Sameer Gupta, MD and Anthony Estrera, MD
McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX,
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 Muhammad Aftab, MD and Ourania Preventza, MD.
Essential Operative Steps
- Lines and monitoring
- General endotracheal anesthesia
- Intraoperative transesophageal echocardiogram
- Right infraclavicular incision for right axillary cannulation or right groin incision for right common femoral artery
cannulation (consider in cases of redo sternotomies) - Dacron graft anastomosis to right axillary artery (alternatively an innominate artery cannulation can be performed after
the chest is opened) - Femoral venous cannulation for CPB (optional)
- Redo sternotomy
- Systemic heparinization (400 U/kg). Ensure that ACT is >450 seconds
- CO2 in the operative field
- Distal ascending aortic cannulation (alternative to axillary artery graft, innominate artery, or femoral artery cannulation)
- Dual-stage venous cannulation of right atrium
- Initiate CPB (2-2.5 L/min/m2)
- Systemic hypothermia (28-32°C)
- Lysis of adhesions
- Left ventricular sump via right superior pulmonary vein
- Retrograde cardioplegia cannula in coronary sinus
- Distal ascending aorta crossclamped
- Antegrade cold blood cardioplegia, except in severe aortic insufficiency
- Combination of antegrade and retrograde cold blood cardioplegia (every 20 min during the operation)
- Make transverse aortotomy above the sinotubular junction of native ascending aorta or just distal to previous graft
anastomosis - Excise all infected tissue, including native cusps or all infected graft and valve prosthesis
- Wide local debridement involving extensive root debridement
- Mobilize the right and left main coronary buttons (may not be able to mobilize if significant scar or inflammation)
- Sharp debridement of the infected annular and subannular region, if necessary
- Reconstruct the tissue defect with autologous pericardium, bovine pericardium or the mitral leaflet of the valved
homograft, as needed - Completely remove all prosthetic material, previous pledgets, and sutures
- Aortic annular sizing and selection of homograft
- Thawing of cryopreserved aortic root homograft as per protocol
- Trim the proximal end of homograft with 3 to 4mm myocardial cuff
- Hemostatic proximal suture line by using a reinforcing collar with Teflon felt or pericardium
- Homograft to aortic annulus/left ventricular outflow tract anastomosis
- Left main coronary and right coronary button anastomoses (may be reinforced with pericardium)
- In case of inadequate mobilization of the left main or right main coronary button, an 8 or 10mm rifampin-soaked Dacron
graft, SVG, or cryopreserved superficial femoral artery homograft in modified Cabrol - Distal trimming of homograft
- Distal anastomosis of homograft to ascending aorta
- Ensure excellent hemostasis along all the anastomoses
- Additional interrupted sutures for anastomotic reinforcement, as needed
- Ensure no tension or kinking of coronary buttons
- Start rewarming
- Place patient in Trendelenburg position, perform deairing maneuvers, and remove the aortic crossclamp
- Confirm spontaneous cardiac rhythm, place pacing wires
- Continue deairing
- Once patient is rewarmed (36.5°C), resume ventilation
- Fill the heart with blood and allow the heart to eject
- Wean from CPB
- Protamine and sequential decannulation
- Ensure hemostasis
- Mediastinal irrigation with antibiotics
- Residual mediastinal abscess cavity debridement. In the event of a large, non-collapsible periaortic cavity, omentum can
be mobilized to fill the mediastinal cavity - Place mediastinal drains
- Sternotomy closure
Potential Complications and Pitfalls
- The primary indication for aortic root replacement with a cryopreserved homograft is endocarditis of the native or
prosthetic aortic valve or composite valved graft with extensive periannular involvement - A safe redo sternotomy is an important initial step in successful reoperative aortic root surgery
Considerations for a safe sternal reentry include:
a. Careful evaluation of preoperative imaging to assess the proximity of vital structures to the sternum
b. Use of an oscillating saw for the anterior table, initially leaving the untwisted sternal wires in place, lifting the
sternal edges, and incising the posterior table under direct vision, and removing the sternal wires after incising
the posterior table OR
c. Lifting the sternal edges of the xiphoid process to dissect the periaortic tissue and cardiac structures under
direct vision from the back of the sternum and then use of regular vertical saw for the sternotomy
d. Use of peripheral cannulation (femoral-femoral bypass, or femoral-to-axillary bypass) before sternal entry in
high-risk situations where the right ventricle or the aorta is adherent at the back of the sternum. In these cases,
placement of the patient on CPB prior to sternal entry is advisable - Dual-stage right atrial venous cannulation is standard. Femoral venous cannulation can be performed in high-risk cases
- Complete debridement of all the infected necrotic tissue and removal of any foreign material from the previous operation
(including sutures, pledgets, and graft material) is paramount in homograft aortic root replacement for aortic root infection - Coronary buttons are prepared and mobilized. In redo root operations, their mobilization becomes increasingly difficult
- Preoperative planning also includes ensuring that the local tissue bank contains the sizes of aortic homografts within your
desired annulus diameter range, based on the preoperative echocardiograms and preoperative CT scan - The aortic annulus is sized by using the standard Freestyle valve sizer or Hagar dilators.
