Yogesh Patel, DO and Jeffery Everett, MD
Indiana University School of Medicine, Indianapolis, IN, 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 Brian Solomon, MD and Eugene Grossi, MD.
Essential Operative Steps
- Lines and monitoring
- Placement of right internal jugular sheath
- General endotracheal anesthesia ± right lung isolation
- Intraoperative TEE (evaluation of aortic atherosclerotic disease)
- Femoral vessel dissection and palpation of cannulation sites
- Pursestring of femoral artery and vein
- Right anterior thoracotomy – 4th intercostal space
- Chest wall retraction, soft tissue retractor, and exposure
- Open pericardium, survey ascending aorta and right atrium
- Carbon dioxide line
- Systemic heparinization (100 u/kg)
- Femoral arterial cannulation
- Long venous cannulation of IVC through femoral vein – placement under TEE guidance
- Placement of venous cannula into SVC via right internal jugular sheath
- Lines tested
- Check ACT (>450 seconds)
- Initiate CPB
- Myocardial protection cannula placement (DLP in aortic root, ±retrograde cannula in coronary sinus)
- Flexible (or rigid, such as chitwood) aortic crossclamp placed (reduce CPB flow rate, apply crossclamp, increase CPB
flow to 2.0-2.5L/min/m2) - Antegrade cardioplegia (20mL/kg initial dose) ± retrograde cardioplegia
- Incision in Sondergaard’s groove. Intra-atrial septal retractor blade and handle placed
- Valve inspected. Saline distention test. Reconciliation with TEE pathology
- Triangular resection of posterior leaflet, reapproximation with primary sutures
- Valve measured along the base and size of anterior leaflet
- Ethibond sutures placed in the posterior annulus from anterior to posterior trigone
- Sutures passed through the annuloplasty band
- Annuloplasty band seated along the annulus and secured
- Saline distention test
- Left ventricular vent placed
- Closure of atriotomy – 2 rows of running 4-0 prolene
- Crossclamp removed with root and LV vents on suction
- Heart defibrillated
- Deairing confirmed with TEE
- Removal of vents and oversewing of vent sites; tying LA closure sutures
- ± Temporary epicardial pacing wire placement
- Removal of arterial and venous cannulae
- Reversal of heparinization
- Hemostasis obtained
- Blake drain placed in pericardium
- Loose closure of pericardium
- Pleural chest tube placement
- Intercostal block
- Closure of thoracotomy and groin incisions
Potential Complications and Pitfalls
- Entering the incorrect intercostal space, resulting in poor exposure
- Avoid injury to the IMA when performing the thoracotomy
- Avoid damage to the femoral vessels or profunda when completing groin dissection (make sure you are right below the
inguinal ligament) - Cannulation catastrophe (aortic dissection/bleeding or right atrial tear)
- Poor choice of location of the aortic cannula/crossclamp (leading to stroke)
- Poor visualization of the ascending aorta during aortic crossclamp application leading to nearby structure injury (such as
pulmonary artery or left atrial appendage) - Insufficient myocardial protection and cardiac arrest (crossclamp not completely across aorta, unrecognized aortic
insufficiency, insufficient venous drainage) - Coronary sinus injury with retrograde cardioplegia cannulation
- Atrioventricular groove dissociation if dissecting posterior annulus
- Incomplete coaptation of the valve with residual mitral insufficiency
- Valve sutures placed excessively deep, risking damage to circumflex artery
- Valve sutures placed excessively deep, risking damage to the conduction system/atrioventricular block
- Valve sutures placed too deep causing injury to the left cusp of the aortic valve resulting in aortic insufficiency
- Mitral annular calcification with resultant annular disruption for valve sutures
- Postoperative systolic anterior motion of the anterior mitral leaflet
- Bleeding
Template Dictation
Preoperative Diagnosis: [INDICATION: e.g. Mitral Valve Insufficiency, Mitral Valve Prolapse, Ischemic Mitral Valve
Disease]
Postoperative Diagnosis: Same (with appropriate adjustments)
Procedure(s) Performed: Minimally invasive mitral valve repair [DETAILS: e.g. resection of posterior leaflet prolapse,
suture valvuloplasty, annuloplasty with #30 Medtronic Future band]
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. congestive heart
failure and shortness of breath]. Preoperative evaluation revealed [PRE-OPERATIVE FINDINGS: e.g. torn chordae in the
posterior mitral valve leaflet and severe mitral valve insufficiency with normal ventricular size and function, but pulmonary
hypertension in response to exercise].
