C. Taylor Geraldson, MD and Christopher Lau, MD
New York-Presbyterian/Weill-Cornell, New York, NY, USA
This chapter is a revision and update of that included in the previous edition of the TSRA Operative Dictations in
Cardiothoracic Surgery written by Fawwaz R. Shaw, MD, and Edward D. Verrier, MD.
Essential Operative Steps
- Review of the preoperative catheterization and cross-sectional imaging with attention to coronary anatomy, annulus size,
location of sinotubular junction, and distal extent of aneurysm - Operating room briefing with anesthesia, perfusion, and nursing teams regarding intraoperative plans, including arterial
and venous cannulation, LV venting strategies, myocardial protection, valved conduit material availability, inotropic
needs, antibiotic coverage, blood products, topical hemostatic agents - Lines and monitoring
- General endotracheal anesthesia
- Intraoperative TEE
- Median sternotomy
- Open pericardium and place pericardial stay sutures
- Systemic heparinization (400u/kg)
- Check ACT (>480 seconds)
- High ascending aortic cannulation
- Right atrial two stage venous cannulation
- Myocardial protection cannula placement (antegrade with root vent and retrograde cardioplegia)
- Retrograde autologous priming of the bypass circuit if indicated
- Initiate CPB
- Place LV vent via the right superior pulmonary vein (other options: pulmonary artery vent, or venting directly through
the aortic valve) - Start active cooling (moderate versus deep hypothermia if circulatory arrest is necessary)
- Aortic crossclamp
- Arrest heart with antegrade cardioplegia (± retrograde cardioplegia), with cardioplegia given every 15 minutes via the
retrograde cannula. (If significant AI, can use retrograde cardioplegic arrest or direct ostial cardioplegia after aortotomy) - Resection of the ascending aorta down to the sinotubular junction
- Identification of coronary ostia and evaluation of the aortic valve and root to: confirm need for root replacement, evaluate
for possible valve sparing root replacement versus planned root replacement with valved conduit - Excision of the aortic valve with meticulous debridement of the annulus to remove all calcium and properly seat the
valved conduit - Divide the tissue between the aorta and the main pulmonary artery/right pulmonary artery, separating the great vessels
- Resect the non-coronary sinus to within 3-4mm of the annulus
- Resect the left and right coronary sinuses, creating coronary buttons from the aortic tissue and mark the proper orientation
with stay-sutures - Placement of the annular pledgeted valve sutures using a top-down intra-annular technique
- Size the annulus and select an appropriately sized composite valved conduit. If a prefabricated valved conduit is not
available, it must be created by sewing a Dacron graft 5mm larger than the valve size to the valve sewing ring - Pass the annular sutures through the sewing ring of the valved conduit
- Tie the valve sutures and check for gaps between the valved conduit and annulus (take this opportunity to place additional
repair sutures prior to coronary button reimplantation) - Reimplantation of the left coronary button (pressurize root to test anastomoses and check for bleeding in areas of
dissection) - Begin the posterior wall of the distal aortic anastomosis
- Reimplant the right coronary button
- Complete the anterior wall of the distal aortic anastomosis
- Deair
- Crossclamp removal and further deairing
- Placement of temporary epicardial pacing wires
- Wean from CPB
- Post-bypass TEE examination of the heart for function and the valve for leaflet excursion, function, and paravalvular
leaks (if using backtable constructed valved conduit) - Protamine administration for heparin reversal
- Aortic and venous decannulation
- Assess hemostasis
- Chest tube placement
- Sternotomy closure
Potential Complications and Pitfalls
- If no prefabricated composite valved conduit is available, a backtable valved conduit may be constructed using the
appropriately sized prosthetic valve and a prosthetic aortic conduit approximately 5mm larger than the selected valve.