- A properly matching homograft with an annular (internal) diameter of equal size or a size difference of no more than
2mm is ideal - The homograft should be carefully evaluated for valve morphology and integrity, as well as for any injuries sustained
during the processes of procurement, preservation, and thawing - The proximal end of the homograft is trimmed, such that a 3 to 4mm cuff of myocardium is left below the nadir of the
cusps. The anterior mitral leaflet is initially retained during the trimming to repair any annular or periannular defect, if
needed - The proximal suture line is reinforced by Teflon felt or pericardium. This not only helps with hemostasis but prevents
dilation of the aortic allograft root - Allograft implantation in anatomic orientation can be straightforward, when the native aortic valve is tricuspid and both
annuli match closely - All the anastomoses are performed with monofilament sutures (e.g., polypropylene) in a continuous or interrupted fashion
- Constant tension on the suture line should be maintained by the assistant during the anastomosis. Tightening the loose
suture line with nerve hooks ensures a hemostatic anastomosis. Interrupted suturing is more accurate, especially if there
is a size mismatch. Continuous suturing is faster and more hemostatic - Any kinking or overstretching of the main coronary arteries during the reimplantation of coronary buttons into the
homograft root should be avoided - In reoperative situations, when significant scarring and inflammation around the root or heavy calcification around the
coronary ostia precludes the safe direct coronary button reimplantation, an interposition saphenous vein graft, Dacron
graft, or superficial femoral artery homograft between the origin of the coronary buttons and the homograft (a modifiedCabrol) can be used. - Postoperative bleeding due to coagulopathy should be addressed with targeted blood product transfusion guided by the
laboratory results - Postoperative hypertension should be avoided to prevent any suture line disruption
Template Dictation
Preoperative Diagnosis:
- Group B streptococcal endocarditis of composite (mechanical) valved graft
- Postresection and replacement of aortic root (Bentall procedure) for annuloaortic ectasia and aortic valve insufficiency
- Periannular abscess
- New York Heart Association classification III
Postoperative Diagnosis: Same (with appropriate adjustments)
Procedure(s) Performed:
- Redo median sternotomy
- Right axillary artery or innominate artery cannulation with a [BLANK] mm Dacron end-to-side graft for pump return
- Total cardiopulmonary bypass
- Resection of previous composite valve graft (Bentall) prosthesis and wide debridement of infected tissue
- Extensive debridement of mediastinal abscess cavity
- Replacement of aortic root with [BLANK] mm × [BLANK] cm valved homograft root
Drainage: Two 36 Fr Argyle chest tubes were placed in the mediastinum for the drainage
Fluids and Products: [BLANK] crystalloid, [BLANK] colloid, [BLANK] PRBC, [BLANK] FFP, [BLANK] platelets,
[BLANK] cell saver
Urine Output: [BLANK]
CPB Time: [BLANK]
Cardiac Ischemia Time: [BLANK] (cardiac ischemia and aortic crossclamp are the same in cases for which circulatory arrest
is not performed)
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [SEX] who had undergone aortic root replacement with a composite mechanical
valve graft 3 years earlier. He initially developed a right eye and sinus infection. Two weeks later, he presented to the hospital
with a high-grade fever and dyspnea on exertion. He was febrile and in respiratory distress. Empiric antibiotics were
immediately started. CT showed abnormal fluid collection around the graft. Group B streptococcus was identified in the blood
culture. Transthoracic echocardiography revealed mechanical aortic valve stenosis with a 16mm x 6mm mass at the aortic
annulus and a fluid collection around the graft, consistent with the infective endocarditis of previous composite valve graft and
perigraft abscess. Consequently, it was decided that operative intervention was indicated, with resection of composite valve
graft and replacement with a homograft.
