Perel A Baral, DO and Alexander Schutz, MD
Baylor College of Medicine / Texas Heart Institute, 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 Kenan W. Yount, MD, MBA and Leora T. Yarboro, MD.
Essential Operative Steps
- Lines and monitoring (e.g. large bore central ± pulmonary artery catheter; arterial)
- Intraoperative TEE
- Median sternotomy
- Conduit harvests (e.g. endoscopic saphenous vein harvest, LIMA harvest)
- Open pericardium, create pericardial well, survey ascending aorta for plaque burden with epiaortic ultrasound for
cannulation, and mark proximal anastomosis sites - Systemic heparinization
- Arterial cannulation
- Bicaval cannulation
- Myocardial protection, aortic root placement, and LV vent placement
- Check ACT
- Initiate CPB
- Identify whether the right atrial or transseptal approach will be taken
- Aortic crossclamp
- Anterograde ± retrograde cardioplegia ± topical cooling for cardiac arrest
- Distal anastomoses (consider starting with the right side for instillation of cardioplegia down completed vein graft for
better right heart myocardial protection) - Interatrial vs transseptal groove dissection and retractor (e.g., Cosgrove retractor) insertion
- Inspect valve for pathology and mechanism; decide on repair vs replacement
- Leaflet excision with chordal sparing (or valve leaflet repair/resection); careful debridement
- Sutures through annulus and through replacement valve (or annuloplasty ring)
- Close atriotomy ± leave LV vent
- Proximal anastomoses
- Remove aortic crossclamp
- Check for hemostasis
- Temporary pacing wire placement
- Chest tube placement
- Wean from CPB
- Venous decannulation
- Protamine administration for heparin reversal (test dose first)
- Aortic decannulation
- Assess hemostasis
- Sternotomy closure
Potential Complications and Pitfalls
- Review left heart cath preop to ascertain whether the patient is right or left heart dominant and where the circumflex
artery runs - Entry
a. Stay midline during sternotomy
b. Avoid innominate vein injury while making pericardial well - LIMA injury during harvest: use no touch technique
- Cannulation
a. Aortic dissection with arterial cannula insertion
b. Use epiaortic US prior to aortic cannulation and crossclamp placement
c. Right atrial or caval tear with bicaval venous cannula insertion
d. Coronary sinus injury with retrograde cannula insertion - Protection
a. Inadequate myocardial protection and cardiac arrest (e.g. crossclamp not across, aortic insufficiency, insufficient
venous drainage) - Bypass Grafting
a. Difficulty finding coronary arteries (e.g. intramyocardial segments)
b. Posterior wall injury during opening of coronary arteries
c. Ordering of bypass grafts: Right side then left LAD last)
- Mitral valve
a. Consider approach (e.g. generally interatrial, but may require a transseptal approach if the atria are not enlarged such
as in patients with acute endocarditis). May also incidentally enter the right atrium during the left atrial approach. If
this happens, repair the right atriotomy when the left atriotomy is closed
b. Decision to repair vs replace the mitral valve
c. Consider whether mechanical or tissue valve is most appropriate
d. Careful leaflet excision and annular debridement if the valve is calcified (to avoid stroke from embolization or risk
of AV dissociation)
e. Careful placement and tying of sutures (to avoid paravalvular leak and injury to surrounding structures, including
the circumflex artery and aortic valve leaflets)
f. Adequate venting ± valsalva to deair during atriotomy closure - Closure and Decannulation
a. Kinking of bypass grafts and/or insufficient graft length resulting in graft tension after completion of the proximal
anastomosis
b. Avoid excessive manipulation of the heart (to prevent AV dissociation; generally, this is why distal bypasses are
completed before mitral valve intervention in addition to augmenting myocardial protection)
i. Atrioventricular groove disruption: suspect this complication if there is hematoma formation or uncontrolled
bleeding from posterior to the heart which will become apparent once the patient is off bypass. In this case,
bypass must be re-initiated, the source of bleeding investigated, and the annular ring removed and replaced
once the disruption is repaired
c. Inspecting postoperative TEE for regurgitation
d. Improper deairing prior to vent removal
e. Bleeding from atriotomy site, anastomotic sites
f. RIMA injury during sternal wire placement
Template Dictation
Preoperative Diagnosis: [INDICATION: e.g. severe mitral regurgitation, coronary artery disease, congestive heart failure]
Postoperative Diagnosis: Same (with appropriate adjustments)
Procedure(s) Performed:
- Coronary artery bypass grafting x [NUMBER], [DETAILS: e.g., LIMA-LAD, SVG-PDA]
- Mitral valve [REPAIR/REPLACEMENT] with a [NUMBER]mm [TYPE OF VALVE OR ANNULOPLASTY
RING] - [SIDE] endovascular vein harvest
- Epiaortic ultrasound
- Transit-time flow measurement
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [SEX] with a [DURATION] history of [COMPLAINT: e.g. worsening chest
pain and shortness of breath]. [HE/SHE] was found to have severe mitral insufficiency on a recent echocardiogram and a
preoperative coronary catheterization revealed multi-vessel coronary artery disease with [FINDINGS: e.g. 90% stenosis of
LAD and 80% stenosis of the proximal PDA with an estimated ejection fraction of 35%]. After a discussion of the risks and
benefits, the patient was consented for coronary artery bypass grafting with a mitral valve repair versus replacement. [IF PLAN
FOR REPAIR/REPLACEMENT: A discussion was had with the patient regarding use of mechanical vs bioprosthetic valve,
with the decision made to plan for a [TISSUE/MECHANICAL] valve should it be necessary.
