Thuan Nguyen, MD and Arun Singhal, MD
University of Iowa Hospital and Clinics, Iowa City, IA, 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 Sandeep Sainathan, MD and David D. Yuh, MD.
Essential Operative Steps
- Informed consent
- Calculate the effective orifice area for the prosthetic valve indexed to the body surface area with the chart provided by
the manufacture. A value less than 0.85 cm2/m2 can lead to a patient-prosthesis mismatch and a value below 0.65 cm2/m2
represents severe patient-prosthesis mismatch. A value between 0.85 to 0.65 cm2/m2 may be acceptable in a sedentary,
high-risk patient with significant annular calcification, as compared to the risk from a more extensive aortic root
enlargement procedure - Large bore IV insertion and general endotracheal anesthesia
- Intraoperative monitoring line insertion (arterial line and pulmonary artery catheter) and Foley catheter insertion
- Intraoperative TEE. Confirm valvular morphology, gradients, valve area, annular dimensions, and assessment of left
ventricular dimension and function - Median sternotomy
- Survey ascending aorta for plaque burden with epiaortic ultrasound
- Mobilize the ascending aorta from the main pulmonary artery
- Arterial cannulation
- Venous cannulation with a two-stage venous cannula inserted via the right atrial appendage
- Antegrade aortic cannula insertion (± retrograde coronary sinus cannula insertion based on preoperative and intraoperative
echo finding of AI) - Systemic heparinization (400 u/kg) with goal ACT (>480 seconds)
- LV vent via the right superior pulmonary vein
- Initiate CPB, cool to 32oC
- Aortic crossclamp (reduce CPB flow rate, apply crossclamp, and increase CPB flow to 2.0-2.5L/min/m2)
- Saturate the field with CO2 gas
- Give cardioplegia. For a patient with AS without AI: antegrade cardioplegia and topical cooling with cold saline for
cardiac arrest. For a patient with AS and significant AI: retrograde cardioplegia. The adequacy of right ventricular
protection needs to be confirmed after performing an aortotomy and observing good retrograde flow from the right
coronary ostia. If flow is poor, supplement with antegrade ostial injection - Perform limited aortotomy in a transverse manner starting 15-20mm above the right coronary artery
- Identify the left main coronary artery, left-non coronary commissure, and inspect the aortic valve. If one encounters
difficulty, one can extend the incision toward the PA - Excise aortic valve leaflets. Debride and size the annulus.
- Options to address a small aortic annulus include: Using a valve one size up than the measured size with position slightly
canted up in the non-coronary sinus, use of a Medtronic Freestyle valve, aortic annular enlargement, aortic root
replacement, and left ventricle apical to descending aortic conduit. In adults, annular enlargements are made posteriorly
(Nick’s and Manougian’s techniques) in the fibrous part of the aortic annulus in the region of the aortic-mitral valve
continuity. In children, annular enlargements are generally made anteriorly (Konno), in the muscular part of the aortic
annulus as generally there is an associated subannular obstructive component. - Once the decision is made to perform an aortic annular enlargement, extend the hockey stick incision towards the middle
of the non-coronary sinus (Nick’s method). This provides an annular enlargement to accommodate a valve one size larger
than originally sized. When the aortotomy is carried down the commissure between the non-coronary and left coronary
cusp into the anterior mitral leaflet (Manougian’s method), a much larger annular enlargement to accommodate a
prosthesis two sizes larger than originally sized can be obtained. The Konno, which is a method used predominantly in
children, provides the maximum enlargement but with more technical complexity. Each of the resultant defects is repaired
with native pericardium, bovine pericardium, or Dacron graft. Care needs to be taken to repair the roof of the left atrium
in Manougian’s method. - Valve replacement and closure of the aortotomy followed by deairing of the aorta
- Antegrade warm blood cardioplegia “Hot Shot” administration for rewarming
- Remove aortic crossclamp with continued deairing of the left heart
- Check for hemostasis
- Arterial and ventricular pacer 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
- Ventricular fibrillation on induction of general anesthesia in AS: place defibrillator pads on the patient prior to intubation
or utilize operating bed with a built-in defibrillating mat - Inability to arrest a hypertrophied left ventricle with significant AI with antegrade cardioplegia: always place a retrograde
cardioplegia catheter for patients with significant AI. Attempt retrograde first, if inadequate arrest is observed, then
perform aortotomy and give direct ostial antegrade cardioplegia - Avoid fracturing a plaque during aortic crossclamping. If not able to avoid the plaque, avoid application of the crossclamp
perpendicular to the plaque to prevent a fracture, or consider circulatory arrest - Injury to the pulmonary artery during aortotomy due to inadequate mobilization of the ascending aorta from the pulmonary
