Atrial Septal Aneurysm

conleyclan

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Hello. Not sure if it is because it is Friday, or I am reading too much into this report. I would appreciate any help. Thanks.


PREOPERATIVE DIAGNOSES:
1. MODERATE TO SEVERE MITRAL REGURGITATION, BARLOW SYNDROME WITH SEVERE
BILEAFLET PROLAPSE.
2. PERSISTENT ATRIAL FIBRILLATION.
3. ATRIAL SEPTAL ANEURYSM.
4. LEFT ATRIAL ENLARGEMENT.
5. CONGESTIVE HEART FAILURE, NEW YORK HEART ASSOCIATION CLASS II TO III,
CHRONIC, DIASTOLIC.
6. HYPERTENSION.
7. HISTORY OF BREAST CANCER WITH LUMPECTOMY AND RADIATION TO THE RIGHT
BREAST AND RESIDUAL BREAST THICKENING.

OPERATIVE PROCEDURES:
1. Complex mitral valve repair [posterior leaflet partial resection with
extensive sliding valvuloplasty and reconstruction of posterior leaflet
annulus along with primary leaflet valvuloplasty, 34 mm cg future band].
2. Full, biatrial cox-maze procedure.
3. Primary repair of atrial septal aneurysm/aneurysmal defect.
4. Left atrial reduction [left atria reduced from 6.5 cm to 4.5 cm].
5. Surgical interpretation of transesophageal echocardiography.



OPERATIVE NOTE: The patient was prepped and draped in standard fashion,
after induction of endotracheal anesthesia and percutaneous placement of a
central venous catheter, Foley catheter, and arterial line. A small skin
incision but median sternotomy was performed, and the heart and vascular
structures dissected. Systemic heparin was administered, and the ascending
aorta was cannulated with a #7 Soft-Flow aortic cannula. The SVC and IVC
were cannulated directly with 24, right-angled, metal-tipped DLP cannulae.
Cardiopulmonary bypass was instituted, and the intraatrial groove was
dissected to the intraatrial septum. Ascending aorta was then
atraumatically cross-clamped with the pump flow down and 400 mL of
hyperkalemic cold blood cardioplegic solution was delivered antegrade down
the aortic root followed by 600 mL of cardioplegic solution delivered
retrograde via coronary sinus perfusion cannula to achieve an excellent
hypothermic myocardial arrest down to myocardial temperature of 6 degrees
centigrade. Topical hypothermia was achieved using iced saline and
cardioplegia delivered regularly to maintain superb myocardial protection
throughout the entire procedure.

The roof of the left atrium was entered, and the mitral valve exposed.
Mitral analysis revealed severe bileaflet prolapse consistent with Barlow
syndrome. The predominant excess leaflet tissue was posteriorly; however,
the anterior leaflet also had significant myxomatous degeneration.
Posterior leaflet annular exposure was performed using retraction sutures,
and this allowed for a detailed analysis of very large clefts in the P1-P2
region and the P2-P3 region. Therefore, careful planning was required to
meticulously go about the mitral reconstruction. The posterior leaflet in
the level of P2 was incised to the annulus and underlined along the entire
annulus up to within a few millimeters from the trigones. The second and
third order chordae posteriorly were then meticulously taken down in a
stepwise fashion, as required, in order to create a smooth, homogenous
posterior leaflet sliding valvuloplasty of P3 and P1. Prolene 4-0 was
utilized for this sliding valvuloplasty. This left residual P2 and the
inferior half of P2 was then preserved, whereas, the superior half was
excised and sent to Pathology. Two strut chordae were preserved for future
implantation using 5-0 Prolene. A rotation valvuloplasty was then
performed at the level of P2 to rebuild the defect, and 2 valvuloplasty
suture lines were then performed between P2 and P3 and P2 and P1 in the
location where the previous clefts were. These were performed using 2
layers of running 4-0 Prolene suture. The valve was then tested and found
to have the anterior leaflet unfurl nicely to recreate coaptation.
Remodeling sutures were placed in trigone to trigone posteriorly and a 34
mm CG Future band was then sutured into place. The valve was tested and
found to be completely free of regurgitation with excellent restoration of
the zone of coaptation. No Gore-Tex chordae or other anterior leaflet
maneuvers were required, as the anterior leaflet completely unfurled as
part of the posterior leaflet repair.

