Yihan Lin, MD, MPH and T Brett Reece, MD
University of Colorado, Aurora, CO, 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
- Ensure appropriate size of homograft is available
- Lines and monitoring
- General endotracheal anesthesia
- Intraoperative TEE
- Median sternotomy
- Open pericardium and create pericardial well
- High ascending aortic cannulation
- Right atrial two stage venous cannulation
- Cardioplegia cannula placement
- Initiate CPB
- Place aortic crossclamp and administer cardioplegia
- Transect aorta and remove all infected tissue including aortic valve
- Create coronary buttons
- Proximal anastomosis (homograft to aortic annulus)
- Coronary to homograft anastomoses
- Distal homograft to aorta anastomosis
- Remove aortic crossclamp
- Check for hemostasis
- Wean from CPB
- Venous and aortic decannulation
- Sternotomy closure
Potential Complications and Pitfalls
- Insufficient myocardial protection
- Inadequate LV drainage with LV vent
- Bunching of the homograft during anastomosis leading to aortic valve incompetence
- Injury to coronary artery ostia and coronary malposition
- Root dehiscence
- Annular narrowing
- Inadequate control of hemostasis prior to sternal closure
- Bleeding complications
Template Dictation
Preoperative Diagnosis: [INDICATION: e.g., aortic valve endocarditis with aortic root abscess]
Postoperative Diagnosis: Same (with appropriate adjustments)
Procedure(s) Performed:
- Radial debridement of infected tissue [DETAILS e.g., extent of tissue removed]
- Aortic root reconstruction with [SIZE] homograft aortic root conduit
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [SEX] with [DURATION] history of [COMPLAINT e.g., sepsis with
persistent bacteremia, aortic root abscess, aortic insufficiency, AV node dysfunction, resistant organism]. Preoperative
echocardiogram reveals [FINDINGS e.g., aortic valve vegetation with aortic root dilation].
Description of the Procedure: The patient was taken to the operating room on [DATE]. The patient’s identity and procedure
were verified, and the patient was placed on the operating room table in the supine position. General anesthesia was obtained.
A right internal jugular central venous line, pulmonary artery catheter, and radial arterial line were inserted. Preoperative
transesophageal echocardiogram was then performed to evaluate cardiac function and aortic valve/root pathology. We then
proceeded to prep and drape the chest, abdomen, groins, and lower extremities in the usual sterile fashion. A timeout was
performed. [ANTIBIOTIC] was given within 60 minutes of incision. Median sternotomy was then performed. The
pericardium was opened and a pericardial well was created. The aortic cannulation sutures were then placed in the ascending
aorta below the level of the innominate artery. The right atrial cannulation sutures were then placed within the right atrium.
A total of [UNITS (400u/kg)] of systemic heparin was administered. The aortic cannula was then inserted, secured, and deaired.
The venous cannula was placed and secured in the right atrium. A retrograde cannula was placed through the right atrium into
the coronary sinus. An aortic root vent was then inserted into the ascending aorta for administration of antegrade cardioplegia.
The aortic crossclamp was placed. Antegrade cardioplegia was administered and rapid arrest of the heart followed. After 1L
of high potassium antegrade cardioplegia, 500cc of retrograde cardioplegia was given. Ice was applied to the heart. The patient
was cooled to [32-34]o C. Additional myocardial protection was achieved with continuous retrograde cardioplegia. A left
ventricular vent was placed via the right superior pulmonary vein.
After arrest of the heart with cardioplegia, the ascending aorta was opened transversely with an #11 blade just above the level
of the sinotubular junction. The aortic root was evaluated to assess involvement of surrounding structures and extent of
debridement required. The aortic root was then dissected free of surrounding structures. All aortic leaflets were then excised.
The aortic sinus tissue was then excised to the level of the aortic annulus. The left and right coronary buttons were then created
leaving adequate aortic tissue to be able to perform the anastomoses. Radical debridement of all infected tissues was then
carried out [include specifics/involved structures]. All contaminated instruments were then removed from the field. The
wound was copiously irrigated with the pump suckers from the cardiopulmonary bypass machine turned off. 4-0 pledgeted
sutures were then placed at each commissure for retraction.
Following this, the aortic root was sized using a [Hegar dilator]. An appropriately sized homograft was selected and the
thawing process was started. A series of interrupted prolene sutures were placed circumferentially around the aortic annulus.
These were then brought through the base of a [SIZE] homograft conduit. [Variation: A running suture technique can be
utilized]. The conduit was then seated down into the LVOT. The sutures were then tied and cut [Variation: if using a running
technique, the dilator was left in position while the suture was tied to avoid significant annular size reduction]. The coronary
ostia on the homograft were then enlarged and the coronary buttons were sewn into the homograft ostia using a running [5- or
6-0] prolene suture. Finally, the distal homograft was anastomosed circumferentially to the ascending aorta using a running 4-
0 prolene suture.
The aortic crossclamp was then removed. All suture lines were evaluated for hemostasis. A total of [NUMBER] chest tubes
were placed in the [LEFT/RIGHT] pleural space, and [NUMBER] chest tubes were placed in the mediastinum.
[ATRIAL/VENTRICULAR] pacing wires were then inserted and tested for appropriate capture. The heart was then deaired
and the LV vent was removed. The patient was weaned from cardiopulmonary bypass and the aortic root vent was removed.
Transesophageal echocardiogram revealed a competent aortic valve. The venous cannula was removed, and the cannulation
sutures were snared. Protamine was then slowly administered. The aortic cannula was then removed, and the aortic cannulation
sutures tied down. The venous cannulation sutures were tied down. Adequate hemostasis was then confirmed within the
mediastinum. The sternum was closed with stainless steel sternal wires. The fascia was closed with a 0 vicryl suture. The deep
dermal layer was closed with 2-0 vicryl suture in a running fashion. The skin and subcuticular layer were closed with 4-0
monocryl in a running fashion.
All instrument, sponge, and needle counts were confirmed to be correct, twice, at the end of the operation. The patient was
subsequently transferred to the postoperative cardiac surgical intensive care unit in critical condition.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of this procedure.
Multiple Choice Question(s)
The following are indications for aortic homograft replacement except:
A. Active aortic valve endocarditis (native or prosthetic) with involvement of the aorto-mitral curtain
B. Aortic valve endocarditis with persistent bacteremia despite long-course antibiotics
C. Aortic valve endocarditis with associated aortic root abscess
D. Aortic valve endocarditis with AV node dysfunction
Answer: A. Involvement of the aortomitral curtain will likely require a more advanced procedure, such as the Commando
procedure.
Sources
Carrel T. Aortic valve and/or aortic root replacement using an aortic homograft. Multimed Man Cardiothorac Surg. 2009 Jan
1;2009(626):mmcts.2009.003905.
Hopkins RA. Aortic Root Replacement with Homograft valved conduit. Operative Techniques in Thoracic and
Cardiovascular Surgery. Nov 1997.
Spindel SM, Itagaki S, Stelzer PE. Homograft Repair of Aortic Root Abscess in Prosthetic Valve Endocarditis. July 2020.
