Linda J. Schulte, MD and Puja Kachroo, MD, MS
Washington University in Saint Louis, MO, 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 Michael O. Kayatta, MD and Michael E. Halkos, MD, MSc.
Essential Operative Steps
- Median sternotomy
- Create pericardial well
- Arterial cannulation
- Venous cannulation
- Initiate CPB
- Place LV vent
- Crossclamp aorta and administer cardioplegia
- Dissect aortic root
- Transect aorta and remove all infected tissue including aortic valve
- Create coronary buttons
- Proximal anastomosis (homograft to aortic annulus)
- Reimplant coronary arteries
- 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
- Bunching of the homograft during anastomosis leading to aortic valve incompetence
- Injury to coronary artery ostia
- Kinking of right coronary artery if implantation is too low
- Inadequate hemostasis prior to sternal closure
Template Dictation
Preoperative Diagnosis: [INDICATION – e.g. aortic valve endocarditis with aortic root abscess]
Postoperative Diagnosis: Same (with appropriate adjustments)
Procedure(s) Performed: Aortic root replacement with [SIZE] homograft aortic root conduit [DETAILS – e.g. extent of
tissue removed]
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 and aortic root abscess]. Preoperative echocardiogram revealed [FINDINGS – e.g. aortic valve
vegetation with aortic root dilation].
Description of the Procedure: The patient was taken to the operating room on [DATE]. After the patient’s identity and
planned procedure were verified, the patient was placed on the operating room table in the supine position. A radial artery line
was placed. General anesthesia via endotracheal intubation was administered. A right internal jugular central venous line and
pulmonary artery catheter were inserted. Preoperative transesophageal echocardiogram was then performed to evaluate cardiac
function, aortic valve, and root pathology. The patient was prepped from the neck down in sterile fashion and draped. A time
out 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.
A total of [UNITS (400 u/kg)] of systemic heparin was administered. The aortic cannula was then inserted on the lesser curve
across from the innominate artery, secured, and deaired. A venous cannula was then placed and secured in the right atrium. A
retrograde cannula was placed through the right atrium into the coronary sinus. A cannula was inserted into the distal ascending
aorta for administration of antegrade cardioplegia and for venting of the aortic root. The aortic crossclamp was applied.
Antegrade cardioplegia was administered and rapid arrest of the heart followed. After 1L of cold blood antegrade cardioplegia,
500cc of retrograde cardioplegia was given [If severe aortic insufficiency, give all retrograde]. Ice was applied to the
heart. The patient was cooled to [32-34]o C. Retrograde cardioplegia was administered every 20 minutes for myocardial
protection. A thermistor was placed to measure myocardial temperature in the intraventricular septum and a cooling jacket was
placed behind the heart. An LV vent was introduced through the right upper pulmonary vein.
After arrest of the heart with cardioplegia, the ascending aorta was transected in the mid ascending aorta. The aortic root was
then dissected free of surrounding structures. All aortic leaflets were then excised. 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]. All contaminated instruments were then removed from the field. 4-0 pledgeted sutures
were placed at each commissure for retraction.
Following this, a series of 30 3-0 prolene sutures were placed circumferentially around the aortic annulus. These were then
brought through the base of a [SIZE] homograft conduit. The conduit was then seated down into the LVOT. The sutures were
then tied and cut. The left main coronary artery anastomosis was performed first in an end-to-side fashion using running 5-0
prolene to the posterior aspect of the homograft. In a similar fashion, the right coronary artery was sewn in an end-to-side
fashion to the anterior aspect, ensuring that it was high enough to prevent kinking when the heart was filled. Finally, the distal
homograft was anastomosed in an end-to-end fashion to the distal 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 vents were removed. The patient was weaned from cardiopulmonary bypass with the aid of [INSERT
INOTROPES]. TEE revealed a competent aortic valve. The venous and arterial cannulas were removed. Protamine was
administered to reverse heparin. Adequate hemostasis was then confirmed within the mediastinum. The sternum was then
closed with stainless steel sternal wires. The fascia was then closed with 1 vicryl suture. The deep dermal layer was then closed
with 2-0 vicryl suture in running fashion. The skin and subcuticular layer was closed with 4-0 monocryl in 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 the procedure.