Full biatrial Cox-MAZE procedure was then performed with a combination of
cut-and-sew as well as adjunctive radiofrequency technology. The
left-sided lesions included bilateral pulmonary vein isolation, the left
atrial box lesion, left atrial appendage isolation, and mitral annular
connecting lesions. The left atrial appendage was oversewn in 2 layers in
a homogenous, longitudinal manner using 3-0 Prolene running suture. A
right atriotomy was performed, and the right-sided lesions included the
right atrial roof lesion, a tricuspid free wall lesion, the intercaval
connecting lesion, and the IVC to tricuspid annular lesion. I elected not
to perform tricuspid valvuloplasty, given the fact that there was some
myxomatous degeneration of the tricuspid leaflets, no significant tricuspid
insufficiency, and a tricuspid annulus of 3.9 to 4.1 cm, and no right
ventricular strain or symptoms. The right atrium was then closed in 2
layers using 5-0 Prolene running suture.

Left atrial reduction was performed by excising a 1.5 cm x 6 cm segment of
left atrial tissue extending from the roof of the left atrium and extending
posteriorly-inferiorly to the midpoint between the right inferior and left
inferior pulmonary veins and then connecting this to the margin of the
heart and excising this large swath of left atrial tissue. The left atrium
was then remodeled using a long, 3-0 Prolene suture to complete the left
atrial closure.

Hot-shot cardioplegic solution was then delivered followed by 2 minutes of
warm blood, and the ascending aortic cross clamp was then atraumatically
removed with the pump flow down. The patient resumed a junctional rhythm
at 50 beats per minute. Atrial and ventricular pacer wires were placed,
and the patient was AV sequentially paced at 70 beats and weaned
successfully from cardiopulmonary bypass on the first attempt. The patient
was decannulated. Protamine reversal was administered, and following
commencement of protamine reversal, the aortic cannula was then
atraumatically removed. Meticulous hemostasis was carried out, and by the
commencement of final closure, the patient has resumed normal sinus rhythm
and was being able to be atrially paced with good AV nodal conduction. Two
mediastinal chest drains were left in situ, and the sternum was
reapproximated using sternal wires, the fascia reapproximated using 0
Vicryl running suture, 2-0 Vicryl for the subcutaneous tissues and 4-0
Monocryl for the skin. Dermabond glue and dry dressings were applied, and
the patient was transferred to the Intensive Care Unit in very stable
condition with all counts being correct at the end of the procedure and no
inotropic support or blood products utilized throughout the entire
procedure.

INTRAOPERATIVE TRANSESOPHAGEAL ECHOCARDIOGRAM: The preoperative TEE
revealed severe bileaflet mitral valve prolapse with a small ruptured chord
at the level of P1 and substantial clefts in the level of P1 and P2 and P2
and P3, with severe bileaflet disease consistent with Barlow syndrome. The
tricuspid valve measured 3.7 cm in one measurement and 4.1 cm in another
measurement, but the pathology was not that of a dilated annulus and
restriction of the triscuspid leaflets but that of tricuspid valve prolapse
with excess leafs of tissue, and there was no significant tricuspid
insufficiency. The left atrium was markedly enlarged at close to 7 cm, and
there was no clot seen in the left atrium appendage. Ejection fraction was
visually estimated at approximately 40%.

The postoperative echocardiogram revealed good concentric ventricular
contraction with an ejection fraction of approximately 40-45%, with no
evidence of mitral insufficiency with excellent restoration of the zone of
coaptation and a transmitral peak gradient of 3 mmHg. Left atrium was
markedly reduced at approximately 4.5 cm with no flow seen in the left
atrial appendage. There was no significant tricuspid insufficiency.
 
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