artery - Injuring the right and left coronary ostia during aortotomy, due to either a low incision or abnormally located high ostial
position - Aggressive annular debridement resulting in annular disruption, injury to AV nodal conduction tissue, or injury to the
anterior leaflet of the mitral valve - Injury to the left atrial dome during annular enlargement
- Injury to the anterior mitral subvalvular apparatus and extensive enlargement of the anterior mitral intertrigonal area
causing mitral insufficiency - Poorly controllable hemorrhage from the posterior annular area or left atrial dome after removal of the crossclamp with
poor access - Insufficient aortic wall to securely close an aortotomy due to extension of the aortotomy less than 15mm from the annulus
- Narrow sinotubular junction preventing adequate closure of the aortotomy around the stent posts of the bioprosthetic
aortic valve - Improper deairing prior to removal of aortic root vent
- Inadequate control of hemostasis prior to sternal closure/bleeding from cannulation sites and aortic suture line
Template Dictation
Preoperative Diagnosis: [INDICATION: e.g. severe aortic stenosis, aortic regurgitation]
Postoperative Diagnosis: Same (with appropriate adjustments)
Procedure(s) Performed: Aortic valve replacement (bioprosthetic/mechanical) with root enlargement
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. shortness of breath,
syncope, chest pain]. Preoperative echocardiography revealed [INSERT FINDINGS].
Operative Findings: [e.g. AS – Trileaflet/bileaflet aortic valve with an area of 0.8cm2 with a mean gradient of 40mmHg and
an annulus size of 19mm and preserved LV function. Preoperative coronary angiography revealed no significant obstructive
disease. AR – Trileaflet/bileaflet aortic valve with a central regurgitation jet, vena contracta of >6mm with a regurgitant volume 50%, annulus size of 19mm, and preserved LV function.]
Description of Procedure: The patient was taken to the operating room on [DATE]. The patient’s identity and planned
procedure were verified, and the patient was placed on the operating room table in the supine position. General anesthesia was
administered via an endotracheal tube. A right internal jugular central venous line, pulmonary artery catheter, radial arterial
line, and urinary catheter was placed.
Preoperative TEE was then performed to evaluate cardiac and valvular function. It confirmed the preoperative transthoracic
findings. We then proceeded to prep and drape the chest, abdomen, groins, and lower extremities in sterile fashion. A timeout
was performed.
Median sternotomy was then performed. After identification of the innominate vein, the pericardium was opened. There were
no pericardial adhesions and pericardial stay sutures were placed. The ascending aorta was mobilized from the main pulmonary
artery. The ascending aorta was measured at the root and the sinotubular junction and was [cm]. In addition, there was no
calcification in the ascending aorta on epiaortic ultrasound. 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 atrial
appendage. Systemic heparin was administered, and ACT was confirmed to be >480 seconds. The aortic cannula was then
inserted, secured, and deaired. A two-stage venous cannula was then placed and secured in the right atrial appendage. A DLP
(dual lumen aortic root cannula with a vent) cannula was then inserted into the ascending aorta for administration of antegrade
cardioplegia and a retrograde cannula was placed in the coronary sinus through a pursestring suture placed in the low right
atrium.
Cardiopulmonary bypass was initiated, and the patient was cooled to 32oC. A left ventricular vent was placed via the right
superior pulmonary vein. The aortic crossclamp was placed. Antegrade cardioplegia was administered and there was rapid
arrest of the heart. [For patients with AI: Retrograde cardioplegia was administered and there was rapid arrest of the heart. In
addition, an ascending aortotomy was performed and antegrade cardioplegia was directly administered via the coronary ostia
via ostial cannulas.] The operative field was saturated with CO2 gas.
After administering [BLANK]mL of cardioplegia, a transverse aortotomy was made 15-20mm above the right coronary artery.
The left main coronary artery was identified, and the aortic valve was inspected. It was tricuspid/bicuspid with severe
calcification of the leaflets with/without commissural fusion. The leaflets were excised keeping as close as possible to the
annulus. Following this, the left ventricular outflow tract was packed with a gauze and the annulus gently debrided of
calcifications. The debris were carefully collected via an open-ended sucker. Following this, the left ventricular outflow tract
pack was removed, and thorough cold saline irrigation was delivered into the aortic root and left ventricular cavity to wash out
any missed debris. The annulus was sized to [BLANK]mm with an effective orifice area indexed to the patient’s body surface
area at less than 0.85cm2/m2. Hence, a decision was made to enlarge the aortic annulus.
