DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Moderate to severe aortic stenosis.
2. Moderate to severe mitral regurgitation.
3. Severe 3-vessel coronary artery disease.
4. Ejection fraction 30%.
POSTOPERATIVE DIAGNOSES:
1. Moderate to severe aortic stenosis.
2. Moderate to severe mitral regurgitation.
3. Severe 3-vessel coronary artery disease
4. Ejection fraction 30%.
OPERATION PERFORMED:
1. Aortic valve replacement.
2. Mitral valve replacement.
3. Coronary artery bypass grafting x3 using the internal mammary artery and segments of the saphenous vein.
4. Endoscopic saphenous vein harvesting.
SURGEON: John Doe, MD
ANESTHESIA: General.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old gentleman with a several month history of exertional shortness of breath. He has multiple risk factors including diabetes, hypertension and elevated cholesterol. The patient has a history of heart failure and also a previous pacemaker implantation.
His cardiac catheterization showed severe 3-vessel coronary artery disease. The anterior descending had at least a 70% proximal to mid area stenosis. The circumflex had a 70% area of narrowing before giving rise to the obtuse marginal branch. The right coronary artery was a dominant vessel with at least 80-90% stenosis beyond the origin of the posterior descending branch and before terminating into 2 large posterolateral branches. Also identified was moderate to severe aortic stenosis with a valve area of 1 sq cm. Ejection fraction was about 30%.
DESCRIPTION OF OPERATION: The patient was brought to the operating room where he was placed supine and then induced under suitable general anesthesia. He was then prepped and draped in the usual sterile fashion. Intraoperative transesophageal echocardiography was carried out and moderate to severe mitral regurgitation was identified. There was a central jet with no structural problems involving the valve or chordae tendineae. Because of the moderate to severe regurgitation, it was felt that a mitral valve replacement was also indicated.
The sternotomy incision was made and the sternum divided with the use of the sternal saw. Using a self-retaining retractor, the left internal mammary artery was mobilized in a pedicle, which included the slip of the endothoracic fascia as well as accompanying vein. A length of the left greater saphenous vein was harvested endoscopically. Systemic heparin was administered. The pericardium was opened in the midline and the distal ascending thoracic aorta cannulated. The superior vena cava was cannulated directly with right angle venous cannula and a second cannula placed in the lateral body of the right atrium and directed down toward the inferior vena cava. The patient was then placed on cardiopulmonary bypass. Successful cardioplegic arrest of the heart was achieved by cross-clamping the aorta and by infusing cold blood cardioplegia into the aortic root at approximately 5 degrees centigrade. Initially, 700 mL of blood cardioplegia was administered. Thereafter, every 15-20 minutes throughout the operation, additional cardioplegia was infused through the retrograde coronary sinus catheter. Using the saphenous vein graft, the first distal anastomosis was completed to the distal posterolateral branch of the right coronary artery. A 4 mm arteriotomy was made and the distal end-to-side anastomosis was completed with a running suture of 7-0 Prolene. A second sequential side-to-side anastomosis was completed to the distal circumflex branch. Again, a 4 mm arteriotomy was made, a corresponding venotomy was made on the vein graft and the second sequential side-to-side anastomosis completed with a running suture of 7-0 Prolene. As mentioned above, every 15-20 minutes throughout the operation, additional cardioplegia was infused into the retrograde coronary sinus catheter. Next, the internal mammary artery was transected distally. The proximal end was appropriately beveled. The left anterior descending was identified in the mid portion where a 4 mm arteriotomy was made. The internal mammary artery to LAD anastomosis was completed with a running suture of 7-0 Prolene.
Next, the mitral valve replacement was carried out. A left atrial incision was made starting at the right superior pulmonary vein and extending the incision down towards the inferior vena cava. A self-retaining retractor was used to provide exposure for the mitral valve. The caudal attachments to the anterior leaflet were preserved. However, the large surface area in the mid portion of the valve was removed as an elliptical patch. Only the caudal attachments to the leading edge of the leaflet were preserved along the anterior leaflet and this was incorporated as part of the suture line. The posterior leaflet was left in place. A series of interrupted pledgeted mattress sutures were then placed circumferentially around the annulus with the pledgets on the atrial or inflow side of the annulus. As mentioned, the sutures along the anterior part of the annulus incorporated the leading edge of the leaflet with the caudal attachments. A 29 Medtronic Mosaic valve was selected as the appropriate size. The sutures were placed through the sewing ring of the valve. The valve was then lowered in place and the suture line secured and tied. The atrial incision was closed in 2 layers with a running suture of 4-0 Prolene.
Next, the aortic valve replacement was carried out. A transverse aortotomy was made about 2 cm above the aortic commissure. Incision was carried down on the left in the sulcus between the pulmonary artery and aorta and on the right toward the noncoronary cusp. The aortic valve had 3 leaflets, which were moderately calcified. The leaflets were excised and the annulus debrided of all calcium. A series of interrupted pledgeted mattress sutures were then placed around the annulus with the pledgets on the inflow or ventricular side of the annulus. A 23 Edwards pericardial tissue valve was selected as the appropriate size. The sutures were then placed through the sewing ring of the valve. The valve was lowered in place and the suture line secured and tied.
Warming was then initiated and the aortotomy closed in a single layer with running suture of 4-0 Prolene. The single proximal anastomosis was completed with the use of a partial occluding aortic clamp. A 5 mm aortic punch was used to remove a single button of the aortic wall. The single proximal anastomosis was then completed with a running suture of 6-0 Prolene. A vent was then placed in the anterior portion of the aorta to remove any air present within the heart. The presence of air within the heart was also monitored with the use of the transesophageal echocardiogram. Warming was continued until a venous temperature of 37 degrees centigrade, at which time, the patient was weaned from cardiopulmonary bypass. All of the cannulas were removed and protamine sulfate administered. The pericardium was left opened. Two #32 Blake drains were used to drain the pericardial space. The sternum was reapproximated with monofilament #5 wire along the sternum in the appropriate end spaces. In addition, sternal plates and screws were used to reinforce the sternal closure. The deep fascia was closed with a running suture of 0 Vicryl and the skin with a running subcuticular stitch of 4-0 Monocryl. The patient tolerated the procedure well and was returned to the ICU in satisfactory condition. The cross-clamp time was 3 hours and 50 minutes. Pump time was 4 hours and 52 minutes.
