1. Mitral valve replacement with a 27 mm CarboMedics mechanical valve.
DESCRIPTION OF OPERATION: The patient was taken to the operating room, placed on the table in supine position, placed under adequate general anesthesia. She was then prepped and draped in a normal sterile fashion from the chin to the toes bilaterally. Sternotomy incision was made. Sternum was divided. Pericardium was opened. Tack-up suture was used to create a pericardial well. Heparin was administered per anesthesia. ACT was greater than 400. Pursestring sutures were placed in the ascending aorta and right atrial appendage and cannula was placed appropriately. The patient was then placed on full cardiopulmonary bypass. The heart was emptied and allowed to fibrillate. Cross clamp was then placed in the ascending aorta. Blood cardioplegia was used to arrest the heart in an antegrade fashion through the aortic root. Once the heart was arrested, the left atrium was opened along Waterston's groove and the mitral valve was exposed using a retractor.
At this point, we could easily see the vegetations on the posterior leaflet of the mitral valve. The valve was then resected, and the leaflet was sent off for cultures and pathology. The annulus was fashioned appropriately and a small abscess in the posterior annulus was debrided and irrigated copiously with antibiotic saline solution. The valve was measured; it was 27 mm annulus. Then, 2-0 Tevdek pledgeted sutures were then placed circumferentially around the annulus of the valve.
The sutures were then brought through the flange of the mechanical valve, the valve was seated, and the sutures were tied and cut. There was no area for perivalvular leak. The leaflets opened and closed well. The area was again irrigated with antibiotic saline solution. The atrium was closed with 3-0 Prolene suture. De-airing maneuvers were performed with the patient in Trendelenburg position. The cross clamp removed. The heart returned spontaneously to normal sinus rhythm. The patient was then successfully weaned off cardiopulmonary bypass. Once off bypass, protamine was given to reverse the heparin. The cannula was removed. All anastomoses, cannula sites, and suture lines were checked for bleeding. Two chest tubes, 2 pacing wires were placed. The chest was closed appropriately. The wound was dressed in a sterile manner. Instrument counts and sponge counts were correct. The patient tolerated the procedure well and was sent to the CVICU in critical but stable condition.
1. Right femoral-to-popliteal artery bypass with in situ saphenous vein.
2. Right common femoral artery bifurcation, endarterectomy with an endarterectomized superficial moderate patch angioplasty.
DESCRIPTION OF OPERATION: The patient was placed on the operating room table in a supine position. General anesthetic was induced and maintained with oral endotracheal tube. The right lower limb was then scrubbed and prepped with DuraPrep and draped with sterile towels and drapes.
Greater saphenous vein was then harvested, was then exposed from the saphenofemoral junction down to the proximal third of the leg. The proximal and distal 10 cm were dissected circumferentially and side branches ligated. The remainder of the vein was left in its in situ tunnel with side branches being ligated long enough for introduction of the Mills retrograde valvulotome. Next, the common femoral artery bifurcation was dissected circumferentially. It was markedly atherosclerotic with no suitable area to do an anastomosis. The distal external iliac artery had a good pulse and some soft areas. A large, what appeared to be a, stent was identified within the external iliac artery. Next, the popliteal artery was dissected. It appeared to be soft and suitable for anastomosis in the below-knee popliteal fossa.
He was then given 5000 units of heparin. After this had circulated for about 5 minutes, atraumatic vascular clamp was placed upon the common femoral artery. The vessel loop was pulled snug on the deep femoral artery. An arteriotomy was then made and deepened down through the atherosclerotic plaque into the lumen. It was then impossible to suture this area, so the incision was extended up the entire length of the common femoral artery and a complete endarterectomy was performed including a portion of the distal external iliac artery. The superficial femoral artery was then harvested and opened longitudinally and then endarterectomized to create a patch. This patch was then sutured in place, onlay patch angioplasty under the common femoral artery with running 6-0 Prolene.
Next, an atraumatic vascular clamp was placed on the common femoral vein partially occluding it at the point of the saphenofemoral junction. The greater saphenous vein was then taken off of the common femoral vein with running 6-0 Prolene. The first set of valves within the vein was removed under direct vision. A small incision was then made within the patch on the common femoral artery and an end-to-side anastomosis was made with running 6-0 Prolene. After completing this anastomosis, Mills retrograde valvulotome was passed through side branches. The vascular clamps were removed, and there was good pulse down to the first set of competent valves. Mills retrograde valvulotome was then used to lyse the valves. The valvulotome was inserted through side branches, except in the distal third, where the valvulotome was inserted through the end of the vein. Brisk arterial flow was then achieved. The continuous wave Doppler was used to interrogate the entire vein and no patent perforators could be identified.