Operative Findings: Fibroelastic deficiency of the valve with ruptured chordae in the P2 segment of the posterior leaflet. Left
ventricular systolic function was normal
Wound Classification: Clean
Specimens: Segment of posterior mitral valve leaflet was sent to Pathology
Implant: Mitral valve annuloplasty – [Make, Model, Size, Serial Number]
Pump Data:
Crossclamp time: [TIME]
CPB time: [TIME]
Blood: [BLANK]
Description of the Procedure: The patient was taken to the operating room and general anesthesia was induced without
hemodynamic change. A left central venous catheter and an arterial pressure measuring line were placed. A right venous sheath
was also placed into the right internal jugular vein. TEE was performed and preoperative pathology was confirmed. TEE was
used to monitor throughout the case. The patient was prepped and draped in the usual sterile fashion. Evaluation confirmed
that the patient was a good candidate for retrograde arterial perfusion. A 3-4cm transverse small incision was made in the right
groin, inferior to the inguinal ligament. The common femoral artery and vein were exposed. The artery was palpated. It was
noted to be soft, without visible or palpable calcifications. A pursestring suture using a 5-0 prolene was then placed in the
anterior wall of the femoral vein and artery. A 6-8cm right anterior thoracotomy incision was performed at the level of the
4th intercostal space, adjacent to the right sternal border. The 4th intercostal space was entered using electrocautery. A skin
retractor was secured within the incision and a soft tissue retractor was placed in the intercostal space using the [Size] blades
to expose the underlying pericardium. The pericardium was visualized and opened, exposing the lower ascending aorta and
right-sided cardiac structures. Horizontal mattress stay sutures were placed in the pericardium and brought out of the skin to
tack the pericardium. The field was flooded with carbon dioxide throughout the case to minimize intracardiac air.
The patient was systemically heparinized. Next, an arterial cannula was placed in the right common femoral artery over a
guidewire, using the modified Seldinger technique, within the arterial pursestring. A long venous cannula was placed through
a pursestring suture in the right common femoral vein, also using the modified Seldinger technique. The long venous cannula
was positioned in the IVC with the tip protruding slightly into the right atrium, confirmed by echocardiography. Next, a wire
was placed into the right internal jugular vein sheath. Using Seldinger technique, a venous cannula was inserted into the SVC
using echocardiography guidance making sure the tip of the cannula was at the cavo-atrial junction. The cannulae were attached
to the cardiopulmonary bypass machine and the lines were tested. CPB was initiated and the patient was systemically cooled
to 32oC. A cardioplegia catheter was placed into the aortic root. The ascending aorta was occluded with a flexible crossclamp
through the thoracotomy. Cardioplegia was then re-injected part way through the crossclamp time and myocardial protection
was excellent.
In the event of concurrent aortic insufficiency: The heart became somewhat distended, due to a degree of aortic insufficiency.
A small atriotomy incision was made and, under direct vision, a retrograde cardioplegia catheter was placed in the coronary
sinus. The atriotomy was closed and cardioplegia was reinitiated with retrograde cardioplegia.
An incision was made in the left atrium posterior to the interatrial septum in Sondergaard’s groove. A septal retractor blade
was placed, nicely exposing the mitral valve. It was secured to an “iron intern” retractor through a 0.5cm separate incision
placed just medial to the thoracotomy. The valve was carefully inspected, comparing all leaflets to P1. The mitral valve was
inspected for deformity, coaptation, ruptured chordae, and prolapse. Cold saline was gently instilled into the left ventricle and
the valve was assessed for regurgitation. The following findings were observed: [FINDINGS: e.g. P2 segment of the posterior
leaflet had several ruptured chordae and was flail in its midportion, with intact chordae on each side]. The decision was made
to repair the mitral valve.