Description of the Procedure: The patient was correctly identified in the holding area and brought to the operative suite where
[HE/SHE] was placed supine on the operative table. The patient’s identity and planned procedure were verified. General
anesthesia was induced without issue and the patient was intubated with a single lumen endotracheal tube without complication.
A right internal jugular central venous line with a pulmonary artery catheter was placed, as well as a radial arterial line, foley
catheter, and transesophageal echocardiogram probe. A preoperative transesophageal echocardiogram was performed to
evaluate cardiac function and valve function. The patient’s chest, abdomen, groins, and lower extremities were then prepped
and draped in the usual sterile fashion. A second timeout was completed.
The patient’s chest was entered via median sternotomy while a physician assistant performed an endoscopic saphenous vein
harvest in the right lower extremity. The left internal mammary artery was harvested in a pedicled fashion. After harvest of the
conduit, the patient was systemically heparinized fully and the LIMA was divided. There was excellent flow after distal
division. Hemostasis of the vascular bed was confirmed. The mammary retractor was then removed and replaced with a sternal
retractor.
After identification of the innominate vein, the pericardium was opened and a pericardial well was fashioned. The LIMA was
prepared and then a bulldog clamp was applied; the LIMA was carefully placed back into the left pleural space. Epiaortic
ultrasound was used to survey the ascending aorta. There was no evidence of calcification or atheroma. Aortic cannulation
sutures were placed in the ascending aorta. The aortic cannula was then inserted into the ascending aorta, deaired, and secured.
TEE confirmed no dissection. Bicaval cannulation was then performed through the SVC and through the base of the right
atrium into the IVC. The SVC and IVC were encircled with umbilical tape. A retrograde perfusion catheter was then placed
through the right atrium into the coronary sinus, with placement confirmed on TEE. Once appropriate elevation of ACT was
confirmed, cardiopulmonary bypass was established with initiation of systemic cooling to 32oC. An antegrade cardioplegia
cannula was placed in the ascending aorta. Initial dissection of the interatrial groove was performed. The crossclamp was
applied; antegrade and retrograde cardioplegia were given with immediate arrest of the heart and appropriate emptying of the
heart. Topical cooling with ice slush was also used. Cardioplegia was redosed every [X] minutes as well as administered down
the vein grafts once they were placed.
We began by performing the SVG-PDA anastomosis. The PDA was opened carefully, taking care not to injure the backwall
of the vessel. The anastomosis was completed distally in an end-to-side fashion using a running 7-0 prolene. Antegrade
cardioplegia was then administered through the graft, which was found to be patent and hemostatic. Transit-time flow
measurement was used to measure graft flow, resistance, and diastolic filling; these parameters were found to be adequate. A
suitable site on the LAD was identified along its mid-portion, corresponding to an area distal to the stenosis identified on
angiography. The LIMA graft was then trimmed to the appropriate length and clamped with a bulldog. The anastomosis was
completed in an end-to-side fashion using a running 7-0 prolene. The bulldog clamp was removed, and the graft was found to
be patent and hemostatic. Transit- time flow measurement was used to measure graft flow, resistance, and diastolic filling;
these parameters were and found to be adequate.