Next, the distal anastomosis was done. Vessel was pulled snug on the popliteal artery. Arteriotomy made with a 15 blade knife, extended proximally and distally with Potts scissors. Stay sutures of 7-0 Prolene were placed, regional heparinization was used. The vein was spatulated, anastomosed end-to-side to the artery without twisting it with running 6-0 Prolene. Prior to completing the anastomosis, the anastomosis was flushed. There appeared to be good flow. The anastomosis then completed, the vessel loops loosened, and the vascular clamp removed. There appeared to be good flow in the distal popliteal artery, dorsalis pedis, and posterior tibial artery signals were both audible with a Doppler.
Completion of arteriogram was then done by placing a 20-gauge angiocatheter to side branch. This revealed a widely patent anastomosis, but there appeared to be some spasm within the distal aspect of the vein. The vein was inspected. There did not appear to be any spasm. There appeared to be reasonable pulse in this area. Doppler flow was satisfactory. I concluded that this was artifact and shot the study again, but the same result was obtained. Since he had a good dorsalis pedis Doppler signal, good Doppler within the graft, I elected to close. The wound was closed with running 2-0 Vicryl for the subcutaneous tissue, running 4-0 Vicryl subcuticular suture for the skin. Sterile bandage was applied, tolerated the procedure without complications, left the operating room to go to the recovery room in satisfactory condition.
1. Re-entry sternotomy.
DESCRIPTION OF OPERATION: The patient was taken to the operating room, placed on the table in supine position and placed under adequate general anesthesia. He was then prepped and draped in normal sterile fashion from the chin to the toes bilaterally. Saphenous vein graft was harvested from the left and right thighs. The leg incisions were then closed.
A sternotomy incision was made. The sternum was divided. The left internal mammary artery was harvested appropriately. Heparin was instilled in the artery. We then did a mediastinal dissection which was very difficult and prolonged due to severe adhesions. Once the dissection was completed, purse-string suture was placed in the ascending aorta and right atrial appendage. Heparin was administered per Anesthesia. Cannulas were placed appropriately, and the patient was placed on full cardiopulmonary bypass. The heart was emptied and allowed to fibrillate.
The vessels were then inspected. A cross-clamp was then placed in the ascending aorta. Crystalloid and cardioplegia was used to arrest the heart. The vein grafts of the circumflex and first diagonal were performed, and left internal mammary artery graft to the LAD was performed. Two aortotomies created in the ascending aorta with a 4.8 mm punch. Proximal anastomosis was then completed. De-airing maneuvers were performed, the patient was placed in Trendelenburg position. The cross-clamp was removed. The heart returned spontaneously to normal sinus rhythm. The patient was then successfully weaned off cardiopulmonary bypass.
Once off bypass, protamine was given to reverse the heparin. The cannula was removed on anastomosis. Cannula sites and suture lines were checked for bleeding. Two chest tubes and two pacing wires were placed. The chest was closed appropriately. The wound was dressed in a sterile manner. Instrument counts and sponge counts were correct at the end of the procedure. The patient tolerated it well and was sent back to CVICU in critical but stable condition.
