HELP NEEDED acute Stanford type A ascending aortic dissection with aneurysm

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Postoperative diagnosis:
#1 acute Stanford type A ascending aortic dissection with aneurysm
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procedure:
#1 emergency replacement of the ascending aorta with hemi-arch using a 34 mm Dacron graft
#2 emergency CABG ×1 with vein graft to the LAD secondary to acute coronary dissection
#3 extensive lysis of pericardial adhesions
#4 right axillary artery cutdown with placement of 8 mm end-to-side Dacron graft for cannulation
#5 ultrasound-guided percutaneous right femoral venous cannulation
#6 placement of left femoral arterial line
#7 cardiopulmonary bypass
#8 deep hypothermic circulatory arrest, 18°C
#9 Cerebral Somanetics monitoring
#10 reinstitution of cardiopulmonary bypass
#11 complex management of coagulopathy, 2 hours
#12 open saphenous vein harvest, left lower extremity, 1 vein segment
#13 TEE with visualization and interpretation ×2
#14 epi-aortic ultrasound with visualization and interpretation

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Indication:
77-year-old female presenting with acute onset of chest pain radiating to the back. She was evaluated at M B campus in which a CT, PE protocol was performed which revealed an ascending aortic dissection. She was transferred to Center for further care. She's been taken to the operating suite for emergency repair of ascending aorta.
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Intraoperative findings:
Pre-bypass TEE showed normal left ventricular function. There was mild concentric left ventricular hypertrophy. There were no regional wall motion abnormalities. Right ventricular function was normal. There was trace to mild mitral regurgitation. The left atrial appendage was free of thrombus. The aortic valve leaflets were coapting appropriately, with no evidence of dilation of the aortic root. There was mild to moderate central aortic insufficiency noted his own of coaptation centrally. The sinotubular junctions were thickened, but not effaced. The aortic dissection could be identified with thrombosis within the false lumen.
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Initial TEE upon weaning from cardiopulmonary bypass showed preservation of the ventricular function. However, within a few minutes of weaning from bypass, the patient began having hemodynamic instability. The heart was becoming arrhythmia genic. Reevaluation of the TEE revealed that there was severe hypokinesis/akinesis of the anterior wall. This finding prompted the decision to re-heparinize and go emergently back on cardiopulmonary bypass.
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Once on bypass, epi-aortic ultrasound was actually used to evaluate the LAD territory. At the most proximal portion of the LAD, a dissection flap was identified which explains the severe hypokinesis of the anterior wall. Emergency bypass grafting to the LAD territory was performed using vein graft to the left leg. Once this was completed, final TEE was performed which showed normal ventricular function upon immediate weaning, no alteration in native valvular function. The aortic root was well visualized with no alterations in the native aortic valve function.
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Upon entering the pericardium, it was evident the patient had a combination of subacute and chronic pericarditis. Exact etiology is unknown. There is no purulent fluid. Extensive lysis of pericardial adhesions had to be performed in order to achieve the operation. Femoral venous cannulation was performed because central venous cannulation could not be performed secondary to the severe displacement of the right atrium relative to the IVC because of the ascending aortic aneurysm. The aneurysm itself was over 6 cm in size. It is incredibly thin walled. The intimal tear was identified on the lesser curvature of the distal ascending aorta. This area was completely resected during the repair. There was no evidence of intimal tear within the aortic arch.
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Procedure in detail:
The patient had her history and physical updated prior to the procedure. She was transferred to the operating suite and placed on the operating table where she underwent general anesthesia with endotracheal intubation. Monitoring lines and been placed by anesthesia. TEE probe was placed by anesthesia. The patient was prepped and draped in usual sterile fashion using DuraPrep solution. Timeout was used confirm patient identity as well as the surgery to be performed. Antibiotics given prior the incision.
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A right subclavicular incision was made with a 10 blade scalpel. Soft tissues were divided. The pectoralis muscle was released from its clavicular attachments. The underlying soft tissues were divided to expose the right axillary artery. Great care was taken to preserve the brachial plexus. Right axillary artery was then encircled with Vesseloops proximally and distally for hemostatic control. The patient was given 6000 units of heparin and vascular clamps were placed. A longitudinal arteriotomy was made with a 15 blade scalpel and extended. An 8 mm Dacron graft was then anastomosed to the right axillary artery using 5-0 Prolene. The graft was then de-aired. It was connected to the arterial line for arterial cannulation and bypass.
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Pre-bypass TEE had been performed by this point in time. Findings are as dictated above.
Sternal incision was made. Soft tissues were identified. Sternotomy was performed in the standard fashion. Sternal retractor was placed. The anterior mediastinal soft tissues were divided. The innominate vein was completely collapsed secondary to the size of the aneurysm placed in the vein on stretch. The pericardium was then opened in which there was extensive pericardial adhesions, some of which were subacute and other show evidence of chronicity. Stay sutures then placed create a pericardial well. Great care was taken to minimize any manipulation the ascending aorta, as it was evident that the wall was extremely thin.
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The patient was fully heparinized. ACT was found be therapeutic for bypass. Central venous cannulation was attempted multiple times, but the severe angle created by the displacement of the atrium by the aneurysm made routine central cannulation difficult. Decision was then made to perform right femoral venous cannulation. The ultrasound was used to identify the right femoral vein. The vein was compressed and showed no evidence of DVT. Under real-time ultrasound, single anterior wall puncture was performed and the guidewire was placed and confirmed to be across the IVC and SVC under TEE guidance. Serial dilation over wire was performed and the femoral venous cannulation was placed and confirmed in position by TEE. The patient was then placed on full cardiopulmonary bypass and systemically cooled to 18°C.