We then turned our attention to the mitral valve. The interatrial groove was opened and the left atrium was entered sharply and
then extended with scissors. Mitral retractors were placed to better visualize the mitral valve.
FOR REPAIR: Systematic valve analysis of all leaflet segments was carried out, using P1 as a reference point. Stay sutures
were placed to help expose the valve and pull it into the field. Prolapse involving just under one third of the free margin of the
P2 segment was identified. A triangular resection of P2 was then performed, with leaflet continuity then restored with 5-0
interrupted suture. Commissural sutures were then placed, and the valve was sized for the annuloplasty ring. A size [X] ring
was selected. Circumferential transannular sutures for the annuloplasty ring were then placed, taking care to avoid injury to the
aortic cusps, the circumflex artery, or catching secondary chordae. The annuloplasty ring was then parachuted into place. The
valve was saline tested and the repair was found to be intact, without leak, and with a symmetrical line of coaptation. The
atriotomy was then closed in 2 layers.
FOR REPLACEMENT: The valve was systematically inspected, and the anterior mitral leaflet was resected in total, sparing
the tertiary chords. Circumferential transannular sutures of 2-0 ethibond were then placed, taking care to avoid injury to the
aortic cusps or the circumflex artery. The posterior mitral leaflet was incorporated and plicated to the annulus using annular
sutures to perform a chordal sparing replacement. The valve was then sized and a [SIZE]mm [TYPE]
[TISSUE/MECHANICAL] valve was selected. The previously placed annular sutures were then brought through the sewing
ring of the valve, which was then parachuted down, with the posts oriented so as not to obstruct the LVOT. The replacement
valve appeared to be well-seated. It was tested and found to be hemostatic. We then closed the atriotomy in two layers. The
patient was allowed to rewarm. A site for the proximal bypass graft anastomoses was selected on the aorta. An aortotomy for
the proximal anastomosis of the saphenous vein graft was made with an 11-blade followed by an aortic punch. The vein graft
was then anastomosed to the aorta with running 5-0 prolene.
The grafts were deaired, the aortic crossclamp was removed, and the patient’s heart regained spontaneous rhythm without
fibrillation. Temporary pacing wires were then placed and tested for capture with good capture noted. The heart was then
deaired, with the TEE confirming no residual air and the mitral valve with no paravalvular leak or insufficiency. Four chest
tubes were placed: 2 in the mediastinum and 1 in each pleural space. All vents were removed and the patient was subsequently
weaned from bypass. The IVC and SVC cannulas were removed. Protamine was given. The aortic cannula was removed. The
cannulation sites were confirmed to be hemostatic. The patient’s sternum was then reapproximated with stainless steel wires.
The fascia was closed with a running #1 vicryl suture followed by a deep dermal layer of running 2-0 vicryl suture. The skin
was closed in a running subcuticular fashion using 4-0 monocryl. Dermabond was applied.
All instrument, sponge, and needle counts were confirmed to be correct, twice, at the end of the operation. The patient was
transferred to the post-operative unit intubated and in critical but stable condition.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of the procedure.
Multiple Choice Question(s)
A 69-year-old male undergoes a left heart catheterization for worsening exertional chest pain and is found to have a 90% LAD
lesion, 70% OM1 lesion, and 80% RCA lesion. A preoperative workup for CABG is initiated. On transthoracic
echocardiogram, he is found to have moderate mitral valve stenosis. Which of the following would NOT be an indication for
mitral valve replacement concomitantly with a CABG?
A. Recurrent embolic events
B. Moderate-severe mitral stenosis with NYHA class III-IV heart failure
C. New onset atrial fibrillation
D. Evidence of RV dysfunction
E. Pulmonary artery pressures >40mmHg and left main stenosis >50%
Answer: E. In general, combined procedures should be done when the indication for each procedure exists on its own. The
indications for an isolated MVR include moderate-severe mitral stenosis with NYHA class III-IV heart failure, new onset atrial
fibrillation, recurrent embolic events, and evidence of right heart failure. If a patient is asymptomatic, mitral valve replacement
may be considered if he/she has pulmonary artery pressures >60mmHg.
Sources
Carpentier, Alain et al. Carpentier’s Reconstructive Valve Surgery from Valve Analysis to Valve Reconstruction. Maryland
Heights, Mo: Saunders/Elsevier, 2010. Print.