The sewing ring of the valve is then secured to the graft with a running 3-0 polypropylene suture creating a watertight
anastomosis between the sewing ring and the aortic conduit. The valve leaflets are then examined for appropriate
excursion and to ensure no leaflet impingement prior to tying the suture - Inappropriately placed arterial cannula too proximal in the ascending aorta with insufficient room for crossclamp
placement - Injury to the conduction system because of deep valve stitches in the region of the right coronary sinus
- Coronary artery injury/dissection from mishandling or suturing the coronary artery itself rather than the button of aortic
tissue - Coronary obstruction from button twisting, kinking or length issues
- Length of conduit may also cause button issues after the graft is pressurized; a conduit too long may cause coronary
kinking, a conduit too short may cause coronary tension problems - Incomplete mobilization of the coronary arteries leading to tension, twisting, or kinking of the coronary anastomosis
- Failure to completely debride a calcified aortic annulus leading to abnormal seating of the valved conduit and poor
hemostasis - Inadequate deairing maneuvers or air embolus down the right coronary leading to right ventricular dysfunction
- Breaking a stitch during tying of conduit to annulus (leading to possible loss of pledget and need for a repair stitch)
- Improper sizing of the valve prosthesis leading to poor seating
Template Dictation
Preoperative Diagnosis: Ascending aortic aneurysm, Annuloaortic ectasia
Postoperative Diagnosis: Same (with appropriate adjustments)
Procedure(s) Performed: Repair of ascending aortic aneurysm and aortic valve replacement using a composite valve-graft
[VALVED CONDUIT TYPE, e.g., #25 Konect Resilia].
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] old [SEX] who developed [SYMPTOMS e.g., progressively worsening shortness of
breath and dyspnea] and was found to have [FINDINGS e.g. 6.5cm ascending aortic aneurysm with a bicuspid aortic valve].
Description of the Procedure: The patient was brought to the operating room where an intraoperative briefing was performed
with the surgical, anesthesia, nursing, and perfusion teams, confirming the correct patient, diagnosis, and operative plan. The
patient was placed in the supine position and general endotracheal anesthesia was initiated. Appropriate monitoring lines were
then placed. Preoperative TEE was performed to evaluate cardiac and valve function. It confirmed the preoperative
transthoracic findings. The chest, abdomen, and lower extremities were prepped and draped in the usual sterile fashion. A
timeout was performed.
Skin incision was made and carried through the subcutaneous tissues. A median sternotomy was created with the reciprocating
saw. Pericardium was opened longitudinally. Mediastinal anatomy was then carefully reviewed. Heparin was given. Cannulas
were placed in the aorta and right atrium. After confirmation of ACT >480 seconds, cardiopulmonary bypass was instituted,
maintaining flows of 2.4L/min/m2 maintaining a mean arterial pressure of 80mmHg. The patient was cooled to 32oC. A left
ventricular vent was placed via the right superior pulmonary vein. A cannula was placed in the proximal ascending aorta for
venting and delivery of antegrade cardioplegia. The ascending aorta was crossclamped.
Antegrade cold blood cardioplegia was used to induce diastolic arrest, ensuring myocardial temperature probe registered less
than 10oC. Iced saline slush was used for topical protection. Cardioplegia was readministered every 25-30 minutes.
The ascending aorta was resected and [FINDINGS e.g., a congenitally bicuspid aortic valve with heavy calcification and
marked dilation of the sinuses] was encountered. The aortic valve was resected and the annulus was debrided of all calcium.
The aorta was resected down to the annulus. Coronary buttons were cut from the surrounding aortic tissue and marked with
sutures to maintain proper orientation.
A total of [NUMBER e.g., 16] pledgeted 2-0 ethibond sutures were placed on the supra-annular side of the annulus. The
annulus was sized. The valve sutures were brought through a [SIZE e.g. 25mm] composite valved graft. The sutures were
tied.
The left coronary artery was reattached at the appropriate height in the sinus using two layers of 5-0 prolene suture. The distal
aortic anastomosis was performed with running 3-0 prolene suture. The right coronary artery was reattached with 5-0 prolene
suture. The patient was placed in the Trendelenburg position. Deairing was carried out. Crossclamp was removed.
The heart was defibrillated as necessary. Spontaneous rhythm was ensured and temporary epicardial pacing wires were placed.
The LV vent was removed. The patient was warmed to 36°C and separated from cardiopulmonary bypass [INOTROPES e.g.,
with/without the assistance of low dose inotropes]. TEE demonstrated preserved ventricular function, no aortic insufficiency,
and appropriate excursion of valve leaflets.
Protamine sulfate was administered to reverse the heparin. Cannulas were removed and cannulation sites oversewn with 4-0
prolene suture. Hemostasis was ensured and mediastinal drains were placed. The sternum was reapproximated with
[NUMBER e.g. 8][SIZE e.g. #7] stainless steel wires. Fascia and subcutaneous tissues were reapproximated with running
vicryl sutures and the skin was reapproximated with 4-0 monocryl sutures in running subcuticular fashion. Steri-strips were
applied. Sterile dressings were applied over the incision and drainage tube sites.
All instrument, sponge, and needle counts were confirmed to be correct, twice, at the end of the surgical procedure. The patient
was subsequently transferred to the postoperative cardiac surgical intensive care unit in stable condition.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of this procedure.