In the event of a mitral valve repair: The flail leaflet was excised in a triangular V-type fashion. A primary repair was
performed with figure-of-eight 4-0 ethibond sutures. The mitral valve was measured using mitral valve sizing tools. It was
measured along the anterior leaflet from the anterior to posterior commissure and a [SIZE] annuloplasty ring was selected.
Next, 2-0 ethibond sutures were placed in each trigone. Additional 2-0 ethibond sutures were placed along the annulus
posteriorly. The sutures were placed through the sewing ring of the annuloplasty. The annuloplasty device was seated on the
mitral valve annulus and each suture was tied using [extracorporeal knot pusher or CorKnot] and cut.
In the event of a mitral valve replacement: The mitral valve was measured using mitral valve sizing tools. It was measured
from along the anterior leaflet from anterior to posterior commissure and a [SIZE] mitral valve prosthesis was selected. The
anterior leaflet of the mitral valve was excised sharply from the posterior to anterior commissure. The posterior leaflet was
debrided, leaving as many chordae and subvalvular apparatus intact as possible to protect the atrioventricular groove and keep
LV geometry. Next, 2-0 ethibond sutures were placed in each trigone. Additional 2-0 ethibond horizontal mattress sutures were
placed along the annulus posteriorly. Finally, 2-0 ethibond horizontal mattress sutures were placed along the anterior annulus.
The sutures were then placed through the sewing ring of the valve prosthesis. The prosthesis was seated on the mitral valve
annulus and each suture was tied using [extracorporeal knot pusher or CorKnot] and cut.
Gentle distention of the left ventricle with cold saline revealed a competent valve in all zones. A vent was placed through the
atriotomy incision, across the valve, and into the left ventricle. The atriotomy incision was closed with a double layer of 4-0
prolene. With the left ventricular vent and the aortic root vent on suction, the crossclamp was removed and the heart
reperfused. It was subsequently defibrillated and returned to normal sinus rhythm. The vents remained on suction until all
microbubbles were cleared from the circulation and cardiac tone returned. This was confirmed on echocardiography. The vents
were then removed. The vent sites were securely sutured with 4-0 prolene.
Alternative venting strategy: During the initial left atrial incision, a separate vent (using an actual vent or cardiotomy sucker)
is inserted through the atriotomy incision into the left sided pulmonary veins via a separate skin stab incision to minimize blood
from flooding the field during mitral repair/replacement. The vent is removed just prior to closure of the left atrial incision and
the left atrium is deaired using cold saline on a soft, pliable red rubber catheter.
Temporary right atrial and right ventricular pacemaker wires were placed on the heart (if needed). Left ventricular function
was [BLANK] and the echocardiogram confirmed no residual mitral valve insufficiency. The venous cannula was removed,
and bleeding was controlled by tying the pursestring suture in the anterior wall of the femoral vein. It was then oversewn with
5-0 prolene. The femoral arterial cannula was removed and the 5-0 prolene pursestring suture was tied down. No significant
bleeding was noted from the femoral artery. After palpating distal and proximal to the pursestring, excellent pulses were felt
without any thrills. [If repairing the artery: After obtaining proximal and distal control of the femoral artery with vascular
clamps, the arterial cannula was removed. The arteriotomy was then closed with a running 5-0 prolene suture]. Heparin was
reversed with protamine.
Hemostasis was obtained at all operative sites. A 24Fr Blake drain was placed within the pericardium. The pericardium was
partially closed over the ascending aorta and the right atrium. A 28Fr straight chest tube was placed in the right pleural cavity.
An intercostal block was performed using 0.25% Marcaine. The intercostal space was then closed with blunt #2 vicryl sutures.
The fascia was closed in 3 layers with vicryl suture. The skin was then closed with 4-0 monocryl sutures in a running
subcuticular fashion. The groin incision was also closed in layers with vicryl and monocryl suture. The patient was brought to
the recovery room in stable condition without complication.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of the procedure.
