Sample Report Mitral Valve Replacement
Title of Procedure
1. Mitral valve replacement with size 27 CarboMedics valve.
2. Repair of left ventricular rupture, secondary to myocardial infarction.
Procedure in Detail: The neck, chest, abdomen and legs were prepped with Betadine solution. Combination sterile dressings were placed in the usual sterile fashion. A #10 scalpel blade was used to make an incision from the sternal notch to the xiphoid. The presternal fascia and subcutaneous tissue were transected with electrocautery. The sternum was divided with a sternal saw. The chest was then exposed using the sternal retractor. The pericardium was entered from the innominate vein and teased off from the diaphragm. Approximately 500 cc of gross blood was aspirated from the pericardium. The patient was heparinized.
The aorta was soft without any calcification. It was cannulated with the aortic cannulation device. The superior vena cava was cannulated with a size 32 French venous cannula. The inferior vena cava was cannulated with a size 36 French cannula. After adequate activated coagulation time was achieved, the patient was placed on cardiopulmonary bypass and cooled to 38 degrees centigrade. The aorta was cross-clamped, and cold blood cardioplegia was given antegrade. To achieve electromechanical arrest, 500 cc was given antegrade, and 500 cc was given retrograde through the cannulation device. The heart was also cooled with topical hypothermia using iced slush solution throughout the procedure. Throughout this procedure, every 15 minutes, 250 cc of cold blood cardioplegia was given retrograde to maintain electromechanical arrest and hypothermia. Snares were placed around the superior and inferior vena cava to complete full unloading of the right heart. The intraatrial septum was dissected, the left atrium was elevated, and atriotomy was performed through the left atrium. An atrial retractor was used to expose the entire left atrium. The mitral valve was difficult to expose due to the acuteness of the mitral regurgitation and the small size of the left atrium.
Eventually, the anterior and posterior leaflets were identified. Part of the posterior leaflet was completely ruptured from the papillary muscle with a large amount of papillary muscle still intact with the chordae. The leaflet was then debrided. The anterior leaflet was debrided as well along the chordae attachments. The commissures were sewn with interrupted 2—0 Ethibond pledgeted sutures, and the valve anulus was sized. A size 27 CarboMedics valve was chosen. Using interrupted green and white pledgeted horizontal mattress suture technique, the entire anterior and posterior leaflets were sewn. The valve was then sewn to the anulus, and the valve was lowered into the position carefully. There appeared to be good coaptation of the leaflets. A vent was then placed between the prosthetic valve leaflet and brought out through the atriotomy. The atriotomy was closed with a running 4—0 Prolene suture, and the left ventricle was allowed to fill with blood. Using gentle massage technique, the left ventricle was de-aired. The atriotomy was completely closed, and the patient was rewarmed. The snares around the vena cava were loosened, and the patient was given a hot shot of blood cardioplegia retrograde. The cross-clamp was removed after the aorta was de-aired as well. The aortic vent was kept on to help remove any additional emboli. A transesophageal echocardiogram was used to assess the valve. The valve appeared to be functioning adequately; a small amount of air was noticed in the left atrium. This was again suctioned with the LV vent. The LV vent was removed. There appeared to be good contractility of the heart.
The patient was weaned from cardiopulmonary bypass slowly. After approximately 30 minutes of the cross-clamp being off, the patient was weaned from cardiopulmonary bypass with some inotropic support, including dopamine at 5 mcg/kg per minute and 0.05 epinephrine. The intraaortic balloon pump was placed on 1:1 augmentation, and the patient had adequate hemodynamics and adequate cardiac output hemodynamics. The protamine was begun. After the protamine was given, the aortic and venous cannulas were removed. The protamine was well tolerated. The retrograde and antegrade cardioplegia cannulas were removed as well. There appeared to be no bleeding along the aortotomy site or the atriotomy site; however, there appeared to be some bright red bleeding along the base of the heart and along the apex of the heart, apparently an area where the left ventricle had ruptured and probably secondary to the myocardial infarction. Interrupted 4—0 pledgeted Prolene sutures were used to close this rupture.
The patient was placed back on cardiopulmonary bypass by placing the aortic cannula back in the aorta, and the left groin was prepped. A 32 French venous catheter was placed through the left femoral vein. The patient was heparinized. After adequate ACT was achieved, the patient was placed on cardiopulmonary bypass, and the apex of the heart was elevated. There appeared to be a 2-cm rupture along the lateral wall of the heart. This rupture was closed with an approximately 4-cm pledgeted Telfa in a horizontal mattress fashion. It was closed quite securely, and the patient tolerated it well. The patient was weaned from cardiopulmonary bypass without any difficulty. Protamine was reinstituted, and the venous and aortic cannulas were removed. The patient had adequate hemodynamics and blood pressure, and there appeared to be no other bleeding from this rupture site. Mediastinal and bilateral chest tubes were placed through separate stab wounds, and the sternum was reapproximated with six stainless steel wires. The subcutaneous tissue and the skin were closed with 2—0 Vicryl and skin staples. The patient tolerated the procedure well, with no intraoperative complications.
