Meghan E. Halub, MD and John M. Stulak, MD
Mayo Clinic, Rochester, MN, 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 Michelle C. Ellis, MD and Jonathon W. Haft, MD
Essential Operative Steps
- Lines and monitoring
- General endotracheal anesthesia
- Intraoperative TEE
- Median sternotomy
- Conduit choice and LIMA harvest
- Open pericardium, create pericardial well, and assess ascending aorta for plaque burden (consider epiaortic ultrasound or
alternative cannulation strategy) - Systemic heparinization (400 u/kg)
- Arterial cannulation
- Venous cannulation
- Cardioplegia cannula placement (antegrade via aortic root, retrograde via coronary sinus)
- Check ACT (>480 seconds)
- Initiate CPB
- Aortic crossclamp
- Antegrade cardioplegia ± topical cooling followed by retrograde cardioplegia (if used)
- Assess and plan distal targets
- Aortotomy, excision of aortic valve leaflets, and debridement of the annulus
- Choose prosthetic valve and size
- Irrigate left ventricle and aortic root copiously while giving retrograde cardioplegia
- Distal coronary anastomoses
- Place annular sutures and implant valve
- Close aortotomy
- Proximal anastomoses
- Retrograde warm blood cardioplegia (“Hot Shot”)
- Remove aortic crossclamp
- Check for hemostasis
- Temporary epicardial pacer wire placement
- Wean from CPB
- Protamine administration and decannulation
- Assess hemostasis, place pleural/mediastinal drains
- Sternotomy closure
Potential Complications and Pitfalls
- Stay midline during sternotomy
- IMA injury: use low Bovie settings such as 20, and clip/cut branches when able, minimal touch technique.
- Cannulation complication (aortic dissection/disruption, inadequate anticoagulation)
- Poor choice of aortic cannula/crossclamp location (too low/inadequate space for aortotomy and proximals, stroke risk)
- Insufficient myocardial protection (retrograde cannula malpositioned)
- Coronary sinus injury
- Quality/caliber of targets
- Twisting, kinking, or inadequate length of graft
- Patient-prosthesis mismatch: prevent by planning minimal valve size in the preoperative period based on BSA
- Inadequate debridement of annulus, overly aggressive debridement of annulus (damage to important structures)
- Poor seating of valve, occlusion of coronary ostia
- Damage to prosthetic valve (commissure posts, leaflets) during suture tying
- Inadequate deairing prior to aortic root vent removal: consider LV vent during procedure
- Paravalvular leak (meticulous suture placement through valve sewing ring to avoid gaps between sutures)
- Inadequate control of hemostasis prior to sternal closure (check hemostasis of aortotomy during “Hot Shot”)
Template Dictation
Preoperative Diagnosis: [INDICATION: Exertional or unstable angina, dyspnea]
Postoperative Diagnosis: Same (with appropriate adjustments)
Procedure(s) Performed:
- Endoscopic vein harvesting
- Coronary artery bypass grafting [DETAILS: conduit used and targets]
- Aortic valve replacement [PROSTHETIC IMPLANT INFORMATION]
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Complications: If encountered
Indication(s) for Procedure: [AGE] year old [SEX] with [DURATION] history of [COMPLAINT: Exertional chest pain,
syncope]. Preoperative cardiac catheterization reveals [FINDINGS]. Preoperative cardiac echocardiography demonstrates
[FINDINGS]. The patient has chosen a [VALVE CHOICE: bioprosthetic to avoid lifelong warfarin, or a mechanical
prosthetic to reduce risks of future degenerative valve dysfunction].
Description of the Procedure: The patient was taken to the operating room on [DATE] and was placed upon the operating
room table in the supine position. General endotracheal anesthesia was administered. Swan Ganz catheter and radial artery
lines were inserted. Preoperative transesophageal echocardiogram was then performed to evaluate cardiac and valve function.
The patient was prepped and draped in the usual sterile fashion.
The saphenous vein was endoscopically harvested from the lower extremity with length sufficient for [X Number] bypass
grafts. The tributaries of the vein were controlled with clips and silk ligatures. The access incision was closed in layers.
The chest was opened through a median sternotomy incision. The left pleural cavity was opened and the left internal mammary
artery was fully mobilized. The patient was heparinized systemically with 400 u/kg after which the internal mammary was
transected distally and prepared for anastomosis. The pericardium was opened. Pericardial stay sutures were used for retraction.
The space between the aorta and pulmonary artery was exposed. Pursestring sutures were placed in the [LOCATION: distal
ascending aorta or transverse aortic arch], right atrial appendage, and right atrium. A Prolene pursestring suture was placed in
the right superior pulmonary vein. After ensuring adequate anticoagulation, arterial cannulation and dual-stage venous
cannulation was achieved. An antegrade cardioplegia catheter was placed in the ascending aorta. A retrograde cardioplegia
catheter was placed via the right atrium into the coronary sinus, positioning confirmed by TEE and pressure transduction. A
left ventricular vent was placed via the right superior pulmonary vein. CPB was initiated. The aortic crossclamp was applied.