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A total of 90 minutes was dedicated purely to lysis of adhesions. This included off-pump lysis of adhesions as well as lysis of adhesions on the patient was on bypass.
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The innominate artery could not easily be accessed in order to perform selective antegrade cerebral perfusion. Secondary to this, decision made to perform deep hypothermic circulatory arrest. The patient was cooled to 18°C for at least 20 minutes. Once this was completed, the deep hypothermic circulatory arrest was instituted. The bypass pump was turned off. The aorta was opened which revealed a large aneurysm with acute thrombus within the false lumen. The left main coronary artery was evaluated and noted cardioplegia to the left main as well as right coronary ostia was given to achieve complete diastolic cardiac arrest. Left main appeared to be uninvolved in the dissection. The dissection extended to just above the right coronary ostia. This ostomy later be secured with pledgeted 5-0 Prolene sutures.
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The ascending aorta was then resected with accommodation of Metzenbaum scissors as well as cautery. It was taken to the level of the innominate takeoff and a hemi-arch configuration was constructed. The intimal tear was resected during this portion of the procedure. Using a felt sandwich technique, a felt strip was tacked intraluminally as well as extraluminally and secured with 5-0 Prolene. It was sized to a 34 mm graft. The graft was then anastomosed to the proximal aortic arch using 3-0 Prolene in a running fashion. BioGlue was placed over the anastomosis. The patient was placed in steep Trendelenburg and de-airing maneuvers were performed. After the graft was adequately de-aired, cross-clamp was placed in full antegrade perfusion was reinstituted and the patient was warmed to 32°C.
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The remainder of the ascending aorta was resected to the level of the sinotubular junction. As stated above, the right coronary artery was widely patent, but the dissection didn't extend to just above the right coronary artery. The right coronary ostia was slightly higher than the initial attachments. This was secured with pledgeted 5-0 Prolene suture. Once this was completed, a double felt sandwich technique was used to find the proximal anastomosis in a similar fashion as previously described. The patient had been systemically rewarmed. The needle vent was placed and de-airing maneuvers were then performed. Once this was completed, the cross-clamp was removed and the heart was allowed to be reperfused.
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The heart regained spontaneous rhythm. Pacing wires placed on the right ventricle brought out to the level of the skin. Lungs were ventilated. Anastomoses were found to be hemostatic. The heart was then weaned from bypass without difficulty. Protamine had initially been started and venous cannula was removed. Shortly after this, the patient began having hemodynamic issues with hypotension and the heart was with the genetic. TEE was then used to evaluate the heart. During the TEE evaluation, the left ventricular function was severely depressed and there was severe anterior wall hypokinesis. She was initially treated medically with significant improvement, but quickly deteriorated into the similar situation previously described. Decision was made to re-heparinize and reinstituted cardiopulmonary bypass.
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Decision was made to bypass the LAD. The LAD was identified and isolated. The vein graft had been harvested from the left lower extremity using an open incision technique by . After was prepped, bleeding heart pump-assisted bypass to the LAD was performed. Arteriotomy was made and extended. The vein grafts beveled and spatulated. It was anastomosed using 7-0 Prolene. The proximal anastomosis was then placed on the ascending aortic graft using a side-biting clamp to achieve hemostasis while creating the anastomosis. The vein graft was de-aired after the clamp was removed.
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Lungs were ventilated. Pacing wires were placed on the right ventricle. The heart was then weaned from bypass without difficulty. The TEE was reevaluated which showed significant improvement in the anterior wall function with adequate de-airing of the left ventricle. Left ventricular function was found to be normal. Decision was made to give protamine to reverse the effects of heparin. The femoral venous cannula was removed and pressure was held to assist with hemostasis.
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The next 2 hours were spent administering blood products which include packed red cells, FFP, platelets, cryo-, factor VII in order to achieve hemostasis. As the patient required more and more volume, the hemodynamics were marginal at best. She is being supported by epinephrine drip, milrinone, vasopressin, as well as several doses of bicarbonate for the management of metabolic acidosis, calcium chloride. Once hemostasis was achieved, decision was made to close the chest. The sternum was reapproximated with #7 wires. Prior to closure, a right angle chest tube as well as a 32 French straight mediastinal chest tube were placed in the mediastinum. The superior abdominal fascia was reapproximated with 0 Ethibond. Soft tissues reapproximated with 0 Vicryl. Skin was closed with 4 Monocryl in a running subcuticular manner.
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Throughout the procedure, the patient was being monitored with cerebral Somanetics. Her initial readings ranged between 40 and 60th percentile. During hypothermic circulatory arrest, readings ranged from 30-45 percentile. She had lower numbers after weaning from bypass, largely related to severe anemia which was being treated with transfusions.
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Also, during her hemodynamics instability, the left radial arterial line was transducing, but could not be drawn back. Decision was made to place a left femoral arterial line. A percutaneous access left femoral artery and placed the wire. Small stab incision was made. Dilator was placed over wire and a Seldinger technique. The femoral arterial line was placed and secured with 2-0 silk.
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The right axillary Dacron graft was clipped proximally and then oversewn with 5-0 Prolene. The excess graft was excised and the deep soft tissues were closed with 2-0 Vicryl. Skin was closed with 4 Monocryl running subcuticular manner. Dermabond was placed over the wounds. The patient was then transferred to CVRU in critical condition.

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