1. Redo median sternotomy with lysis of adhesions.
OPERATION IN DETAIL: With the patient in supine position, after the induction of satisfactory general endotracheal anesthesia, the chest, abdomen and legs were prepped and draped using DuraPrep. The previous median sternotomy incision was reopened. We safely dissected out the heart to perform bypass surgery. We identified the LIMA to the LAD and preserved it throughout its course. The right internal mammary artery was harvested as a pedicle from the anterior chest wall using electrocautery and hemoclips. It was dissected distally down toward the bifurcation. After satisfactory heparinization was achieved, the mammary was divided. Intraluminal papaverine was employed. The pericardium was opened and traction sutures placed. We dissected out the obtuse marginal as previously noted. A nice spot in the left radial artery was identified and we used the Octopus to stabilize and a Silastic snare to control the inflow at the obtuse marginal. We constructed a running 8-0 Prolene anastomosis without difficulty. In a similar fashion, we used the left radial artery to graft side-to-side of the right posterolateral ventricular branch. So now, we constructed an end-to-side to the obtuse marginal and a side-to-side to the same left radial artery conduit to the RPLV branch. Having completed these, we then constructed an end-to-end anastomosis of the right internal mammary artery to the left radial artery in an end-to-end fashion to complete the inflow arterial supply for our grafts. This was constructed with running 8-0 Prolene. The pedicle was tacked to the apical surface of the heart with a few 6-0 Prolene sutures. Mediastinal and pleural chest tubes were placed and the chest was closed using standard sternal wire closure, running 0 PDS, running 2-0 Vicryl and 3-0 Vicryl. Steri-Strips and sterile dressings were applied to all wounds. The patient tolerated the procedure well and was brought to the recovery room in satisfactory condition.
DATE OF OPERATION: XX/XX/XXXX
1. Video-assisted endoscopic vein harvesting.
2. Coronary arterial bypass graft x4 using the left internal mammary artery to the left anterior descending, reverse saphenous vein graft to the obtuse marginal sequential to the high diagonal and reverse saphenous vein graft to the distal right coronary artery/proximal posterior lateral branch of the right coronary artery.
3. Insertion of On-Q pump.
FINDINGS AND PROCEDURE: The left internal mammary artery and reverse saphenous vein grafts were good conduits. LAD showed severe diffuse disease with proximal heavy calcification. The target was good, was 1.75 mm in diameter. Diagonal was with severely diffuse disease with proximal calcification. The target was good, 1.25 to 1.5 mm in diameter. Obtuse marginal was a good 1.25 mm target. The right coronary artery showed severe distal disease with heavy calcification at the bifurcation as well as stenosis at the bifurcation.
The patient was taken to the operating room and placed on the operating table in supine position and support lines were placed. General anesthesia was given via endotracheal intubation. The chest, abdomen and lower extremities were prepped and draped in the usual sterile fashion. Video-assisted endoscopic vein harvesting was performed. Hemostasis was ensured. Wounds were closed in layers. Simultaneously, a median sternotomy was performed. The left sternum was elevated, and the left internal mammary artery was harvested as a pedicle graft. Systemic heparinization was performed. Distal pedicle was divided and the left internal mammary artery was prepared for future grafting. Intrapedicle papaverine was administered. A Morse sternal retractor was placed. Pericardium was opened and a cradle was created. Cannulation for cardiopulmonary bypass was achieved. Catheter was placed in the ascending aorta for administration of blood cardioplegia as well as venting. Cardiopulmonary bypass was instituted once the ACT was satisfactory.
Distal target coronary arteries were identified and marked. Saphenous vein lengths were measured and the saphenous vein was prepared. Systemic cooling was begun. Aortic cross-clamp was applied. Antegrade cold cardioplegia was administered. Topical cooling was utilized. Repeat cardioplegia and topical cooling were administered following each distal anastomosis. Cardioplegia was also given down each vein graft following each distal anastomosis. The obtuse marginal and high diagonal arteries were individually exposed and opened longitudinally. Using an individual saphenous vein graft, a side-to-side anastomosis was performed between the distal third of the vein graft and the high diagonal artery using continuous 7-0 Prolene suture. Once this anastomosis was finished and using the distal end of the vein graft, an end-to-side anastomosis was performed to obtuse marginal using continuous 7-0 Prolene suture.
Following this, the distal right coronary artery was exposed and opened longitudinally. At this time, we noticed that there were two severely diseased vessels with heavy calcification and stenosis at the bifurcation. In view of this, the arteriotomy was extended towards the posterior lateral branch of the right coronary artery. After the arteriotomy was performed, a reverse saphenous vein graft was then anastomosed in an end-to-side fashion using continuous 7-0 Prolene suture. Next, the LAD was exposed and opened longitudinally, and the left internal mammary artery was anastomosed to the left LAD in an end-to-side fashion using continuous 7-0 Prolene suture. The warming was begun. Warm blood cardioplegia was administered, followed by warm blood perfusate down the veins.
