Sheel Patel, DO and Hassan Reda, MD
University of Kentucky, Lexington, KY, 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 Sameh M. Said, MD, and Hartzell V. Schaff, MD.
Essential Operative Steps
- Lines and monitoring
- General endotracheal anesthesia
- Intraoperative TEE
- Median sternotomy
- Open pericardium, elevate the right side of the pericardium with stay sutures, and survey the ascending aorta for plaque
burden and cannulation site - Systemic heparinization (400 u/kg)
- Aortic cannulation
- Venous cannulation with single two-stage right atrial cannula
- Aortic root vent/cardioplegia needle
- Check ACT (>400 seconds)
- Initiate CPB
- Maintain normothermia
- Aortic crossclamp (reduce pump flow rate, apply crossclamp, increase pump flow rate to 2.0-2.5L/min/m2)
- Antegrade cold blood cardioplegia (1000-1200mL)
- Dissect Waterston’s groove
- Standard left atriotomy
- Expose and assess the mitral valve (fill the left ventricle with cold saline to identify the mechanism of regurgitation)
- Resect the unsupported flail portion of the posterior leaflet
- The annulus is reinforced at the site of resection by using one to two pledged 4-0 prolene sutures
- The remaining edges of the posterior leaflets are sewn together with a running 5-0 prolene suture or in a figure-of-eight
fashion - Posterior annuloplasty band (63mm in length) is placed from trigone-to-trigone and secured with interrupted 2-0 ethibond,
usually 7 or 8 sutures - Ruptured chordae in separate areas are repaired with separate leaflet resections
- Ruptured chordae at the commissure requires recreation of a new commissure. This is done by resection of the
unsupported portion of the leaflet and reapproximation of the anterior and the posterior leaflets and the annulus - For anterior leaflet repair, artificial chordae (Gore-Tex) to the secondary chord of the ventricular surface of the anterior
leaflet are used to correct prolapse - A flail portion of the anterior leaflet may be supported by resecting a quadrangular portion of the posterior leaflet and
transferring the portion with its supporting chordae to the anterior leaflet. The defect in the anterior leaflet is repaired - Consider sliding leaflet repair when the posterior leaflet is too tall (>1.5cm), therefore placing the anterior leaflet at a risk
for systolic anterior motion - The mitral valve is checked with cold saline injection into the left ventricle to assess leaflet mobility and coaptation;
ensure the aortic root vent is off during this time - Left atriotomy closure
- Deairing maneuvers
- Lowering pump flow rate and removal of aortic crossclamp
- Check for hemostasis
- Placement of epicardial atrial and ventricular pacing wires
- Chest tube placement
- Wean from CPB
- Evaluate mitral valve with TEE
- Venous decannulation
- Ensure adequate deairing of the heart prior to removal of the aortic root vent
- Protamine administration for heparin reversal
- Aortic decannulation (systolic blood pressure 90-100mmHg)
- Assess hemostasis
- Sternotomy closure
Potential Complications and Pitfalls
- Stay midline during sternotomy: can try to identify left and right borders of the sternum if unsure
- Avoid injury to the innominate vein while making the pericardial well or while performing the sternotomy: during the
sternotomy, clear the posterior table of the sternum of the soft tissue by using digital palpation. While making the
pericardial well, make a conscious effort to identify the innominate vein - Cannulation catastrophe (aortic dissection/hematoma or right atrial tear)
- Poor choice of location of the aortic cannula/crossclamp (risk of stroke)
- Injury of the pulmonary artery during crossclamp application
- Insufficient myocardial protection and cardiac arrest (crossclamp not across completely, aortic regurgitation with
secondary ventricular distension) - Feel the left ventricle during administration of antegrade cardioplegia to ensure absence of ventricular distension and
uniform cooling of the ventricle with cardioplegia - Remember to ice the surface of the right ventricle
- Poor venous drainage (incorrect choice of cannula size or advancing the two-stage cannula too far in so it is obstructing
the hepatic veins) - Failure to dissect Waterston’s groove
- Improper dissection of Waterston’s groove with inadvertent opening of the right atrium close to the inferior vena cava
- Opening the left atrium close to the right superior pulmonary vein with subsequent difficulty in exposing the mitral
valve - Retractor injury with subsequent shearing tear of the left atrial wall edges which complicates closure
- Failure to recognize important vital structures in relation to the mitral valve: atrioventricular node, coronary sinus,
aortic valve, and circumflex coronary artery - Excessive excision of the prolapsed leaflet tissue which may compromise the repair
- Poor judgment of the neochord length with either persistence of leaflet prolapses or poor leaflet coaptation
- Improper placement of the annuloplasty sutures with misidentification of the mitral annulus and subsequent placement
of the sutures in the left atrial wall - Deep placement of annuloplasty sutures with subsequent injury to the circumflex coronary artery in a left dominant
system - Improper deairing prior to removal of the aortic root vent
- Failure to recognize SAM of the mitral valve anterior leaflet post-repair by TEE. If there is high suspicion of SAM (as
posterior leaflet is too tall), can repair the valve in the following manner: posterior leaflet is detached from the annulus,
