placed. With the aorta
transected I identified the coronary arteries again as of last time there was
a leftward rotation of the coronary arteries such that the right coronary
artery is leftward in the chest and the left coronary artery is rightward in
the chest. I evaluated the valves and there was basically complete central
insufficiency. I did not feel that it would be possible to place an
adequate-sized valve through the existing conduit. For this reason, I then
dissected out the coronary buttons and dissected down to the previous valve. I
then placed interrupted 2-0 Tycron sutures circumferentially around the site
to see if we have valve conduit. This was sized to a 27 mm valve conduit and
this was brought to the field. The sutures were placed through the valve
conduit, 14 sutures were used in all and the sutures were tied being sure that
the valve seated properly. There were such dense fibrotic adhesions around the
coronary arteries. It was impossible to mobilize these adequately to
approximate them back to the graft. For this reason I elected to place short
interposition grafts of 8 mm Dacron in the fashion of Cabrol. I first
completed anastomosis to the left coronary artery. I then beveled this
anastomosis and using an eye cautery opened the aortic wall and anastomosis
completed with a running 5-0 Prolene suture. This Dacron conduit is very short
in length perhaps no more than 5 mm. In similar fashion I sewed the Dacron
conduit to the right coronary artery. Again using the eye cautery I opened the
aortic conduit and I completed this anastomosis with a 4-0 Prolene suture.
Again, this conduit is very short approximately 4 mm. I tested the valve and
it closed and opened nicely. I then completed my distal anastomosis with a
running 4-0 Prolene suture. This was somewhat difficult because of where the
clamps that had been placed. I should note that we administered cardioplegia
every 20 minutes throughout this time. This was all in a retrograde fashion. I
then placed in a head down position and deaired the left ventricle and
then removed the cross clamp. We continued to deair through the ventricular
vent as well as through an aortic root vent. We had cooled to 28 degrees
Celsius and it took a significant period of time to rewarm. Once we were fully
rewarmed we began weaning from cardiopulmonary bypass, however, there was
significant bleeding from the posterior aspect of the aorta where the new
conduit was anastomosed to the previously placed conduit. I attempted to place
repairing sutures, but it was obvious that this was significant bleeding. For
this reason, I elected to rearrest the heart. The heart was recross-clamped
and the heart was arrested again and I opened the conduit. I then placed
several reinforcing sutures posteriorly although no specific bleeding site
could be identified. I then recompleted the conduit anastomosis and again
deaired the left ventricle and removed the cross-clamp. It was immediately
obvious, however, there was a tension of this anastomosis from the repair
suture. For this reason, I again arrested the heart and I again removed to my
sutures to visualize the anastomosis. The repair suture that was causing the
tension was removed. I again completed the conduit to conduit anastomosis with
a running 4-0 Prolene suture. This cross-clamp time was 12 minutes. I again
placed Tim in a head down position, deaired the left ventricle and removed the
cross-clamp. It again took his heart a period of time to recover, but once
ventricular function recovered we had weaned from cardiopulmonary bypass and
the atrial cannula was removed. The pursestring was tied and the aortic
cannula was removed. In the process of tying the pursestring of the aortic
cannula one of the pursestrings probe and the other was not sufficient to
fully occlude. We placed the cannula back in to control bleeding. However at
this time I noted the blood pressure was 190 mmHg and there was significant
bleeding. Medicine was given to lower the blood pressure in order to repair
the aorta. However, this dropped the blood pressure precipitously
necessitating us to go back on cardiopulmonary bypass. This was done by
placing the 20 mm cannula back through the previous site and the atrial
cannula as well. Cardiopulmonary bypass was reinstituted and cardiac function
appeared to recover. However, on observing echocardiogram although there was
good left ventricular function the right ventricular function seemed to be
down. Puzzling was that the RV pressure was elevated to approximately
two-thirds of systemic. Because of this I elected to leave on ECMO and
ECMO was prepared and brought to the field. We weaned down from
cardiopulmonary bypass and connected to the ECMO circuit ensuring that there
was no air. ECMO flow was instituted. Half a dose of protamine was
administered and the wound was observed for hemostasis. We had good ECMO flows
and there was some ejection from the ventricle and the bleeding seemed to be
well controlled and therefore no protamine was given. Two 19-French Blake
drains and a 24 Blake drain was brought separate stab incisions. A Silastic
patch was sewn in place and the wound was covered with Ioban dressing.
left the Operating Room with good urine output and excellent mixed venous
saturations with the plan for recovery of his right ventricle on weaning from
ECMO. The second cardiopulmonary bypass run was 53 minutes.
"I understand that section 1842 (b) (7) (D) of the Social Security Act
generally prohibits Medicare physician fee schedule payment for the services
of assistants at surgery in teaching hospitals when qualified residents are
available to furnish such services. I certify that the services for which
payment is claimed were medically necessary and that no qualified resident was
available to perform the services. I further understand that these services
are subject to post payment review by the Medicare carrier."
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