Left internal mammary artery flow was allowed to pass into the left LAD system. Hemostasis was ensured. De-airing was ensured. The aortic cross-clamp was removed. A partial occluding clamp was placed on the ascending aorta. Two punch aortotomies were performed. Saphenous vein grafts were placed in an end-to-side fashion using continuous 6-0 Prolene suture. Marker rings were placed at the ends of the anastomosis. De-airing was ensured and the partial occluding clamp was removed. A bipolar pacing wire was placed on the right ventricle. Cardiopulmonary bypass was weaned and discontinued without any problems. Protamine was administered. Decannulation was carried out and all sites were secured. Hemostasis was ensured. Two chest tubes were placed, one in the left chest cavity and one in the anterior mediastinum. A Blake drain was placed in the posterior pericardium.
The sternum was then approximated with #6 stainless-steel wire. After this was performed, two small catheters were placed percutaneously and positioned on top of the sternum. Proximal ends of the catheters were connected to pain management pump device. After this was performed, the chest wall was closed in layers. The patient tolerated the procedure and was transferred to the cardiovascular recovery unit in stable condition.
OPERATION PERFORMED: Dual-chamber defibrillator implantation.
FINDINGS AND PROCEDURE: After informed consent was obtained, the patient was brought to the electrophysiology laboratory. He was prepped and draped in surgical fashion. The left subclavian area was anesthetized with 1% Xylocaine. Using a modified Seldinger technique, the left subclavian vein was cannulated twice, and the guidewires were advanced to the level of the inferior vena cava and secured with hemostats. An area 1 inch inferior was anesthetized with 1% Xylocaine. Using a #15 scalpel blade, the skin was incised and the dissection was carried down to the prepectoral fascia using Bovie cautery. The prepectoral fascia was split using scissors and dissection was carried out inferiorly to create a pocket and superiorly to incorporate the guidewires into the wound. The first guidewire was then used to advance a 7-French tear-away sheath under fluoroscopic guidance to the left subclavian vein. The sheath was in turn used to advance a Sprint Fidelis Dual-Coil Active Fixation lead (model #XXXX, serial #LFJXXXXXXV). The sleeve was advanced under fluoroscopic guidance to the level of the inferior vena cava. The sheath was thrown away and pressure was held over the puncture site until hemostasis was obtained. The lead was then fitted with a curved stylet and advanced into the right ventricular outflow tract. Using straight stylet, the lead was slowly withdrawn and then advanced into the right ventricular apex. The active fixation helix was then deployed using the supplied tool.
The lead was then tested and found to have R waves of 13.1 mv with a pacing impedance of 1010 ohms and a pacing threshold of 1.3 volts at 0.6 msec pulse width for current of 1.9 mA. Slew rate was 3 volts per second. Ten-volt pacing did not elicit any diaphragmatic capture. These values were judged acceptable, so the lead was sutured in place using 0-silk on the supplied sleeve. The second guidewire was used to advance another 7-French tear-away sheath under fluoroscopic guidance into the left subclavian vein. The sheath was in turn used to advance a Medtronic CapSureFix Active Fixation atrial lead (model #XXXX, serial #PJNXXXXXXV). The sleeve was advanced under fluoroscopic guidance to the level of the high right atrium. The sheath was torn away and pressure was held over the puncture site until hemostasis was obtained. The lead was then fitted with J-shaped stylet and advanced into the lateral right atrium. The lead was then actively fixed using the supplied tool. The lead was then tested and found to have P waves of 1.2 mV, pacing impedance 615 ohms, and pacing threshold of 0.8 volts at 0.6 msec with a slew rate of 0.5 volts per second. Ten-volt pacing did not elicit any diaphragmatic capture. These values were judged acceptable, so the lead was sutured in place using 0-silk in the supplied sleeve. The leads were then disconnected from the pacing system, analyzed and connected to a Medtronic EnTrust DR (model #DXXXATG, serial #PNRXXXXXXH). The sleeve was identified by its serial number and connected to the appropriate port in the device.
All connections were secured with a torque wrench and the device was then implanted in the newly created pocket after copiously lavaging it with antibiotic/saline solution. The device was fastened to the floor of the pocket using a 0-silk stitch. We then proceeded with device testing. Through the device, P waves were 2.2 mv, R waves were 9.6 mv, pacing impedances were 514 ohms in the atrium, 654 ohms in the ventricle. Pacing thresholds were 0.5 volts at 0.4 msec in the atrium and 0.5 volts at 0.4 msec in the ventricle. The patient was then heavily sedated. Using T-shock mode, sustained ventricular fibrillation was induced. This was quickly detected by the loss of charge delivered. A 20-joule biphasic countershock at an impedance of 35 ohms successfully converted the rhythm to sinus. After 10-minute waiting period, sustained ventricular fibrillation was again induced. At this time, a 15-joule biphasic countershock was successful in converting the rhythm to sinus at an impedance of 34 ohms.