Multiple Choice Question(s)
The following two questions are in the same scenario:
- Following minimally invasive mitral valve repair (triangular resection of the posterior leaflet and annuloplasty ring), you
have difficulty weaning from CPB and your anesthesiologist notices LVOT obstruction and MR. What phenomena is this and
how is it conservatively managed?
A. Systolic anterior motion, increase volume status and afterload, decrease inotropy, and prevent tachycardia
B. Diastolic anterior motion, increase volume status and afterload, decrease inotropy, and prevent tachycardia
C. Systolic anterior motion, minimize volume, decrease afterload, and increase inotropy
D. Systolic posterior motion, increase volume, decrease afterload, decrease inotropy, and prevent tachycardia
Answer: A. SAM occurs when the line of coaptation of the MV leaflets is displaced too anteriorly. This results in the anterior
leaflet being displaced into the LVOT and causing LVOT obstruction. Systolic anterior motion can occur when there is
inadequate reduction in height of the posterior leaflet. - You attempted conservative management, however you still find yourself having difficulty weaning from CPB. Since you
have already performed a triangular resection of the posterior leaflet, how can you manage this surgically?
A. Resect the MV leaflets and replace the MV
B. Perform a triangular resection of the anterior leaflet
C. Replace the annuloplasty ring with a larger ring or a incomplete ring
D. Replace the annuloplasty ring with a smaller ring
Answer: C. Placing a larger annuloplasty ring or an incomplete ring will increase the height of the anterior leaflet and allow
the edges of the MV to line up more appropriately.
- After placement of the crossclamp, you attempt to arrest the heart with antegrade cardioplegia, however you are unable to
achieve an appropriate rest. Which of the following are appropriate reasons as to why you are unable to arrest?
A. Inadequate aortic crossclamp placement resulting in washout of cardioplegia
B. Inadequate placement of antegrade cardioplegia catheter resulting improper cardioplegia dose
C. Unidentified AI preop resulting in inadequate cardioplegia dosing due to incompetent AV
D. All of the above
Answer: D. - Immediately after placement of your aortic crossclamp, you notice bright red blood fill your field. Which of the following
structure/s was most likely injured?
A. Left ventricle
B. Right ventricle
C. Left atrium
D. Right atrium
Answer: C. Out of the answer choices, the left atrium is the most reasonable choice. The left atrial appendage can sometimes
be injured during placement of the aortic crossclamp during minimally invasive mitral valve surgery. Therefore it is very
important to try and visualize the cross clamp during the entirety of placement. Frequently, the aorta can be lifted using a
Yankauer suction which also helps move the left atrial appendage away from the crossclamp. - You have just performed a minimally invasive mitral valve replacement and you are having difficulty weaning from CPB.
Your anesthesiologist is on a significant amount of vasopressor and inotropes and you are unable to come off pump. On TEE,
significant AI is identified which was not read preoperatively. What is the next best step?
A. Re-heparinize and perform minimally invasive aortic valve replacement
B. Re-heparinize and perform open aortic valve replacement
C. Place an IABP for additional mechanical circulatory support
D. Increase volume, reduce vasopressor and inotrope support, and attempt to re-wean from CPB
Answer: B. Most likely, during placement of MV annulus sutures, sutures near the left fibrous trigone were placed too deeply
resulting in injury to the aortic valve leaflets. This was seen as newly found AI on TEE. The best next step is to perform open
aortic valve replacement as the patient has already tolerated one CPB run and aortic cross clamp. Attempting to repair the AV
or revise the MV sutures may not work.
Sources
Kaiser, Larry R, Irving L Kron, and Thomas L Spray. Mastery of Cardiothoracic Surgery. Third edition. Philadelphia,
Pennsylvania: Wolters Kluwer/Lippincott Williams & Wilkins, 2014.
Van Praet, Karel M et al. “Minimally Invasive Surgical Mitral Valve Repair: State of the Art Review.” Interventional
Cardiology (London, England)vol. 13,1 (2018) 12-19.