Cardioplegia was administered in an antegrade fashion followed by retrograde via the coronary sinus (if used) [NOTE: If there
is significant aortic valve insufficiency, then antegrade cardioplegia may not be delivered effectively]. A good diastolic arrest
was achieved. The patient was cooled systemically to approximately 32oC.
300-500mL of retrograde cardioplegia was administered in 20 minute intervals throughout the period of the aortic occlusion.
The aorta was then opened revealing a [DETAILS: heavily calcified tricuspid valve, with/without fused right and left leaflets].
The aortic valve was then excised, the annulus debrided of any remaining calcium deposits, and the left ventricle copiously
irrigated with cold saline. The annulus was sized. A [X]mm prosthetic [IMPLANT type: Trifecta, Magna Ease, St. Jude
mechanical] aortic valve was selected.
The epicardial vessels were identified and incised. The distal anastomoses were accomplished next. Individual segments of
reverse saphenous vein were sewn to the [TARGETS: diagonal, obtuse marginal, posterolateral branch of the circumflex
artery, distal right coronary, or posterior descending] artery, respectively. Each of these anastomoses were carried out with
running sutures of 7-0 prolene. The anastomoses were tested for patency and hemostasis with gentle syringe infusion. The left
internal mammary artery was then brought through a window in the pericardium and was sewn to the left anterior descending
vessel with a running suture of 7-0 prolene. The proximal clamp on the internal mammary was briefly removed to confirm both
patency and hemostasis of the anastomosis.
Pledgeted 2-0 ethibond sutures were placed circumferentially along the aortic valve annulus with pledgets oriented
[DETAILS: on the ventricular side for bioprostheses, on the aortic side for mechanical prostheses]. Sutures were then passed
through the sewing ring, the valve lowered into position, and tied securely in place. The valve was inspected to be certain it
was well-seated and the coronary ostia were unobstructed. The aortotomy was closed with a continuous running suture of 5-0
prolene. The vein grafts were cut to the appropriate length and spatulated. [X number] of aortic tissue buttons were excised
and used as [X] proximal anastomoses for the saphenous grafts, which were carried out with running sutures of 5-0 prolene.
A terminal dose of warm blood cardioplegia (“Hot Shot”) was administered retrograde and the aortic crossclamp was then
released. The heart was deaired using the left ventricular vent and the ascending aortic vent. Temporary pacing wires were
placed on the surface of the [LOCATION: right atrium, right ventricle].
With the patient fully rewarmed, the heart resumed good contractility and resumed a [TYPE: normal spontaneous or paced]
rhythm. The lungs were inflated. [DETAILS: Inotropes were initiated if the ventricular function was impaired or the
crossclamp period was prolonged]. The patient was weaned from cardiopulmonary bypass. Transesophageal echocardiography
revealed a well seated valve with no insufficiency and acceptable gradients. The left chest was aspirated. Protamine was
administered and decannulation was accomplished. Hemostasis was achieved from all sites, including the skin fat, the
mammary bed, cannulation sites, and all proximal and distal anastomotic sites. The entire wound was inspected for hemostasis
and was felt to be adequate. [NUMBER] mediastinal tubes and [NUMBER] left pleural tubes were placed.
The incision was then closed in layers with #5 stainless steel wires used to approximate the sternum, 2-0 PDS suture used to
approximate the fascia, 2-0 monocryl to approximate the subcutaneous tissue, and 4-0 monocryl subcuticular closure used to
approximate the skin. Sterile dressings were applied. The patient tolerated the procedure well and was transferred to the ICU
in stable condition.
All sponge, instrument, and needle counts were correct at the completion of the case.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of the procedure.
Multiple Choice Question(s)
For aortic stenosis, and not considering TAVR, what are the class I indications for aortic valve replacement?
A. Adults with severe high-gradient AS and symptoms of exertional dyspnea, HF, angina, syncope, or presyncope by history or on exercise testing
B. Asymptomatic patients with severe AS and an LVEF <50%
C. Asymptomatic patients with severe AS who are undergoing cardiac surgery or other indications
D. Symptomatic patients with low-flow, low-gradient severe AS with reduced LVEF
E. All of the above
Answer: E. All of the above are class I recommendations for timing of intervention of severe AS. In addition, symptomatic
patients with low-flow, low-gradient severe AS with normal LVEF are recommended an AVR if AS is the most likely cause
of symptoms. These recommendations can be found in the 2020 ACC/AHA Guideline for the Management of Patients with
Valvular Heart Disease, which can be found in the references.
Sources
Doty D.B., Doty J.R. Cardiac Surgery Operative Technique: 2nd Edition. Elsevier Saunders. 2012. ISBN: 9781416036531.
Kaiser L.R., Kron I.L., Spray T.L. Mastery of Cardiothoracic Surgery: 3rd Edition. Lippincott Williams and Williams. 24
December 2013. ISBN/ISSN: 9781451113150.
Otto CM, Nishimura RA; et al. 2020 ACC/AHA Guideline for the Management of Patients with Valvular Heart Disease: A
Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.
Circulation. 17 Dec 2021; 143: e72-e227.