1. Mitral valve replacement with size 27 CarboMedics valve.
2. Repair of left ventricular rupture, secondary to myocardial infarction.
Procedure in Detail: The neck, chest, abdomen and legs were prepped with Betadine solution. Combination sterile dressings were placed in the usual sterile fashion. A #10 scalpel blade was used to make an incision from the sternal notch to the xiphoid. The presternal fascia and subcutaneous tissue were transected with electrocautery. The sternum was divided with a sternal saw. The chest was then exposed using the sternal retractor. The pericardium was entered from the innominate vein and teased off from the diaphragm. Approximately 500 cc of gross blood was aspirated from the pericardium. The patient was heparinized.
The aorta was soft without any calcification. It was cannulated with the aortic cannulation device. The superior vena cava was cannulated with a size 32 French venous cannula. The inferior vena cava was cannulated with a size 36 French cannula. After adequate activated coagulation time was achieved, the patient was placed on cardiopulmonary bypass and cooled to 38 degrees centigrade. The aorta was cross-clamped, and cold blood cardioplegia was given antegrade. To achieve electromechanical arrest, 500 cc was given antegrade, and 500 cc was given retrograde through the cannulation device. The heart was also cooled with topical hypothermia using iced slush solution throughout the procedure. Throughout this procedure, every 15 minutes, 250 cc of cold blood cardioplegia was given retrograde to maintain electromechanical arrest and hypothermia. Snares were placed around the superior and inferior vena cava to complete full unloading of the right heart. The intraatrial septum was dissected, the left atrium was elevated, and atriotomy was performed through the left atrium. An atrial retractor was used to expose the entire left atrium. The mitral valve was difficult to expose due to the acuteness of the mitral regurgitation and the small size of the left atrium.
Eventually, the anterior and posterior leaflets were identified. Part of the posterior leaflet was completely ruptured from the papillary muscle with a large amount of papillary muscle still intact with the chordae. The leaflet was then debrided. The anterior leaflet was debrided as well along the chordae attachments. The commissures were sewn with interrupted 2—0 Ethibond pledgeted sutures, and the valve anulus was sized. A size 27 CarboMedics valve was chosen. Using interrupted green and white pledgeted horizontal mattress suture technique, the entire anterior and posterior leaflets were sewn. The valve was then sewn to the anulus, and the valve was lowered into the position carefully. There appeared to be good coaptation of the leaflets. A vent was then placed between the prosthetic valve leaflet and brought out through the atriotomy. The atriotomy was closed with a running 4—0 Prolene suture, and the left ventricle was allowed to fill with blood. Using gentle massage technique, the left ventricle was de-aired. The atriotomy was completely closed, and the patient was rewarmed. The snares around the vena cava were loosened, and the patient was given a hot shot of blood cardioplegia retrograde. The cross-clamp was removed after the aorta was de-aired as well. The aortic vent was kept on to help remove any additional emboli. A transesophageal echocardiogram was used to assess the valve. The valve appeared to be functioning adequately; a small amount of air was noticed in the left atrium. This was again suctioned with the LV vent. The LV vent was removed. There appeared to be good contractility of the heart.
The patient was weaned from cardiopulmonary bypass slowly. After approximately 30 minutes of the cross-clamp being off, the patient was weaned from cardiopulmonary bypass with some inotropic support, including dopamine at 5 mcg/kg per minute and 0.05 epinephrine. The intraaortic balloon pump was placed on 1:1 augmentation, and the patient had adequate hemodynamics and adequate cardiac output hemodynamics. The protamine was begun. After the protamine was given, the aortic and venous cannulas were removed. The protamine was well tolerated. The retrograde and antegrade cardioplegia cannulas were removed as well. There appeared to be no bleeding along the aortotomy site or the atriotomy site; however, there appeared to be some bright red bleeding along the base of the heart and along the apex of the heart, apparently an area where the left ventricle had ruptured and probably secondary to the myocardial infarction. Interrupted 4—0 pledgeted Prolene sutures were used to close this rupture.
The patient was placed back on cardiopulmonary bypass by placing the aortic cannula back in the aorta, and the left groin was prepped. A 32 French venous catheter was placed through the left femoral vein. The patient was heparinized. After adequate ACT was achieved, the patient was placed on cardiopulmonary bypass, and the apex of the heart was elevated. There appeared to be a 2-cm rupture along the lateral wall of the heart. This rupture was closed with an approximately 4-cm pledgeted Telfa in a horizontal mattress fashion. It was closed quite securely, and the patient tolerated it well. The patient was weaned from cardiopulmonary bypass without any difficulty. Protamine was reinstituted, and the venous and aortic cannulas were removed. The patient had adequate hemodynamics and blood pressure, and there appeared to be no other bleeding from this rupture site. Mediastinal and bilateral chest tubes were placed through separate stab wounds, and the sternum was reapproximated with six stainless steel wires. The subcutaneous tissue and the skin were closed with 2—0 Vicryl and skin staples. The patient tolerated the procedure well, with no intraoperative complications.
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