At this time, the wounds were closed using 2-0 Vicryl interrupted sutures for the fascial layer, 2-0 Vicryl in a running bi-layered suture for the subcutaneous layer and Dermabond for the skin layer. The patient tolerated the procedure well without complications. He was transferred to recovery in stable condition. A postprocedure chest x-ray was ordered.
CONCLUSION: Successful implantation of transvenous dual-chamber defibrillator with defibrillation thresholds of less than or equal to 15 joules.
1. Mitral valve replacement using a 25-mm bovine pericardial valve prosthesis.
DETAILS OF OPERATION: The patient was brought to the operating room, placed in supine position and identified as the correct patient. The patient was then given adequate general endotracheal anesthesia. The chest, abdomen and legs were then prepped and draped in the usual sterile fashion. Transesophageal echo-Doppler was placed by Anesthesia and interpretation of these images revealed the patient had significant mitral and aortic stenosis with very minimal insufficiency at either valve. Left ventricular function was preserved. There was no tricuspid valvular disease. There was no atrial septal defect or patent foramen ovale. There was no clot in the left atrium. This patient has underlying chronic atrial fibrillation.
The chest was then opened through a midline median sternotomy incision. The patient was heparinized and aortic and single right atrial cannulas were inserted in standard fashion. Retrograde cardioplegia line was placed through the right atrium in the coronary sinus. The patient was then placed on cardiac pulmonary bypass and cooled to 27 degrees centigrade. During the cooling process, the aorta was cross-clamped and 1000 mL of cold cardioplegic solution given both antegrade and retrograde. The left atrium was then entered just anterior to the right superior pulmonary vein. Inspection of the mitral valve revealed a severely diseased mitral valvular apparatus with calcification in the annulus. I was able to preserve a few of the secondary and primary chordae in the posterior leaflet but was required to remove the entire anterior leaflet, along with decalcifying the annulus. The annulus was still very stiff. I then placed 2-0 Ti-Cron pledgeted sutures circumferentially in the annulus. I then had to select a 25-mm mitral valve prosthesis, which I then placed the sutures through the sewing ring of the valve. The valve was seated, sutures were tied and there was good seating of the valve. I then closed the atriotomy using double row of 4-0 Prolene sutures.
Transverse aortotomy was then performed and inspection of the aortic valve revealed a trileaflet aortic valve; I then excised the 3 leaflets of the valve. The annulus was sized and found to accommodate a 19-mm bovine pericardial valve prosthesis. Then, 2-0 Ti-Cron simple sutures were placed circumferentially in the annulus and then through the sewing ring of the prepared valve. The valve was seated, sutures were tied and there was good seating of the valve. The aortotomy was then closed using double row of 4-0 Prolene sutures. A de-airing cannula was placed in the ascending aorta and the heart was filled with blood to remove the air. While the lungs were ventilated with the patient in head-down position, light pressure was applied to the carotids. The aorta cross-clamp was removed. The patient was then rewarmed to 37 degrees centigrade. During the rewarming process, multiple de-airing maneuvers were undertaken under the direction of transesophageal echo-Doppler. Once the patient was rewarmed with adequate cardiac output and pulse, he was then weaned from cardiopulmonary bypass. The aortic and right atrial cannulas were removed and protamine was administered to reverse the heparin effect. Following adequate hemostasis, the entire mediastinum was irrigated with copious amounts of warm antibiotic solution. Two mediastinal chest tubes were placed for postoperative drainage. A single ventricular pacing wire was placed on the heart. Sternotomy was then closed in standard fashion after all instrument and sponges were accounted for.
The patient was then weaned from cardiopulmonary bypass and good hemostasis was obtained. Transesophageal echo Doppler demonstrated there was no perivalvular leak in either aortic or mitral position and there was good function of the valve. The sternotomy was then closed in standard fashion. The patient was taken to CCR in stable condition in paced rhythm.