Description of the Procedure: After informed consent was obtained and the patient’s identity and the surgical site were
confirmed, the patient was brought to the operating room and placed in a supine position. Patient was induced under general
anesthesia and intubated. Foley catheter, arterial lines, central lines, and pulmonary artery catheter were placed. Bilateral
cerebral near-infrared spectroscopy sensors were placed to monitor brain oxygenation throughout the procedure. A TEE probe
was inserted by the anesthesia team. The chest, abdomen, and legs were prepped and draped in sterile surgical fashion. An
incision was made under the right clavicle in the deltopectoral groove. The right axillary artery was exposed, getting proximal
and distal control. Care was taken to avoid touching or manipulating the brachial plexus. Intravenous heparin (5000 units) was
administered, and a straight vascular clamp was placed on the axillary artery proximally and distally. A [BLANK] mm Dacron
graft was anastomosed end-to-side with 5-0 polypropylene and connected to the arterial cannula of the cardiopulmonary bypass
circuit for pump return. [For innominate artery cannulation: The innominate artery was exposed. Intravenous heparin (5000
units) was administered by anesthesia, and a partial occluding clamp was placed on the innominate artery. A [BLANK] mm
Dacron graft was anastomosed end-to-side with 5-0 polypropylene and connected to the arterial cannula of the cardiopulmonary
bypass circuit for pump return. During the innominate artery cannulation, we keep the MAP 90mmHg. For femoral cannulation:
A vertical curvilinear incision was made in the inguinal region anterior to the femoral vessels and deepened through the
subcutaneous tissue, exposing the fascia. The left/right common femoral vessels were exposed. Arterial and venous cannulation
were performed using the standard Seldinger technique through a purse string of 5-0 polypropylene. A 19/21 Fr arterial cannula
was then placed, with the arterial line checked with good flow. A 23/25 Fr dual-stage venous cannula was inserted into the
right atrium with TEE guidance, and satisfactory venous drainage was achieved].
A midline incision was made over the sternum and carried down to the presternal fascia with electrocautery. The
chest was entered through the previous median sternotomy (with an oscillating sternal saw initially leaving the untwisted sternal
wires in place, lifting the sternal edges, incising the posterior table under direct vision, and removing the sternal wires after
incising the posterior table to the wire; alternatively, with the regular, vertical saw by initially lifting the sternal edges of the
xiphoid and dissecting the tissue and cardiac structures under direct vision from the back of the sternum) and hemostasis was
achieved with electrocautery. Adhesions from the previous operation were taken down with careful sharp dissection.
The patient was then systemically heparinized to keep the ACT >450 seconds. A dual-stage venous cannula was
introduced though a purse string in the right atrium with the tip directed into the inferior vena cava and secured with a Rummel
tourniquet. Cardiopulmonary bypass was initiated. A retrograde cardioplegia cannula was inserted into the coronary sinus, and
its position was confirmed by palpation, pressure transduction, and/or TEE guidance. A left ventricular sump was inserted via
the right superior pulmonary vein and the patient was cooled to [28-32]°C.
The distal ascending aorta was crossclamped. Antegrade and retrograde cardioplegia was given intermittently and
generously for myocardial protection. The native ascending aorta was divided distal to the previous anastomosis, and stay
suture was placed for retraction. Significant inflammation and purulent material were encountered as the infected composite
valve graft was sharply excised. Portions of the graft were noted to be densely adhered to the surrounding tissue, and some
portions were easily separated. The adhesions were taken down with sharp dissection. The right and left main coronary artery
buttons were mobilized. The prosthetic aortic valve was sharply excised from the aortic annulus. All the previous pledgets and
sutures were carefully and completely removed. The annulus was decalcified, and stay sutures were placed over the site of
commissures for optimal exposure. The aortic annulus and sub annular region were carefully evaluated for any evidence of
aorto-ventricular, periannular abscess, or infected granulation tissue. All the infected annular and subannular tissue was sharply
debrided with a wide local excision. A periannular abscess was encountered and debrided of necrotic tissue. The area was
irrigated with copious amounts of saline with rifampin to remove any debris. The tissue defect was reconstructed with bovine
pericardium (or autologous pericardium), which was secured to the firm, healthy myocardial tissue by using 3-0 polypropylene
in continuous fashion.