leaving behind a 1-2mm scallop of posterior leaflet attached to the annulus; annuloplasty sutures are placed with the
posterior leaflet detached; the posterior leaflet is then reattached to the annulus by imbricating the posterior leaflet,
allowing further shortening of the leaflet - Inadequate control of hemostasis prior to sternal closure/bleeding from cannulation sites
- Improper closure of sternotomy
Template Dictation
Preoperative Diagnosis:
- Severe mitral valve regurgitation
- NYHA class II
- Prolapse of the middle scallop of the posterior leaflet
- Prolapse of the middle segment of the anterior leaflet
Postoperative Diagnosis: Same (with appropriate adjustments)
Procedure(s) Performed: - Mitral valve repair with triangular excision of the unsupported lateral half of the middle scallop of the posterior leaflet
- Placement of two artificial Gore-Tex chordae to the middle segment of the anterior leaflet
- Insertion of C-shaped posterior annuloplasty band (63mm)
- Establishment of temporary extracorporeal circulation using the FX15 membrane oxygenator with 3000mL reservoir with
3/8 loop to 37 oC - Cardioplegic arrest (blood) 4:1
Intraoperative TEE
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Drainage: 2 No. 32 Argyle chest tubes
Indication(s) for Procedure: [AGE] year old [SEX] with [DURATION] history of [COMPLAINT: e.g. increasing
shortness of breath]. Preoperative TTE revealed [FINDINGS: e.g. severe mitral valve regurgitation secondary to bileaflet
prolapse, rupture chord of the middle scallop of the posterior leaflet with estimated ejection fraction of 50-55%], and
preoperative coronary angiography revealed no significant coronary artery disease.
Description of the Procedure: After satisfactory general endotracheal anesthesia was induced, a right internal jugular central
venous line, pulmonary artery catheter, and radial arterial line were inserted. Preincision TEE was then performed to evaluate
the mitral valve and cardiac function. The patient was prepped and draped from chin to knees while in the supine position.
A standard median sternotomy was performed, and a Morse sternal retractor was placed. We opened the pericardium in an
inverted T-shape fashion and pericardial stay sutures were placed to allow creation of a pericardial well. Heparin was given
systemically and a 20Fr DLP cannula was inserted through two pursestring sutures in the distal ascending aorta, secured, and
deaired. A two-stage cannula was placed in the right atrium for venous return and was secured. An aortic root
cardioplegia/vent cannula was then inserted. After confirming ACT of more than 400 seconds, cardiopulmonary bypass was
commenced at 2.4L/min/m2 for [BLANK] minutes. We maintained normothermia during perfusion. The aorta was cross
clamped and 1L of antegrade cold blood cardioplegia was administered. Waterston’s groove was dissected, and an incision
was made posterior to the interatrial groove to expose the mitral valve. There was redundancy of the valve and the appearance
was typical for myxomatous mitral valve disease. The prolapsing portion of the posterior leaflet was the lateral half of the
middle scallop and the medial half of the lateral scallop. We excised this area in a triangular fashion and sewed the middle
scallop to the lateral scallop using running 4-0 prolene. The middle segment of the anterior leaflet was noted to prolapse as
well and we placed two 2-0 Gore-Tex sutures to this prolapsed segment, passing each limb of the suture twice through the free
edge of the leaflet. One mattress suture was anchored to the anterolateral papillary muscle, and one was anchored to the
posteromedial papillary muscle. The valve was tested with saline infusion to facilitate adjustment of the Gore-Tex suture length,
and the sutures were tied with multiple knots. Next, seven interrupted mattress sutures of 2-0 ethibond were placed along the
posterior circumference of the valve beginning at the right and ending at the left fibrous trigones. These sutures were passed
through a 25 Medtronic annuloplasty band (63 mm in length) and tied securely. We tested the valve and there was no
leakage. The left atrial incision was closed using running 3-0 prolene. Air was evacuated from the heart and the aortic
crossclamp was released after 30 minutes. Sinus rhythm was restored with a single countershock. We deaired the heart
thoroughly and discontinued CPB easily. No inotropic agents were required. Postprocedure TEE confirmed the absence of
mitral regurgitation, good ventricular function, and absence of systolic anterior motion.
The right atrium was decannulated. After confirmation of adequate deairing of the heart, the aortic root vent was removed.
Protamine was administered followed by removal of the aortic cannula. All cannulation sites were reinforced with 3-0 and 4-
0 prolene sutures. Two atrial pacing wires were attached to the heart. Two No. 32 Argyle chest tubes were led into the
mediastinum through stab wounds inferior to the incision. After adequate hemostasis was obtained, we closed the chest using
interrupted stainless-steel wire for the sternum and vicryl for the subcutaneous and subcuticular layers.
All instrument, sponge, and needle counts were confirmed to be correct, twice, at the end of the operation. The patient tolerated
the procedure well and was transferred to the intensive care unit in a stable hemodynamic condition.
Intraoperative autotransfusion was present.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of the procedure.