- Nicks method: The aortotomy was carried through the middle of the non-coronary sinus up to the base of the anterior mitral
leaflet. With this incision, we were able to size the annulus up to [BLANK]mm with the effective orifice area indexed to the
body surface area of the patient now greater than 0.85cm2/m2. The resultant defect in the sinus was repaired using a Dacron
graft with running 4-0 polypropylene sutures. Following this, non-everting, 2-0 polyester pledgeted annular sutures were placed
in an interrupted fashion around the aortic annulus. In the area of the repair, in the non-coronary sinus, the pledgeted sutures
were placed from outside the aortic wall incorporating the Dacron graft. Following this, the annular sutures were passed through
the sewing ring of the aortic prosthesis. The aortic prosthetic was gently lowered to sit upon the aortic annulus and the sutures
were tied and cut. The right and left coronary ostia were inspected for adequate clearance from the prosthesis. The sinotubular
junction was of an adequate size to accommodate the stent posts of the prosthesis and hence the Dacron graft was trimmed
accordingly. (In case the sinotubular junction is constrictive around the stent posts, the patch can be incorporated in the
aortotomy closure at this level to enlarge it). The aortotomy was closed with 4-0 polypropylene sutures in 2 layers, with the
first, deeper layer comprised of a continuous suture in a horizontal mattress fashion and the second, superficial layer in a simple
running fashion. Before tying the suture, the aorta and left heart were deaired through the aortotomy. - Manougian method: The aortotomy was carried through the commissure between the left and non-coronary cusp onto the
anterior leaflet of the mitral valve after opening the adjoining roof of the left atrium. The resultant defect was repaired using a
Dacron patch starting at the apex of the anterior mitral leaflet incision with 5-0 polypropylene suture. Care was taken to
incorporate the roof of the left atrium into the patch repair. Following this, non-everting 2-0 polyester pledgeted annular sutures
were placed in an interrupted fashion. In the area of the repair, the pledgeted sutures were placed from outside the aortic wall
incorporating the Dacron graft. Following this, the annular sutures were passed through the sewing ring of the aortic prosthesis.
The aortic prosthetic was gently lowered to sit upon the aortic annulus and the sutures were tied and cut. The right and left
coronary ostia were inspected for adequate clearance from the prosthesis. The sinotubular junction was of an adequate size to
accommodate the stent posts of the prosthesis and hence the Dacron graft was trimmed accordingly. The aortotomy was closed
with 4-0 polypropylene sutures in 2 layers, with the first, deeper layer comprised of a continuous suture in a horizontal mattress
fashion and the second, superficial layer in a simple running fashion. Before tying the suture, the aorta and left heart were
deaired through the aortotomy.
A “Hot Shot” (substrate enhanced blood) of cardioplegia was administered and the patient was rewarmed. The aortic
crossclamp was then removed. The retrograde cardioplegia cannula was removed. Two chest tubes were placed in the
mediastinum. Temporary atrial and ventricular pacing wires were then inserted and tested for appropriate capture. The heart
was deaired and the dual lumen aortic root cannula with a vent was removed. The LV vent was removed. The patient was
weaned from CPB. TEE showed a well-seated valve with no paravalvular leaks, mean gradient [NUMBER], and normal
movement of the anterior leaflet of the mitral valve.
The venous cannula was removed, and the cannulation sutures were tied down. A test dose of protamine was administered, and
the patient was monitored for adverse reaction before the protamine was resumed. The aortic cannula was then removed, and
the cannulation sutures tied down.
Adequate hemostasis was then confirmed within the mediastinum. All instrument, sponge, and needle counts were confirmed
to be correct, twice. The sternum was then closed with a total of [NUMBER] stainless steel sternal wires. There was no change
in the hemodynamics after sternal closure. The wound was irrigated with antibiotic solution. The presternal fascia was then
closed with 0-0 vicryl suture in a running fashion. The deep dermal layer was then closed with 2-0 vicryl suture in a running
fashion. The skin and subcuticular layer were closed with 4-0 monocryl suture in a running fashion. Sterile occlusive dressing
was applied to the skin incision. The mediastinal drains were connected to an underwater seal on suction. The patient was
subsequently transferred to the postoperative cardiac surgical intensive care unit.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of the operation.