To select a homograft of appropriate diameter, the aortic annulus was sized with standard valve sizers. The
homograft was thawed, as per protocol, and trimmed. A strip of bovine pericardium was then cut and incorporated into the
proximal suture line for hemostasis and to prevent dilation of the root. Interrupted 3-0 polypropylene sutures were placed along
the annulus incorporating the bovine pericardium. The sutures were then passed through the homograft. The homograft was
then brought down over the sutures into the outflow tract. The sutures were tied down, incorporating the bovine pericardium.
A saline test was used to confirm the patency of the valve and check for leaks. After adequate mobilization of the left coronary
button, the left coronary button’s alignment with the respective homograft coronary ostium was ensured. The coronary ostium
of the graft was enlarged. With continuous 5-0 polypropylene, the left main coronary button was attached to the posterior
aspect of the homograft. A strip of bovine pericardium was incorporated into the suture line for reinforcement. The right
coronary button was attached to the homograft in similar fashion. [If mobilization of either coronary is inadequate, an 8 or
10mm Dacron graft soaked in rifampin, or an SVG, is used in modified-Cabrol]. The position of the coronary buttons was
checked for orientation, tension and kinking. The homograft was then cut to length and anastomosed to the ascending aorta
with continuous 4-0 polypropylene in an end-to-end fashion.
The patient was placed in the Trendelenburg position, and after deairing maneuvers, the crossclamp was removed.
The patient was rewarmed to 36.5°C. Temporary epicardial pacing wires were placed. The patient was weaned from
cardiopulmonary bypass without difficulty. Protamine was administered to reverse the heparin, and all cannulas were
sequentially removed. All the suture lines and surgical sites were confirmed to be hemostatic. The mediastinum was copiously
irrigated with antibiotics, and the abscess cavity was thoroughly and completely debrided. Two 36 Fr Argyle chest tubes were
placed in the mediastinum for drainage. The sternum was closed with stainless steel wires. The presternal fascia, subcutaneous,
and subcuticular tissues were closed in layers with absorbable suture. Sterile dressings were applied, and the chest tubes were
connected to drainage reservoirs. Sponge, needle, and instrument counts were correct, twice. The patient, intubated, was
transferred to the intensive care unit in a stable hemodynamic condition.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of this procedure.
Multiple Choice Question(s)
A 45-year-old gentleman presents with altered mental status, temperature of 39°C, and WBC of 20. The patient is found to
have Eikenella in the blood and a 3mm abscess extending from the noncoronary sinus down to the aortic root. TEE confirms
the abscess and severe aortic insufficiency with a possible vegetation. CT head shows multiple small ischemic infarcts. What
is the next best step in management?
A. Start IV antibiotics with surgical intervention (aortic root and valve replacement in the same hospitalization)
B. Start IV antibiotics and surgical intervention (aortic root and valve replacement with homograft to be performed as
outpatient after 4 weeks)
C. Start IV antibiotics and repeat imaging after 14 days. If no improvement, then aortic root and valve replacement with
homograft
D. Emergent surgical intervention with aortic root and valve replacement
E. Start IV antibiotics and repeat CT head to rule out hemorrhagic conversion
Answer: A. The patient has signs of severe sepsis with bacteremia and multiple ischemic infarcts. This patient should be
immediately started on broad spectrum antibiotics to cover HACEK (Haemophilus, Aggregatibacter, Cardiobacterium,
Eikenella, and Kingella) and fungal organisms. This patient clearly needs surgery. However, the timing of surgery depends on
the patient’s clinical status. For ischemic strokes, the patient should be operated on within the same hospitalization within 1-2
weeks. Patients with hemorrhagic strokes, should wait a few weeks or when neurology/neurosurgery say it is safe. The above
patient should be operated on sooner rather than later, due to severe sepsis caused by virulent organism and multiple cerebral
infarcts.
