rgunderson
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Procedure(s):
Redo Sternotomy
Exploration of the chest
Cardiopulmonary bypass via left femoral artery and vein cannulation under fluoroscopic guidance.
Findings:
Severe inflammatory adhesions, not possible to proceed with redo aortic valve replacement.
EBL:
N/A. Cardiopulmonary bypass and cell saver used.
PROCEDURE IN DETAIL:
Informed consent was obtained. The patient was taken to the operating room and placed on the table in the supine position. After induction of general endotracheal anesthesia an arterial line and invasive monitoring catheters were inserted by the anesthesia service. The neck, chest, abdomen, groins, and legs were prepared with antiseptic solution and draped in sterile fashion.
TEE was preformed by the Anesthesia team.
A preoperative time out was performed with the operative team. Appropriate preoperative antibiotics were administered.
An incision was made in the left groin identifying the left common femoral artery and left common femoral vein.
5-0 Prolene sutures were placed in both of them. Heparin was administered.
Under fluoroscopic guidance . They were cannulated with arterial and venous groin cannulas to achieve cardiopulmonary bypass. This was accomplished under fluoroscopic guidance.
I then opened the chest with a 10 blade knife, electrocautery. I dissected out the old wires and sternal plates and screws.
I removed the sternal plates and screws and cut the old wires.
Once the ACT was appropriate. Full cardiopulmonary bypass was instituted to fully decompress the heart. We had good flows .
An oscillating saw was used. A redo sternotomy was performed. I utilized the mammary retractor to dissect adhesions bilaterally, this allowed me to place a chest retractor.
I then slowly started dissecting out the old aortic graft.
My goal was to achieve a place to be able to place a cross-clamp.
Trying to dissect on the lateral side on the right side was extremely difficult. My goal was to try and place a left ventricular vent through the right superior pulmonary vein. However dissecting in that area was extremely hostile. Which was extremely inflamed.
I moved back to dissecting between the old aortic graft and the PA. Again this area was extremely hostile and inflamed. I was unable to develop a space to place the cross-clamp so that I would be able to give cardioplegia to arrest the heart and remove the thrombosed mechanical aortic valve.
After continuing to try, I felt the situation was futile. I decided to come off cardiopulmonary bypass.
She came off cardiopulmonary bypass with a small dose of Levophed support.
I chose not to reverse the heparin all the way. I only reversed it to an ACT of 300 given her thrombosed aortic valve.
I irrigated the chest. I placed one 28 Fr blake mediastinal drain.
I closed the bone with interlocking figure-of-eight wires.
I irrigated the subcutaneous tissue. I closed the deep layer with figure-of-eight PDS sutures. I did not closed the superficial fat or skin layers. I chose to place a black VAC sponge to close these layers , and placed them to a VAC machine.
The groin cannulas were removed. The 5-0 Prolene sutures were tied down. The groin was closed with 0 Vicryl, 2-0 Vicryl, skin with 3-0 Monocryl and Dermabond dressing.
The chest tube was hooked to Pleura-vac attached to suction.
Procedure(s):
Redo Sternotomy
Exploration of the chest
Cardiopulmonary bypass via left femoral artery and vein cannulation under fluoroscopic guidance.
Findings:
Severe inflammatory adhesions, not possible to proceed with redo aortic valve replacement.
EBL:
N/A. Cardiopulmonary bypass and cell saver used.
PROCEDURE IN DETAIL:
Informed consent was obtained. The patient was taken to the operating room and placed on the table in the supine position. After induction of general endotracheal anesthesia an arterial line and invasive monitoring catheters were inserted by the anesthesia service. The neck, chest, abdomen, groins, and legs were prepared with antiseptic solution and draped in sterile fashion.
TEE was preformed by the Anesthesia team.
A preoperative time out was performed with the operative team. Appropriate preoperative antibiotics were administered.
An incision was made in the left groin identifying the left common femoral artery and left common femoral vein.
5-0 Prolene sutures were placed in both of them. Heparin was administered.
Under fluoroscopic guidance . They were cannulated with arterial and venous groin cannulas to achieve cardiopulmonary bypass. This was accomplished under fluoroscopic guidance.
I then opened the chest with a 10 blade knife, electrocautery. I dissected out the old wires and sternal plates and screws.
I removed the sternal plates and screws and cut the old wires.
Once the ACT was appropriate. Full cardiopulmonary bypass was instituted to fully decompress the heart. We had good flows .
An oscillating saw was used. A redo sternotomy was performed. I utilized the mammary retractor to dissect adhesions bilaterally, this allowed me to place a chest retractor.
I then slowly started dissecting out the old aortic graft.
My goal was to achieve a place to be able to place a cross-clamp.
Trying to dissect on the lateral side on the right side was extremely difficult. My goal was to try and place a left ventricular vent through the right superior pulmonary vein. However dissecting in that area was extremely hostile. Which was extremely inflamed.
I moved back to dissecting between the old aortic graft and the PA. Again this area was extremely hostile and inflamed. I was unable to develop a space to place the cross-clamp so that I would be able to give cardioplegia to arrest the heart and remove the thrombosed mechanical aortic valve.
After continuing to try, I felt the situation was futile. I decided to come off cardiopulmonary bypass.
She came off cardiopulmonary bypass with a small dose of Levophed support.
I chose not to reverse the heparin all the way. I only reversed it to an ACT of 300 given her thrombosed aortic valve.
I irrigated the chest. I placed one 28 Fr blake mediastinal drain.
I closed the bone with interlocking figure-of-eight wires.
I irrigated the subcutaneous tissue. I closed the deep layer with figure-of-eight PDS sutures. I did not closed the superficial fat or skin layers. I chose to place a black VAC sponge to close these layers , and placed them to a VAC machine.
The groin cannulas were removed. The 5-0 Prolene sutures were tied down. The groin was closed with 0 Vicryl, 2-0 Vicryl, skin with 3-0 Monocryl and Dermabond dressing.
The chest tube was hooked to Pleura-vac attached to suction.