PROCEDURE PERFORMED:
1. Minimally invasive aortic valve replacement utilizing a 21 mm
Trifecta aortic valve.
2. Lengthening of the chordae to the anterior leaflet mitral valve.
DESCRIPTION OF PROCEDURE:
The patient was taken to the operating room and placed supine
position, prepped and draped in usual fashion. A two-team approach was
utilized, one team exposing the left femoral artery and vein. The
patient was heparinized and a Seldinger technique was utilized to
cannulate both vessels. Thereafter, a 6 cm skin incision was performed
in the right anterolateral chest wall. The second-third interspace was
entered. The cartilage was transected and will later be reattached. A
soft tissue retractor was placed, then a rib spreader. A moderate
sized right pleural effusion was aspirated. Of note, the patient to
have chronic lung changes from chronic obstructive pulmonary disease
which would partially account for her severe pulmonary hypertension.
We instituted a full cardiopulmonary bypass. The pericardium was
opened and tacked to the skin. A left ventricular vent was inserted
through the right superior pulmonary vein. The aorta was then cross
clamped. One dose of antegrade cardioplegia was given. Thereafter, due
to the fact the patient had aortic insufficiency cardioplegia was
given directly down the coronary ostia, both left and right.
Thereafter, the aortic valve was inspected and noted to be unicusp
with effusion of all 3 commissures. The leaflets were resected down to
the annulus, then a rongeur was utilized to dbride any remaining
calcium. The aortic root was thoroughly irrigated with a cold saline
solution allowing placement of 2-0 Tevdek pledgeted sutures on the
ventricular side of the anulus.
Looking through the mitral, the aortic
anulus, the anterior leaflet of the mitral valve was identified and
there was noted that there was thickening of the anterior leaflet. So,
thereafter peeling of the ventricular side of the anterior leaflet was
performed and then due the fact that the chordee were extremely
thickened, an 11 blade was then utilized to extend or lengthen the
course of the anterior leaflet and extending the incision down onto
the papillary muscles.
Thereafter, the anulus was sized, noted to
accommodate a 21 mm Trifecta pericardial valve. The valve was washed.
The aortic root was thoroughly irrigated with a cold saline solution.
Thereafter, the sutures were placed through the sewing cuff. The valve
was seated in a supra-annular position. The sutures were tied down and
transected. Thereafter, the aortotomy was closed with 5-0 Prolene
suture two layer closure, one ventricular pacing wire was placed. The
patient was placed in Trendelenburg position. The cross-clamp was
removed. Then multiple de-airing maneuvers were performed utilizing a
vent in the root of the aorta. After adequate de-airing and adequate
function of the valve, which was evident by intraoperative TEE, the
patient was weaned from cardiopulmonary bypass. The venous cannula was
removed. The purse suture tied down. The patient was given protamine
which he tolerated well. Then the arterial cannula was removed and
direct repair of the femoral artery performed. Thereafter, a Blake
chest tube left in pericardial and pleural space, as well as the On-Q
system. These along with the pacing wire, were exited through the
chest tube incision. A figure-of-eight suture was utilized to
approximate the rib. The ribs were reattached back to the sternum with
0 Vicryl, then the muscle, subcutaneous tissue, and skin were all
closed in routine fashion.
