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1. Severe mitral regurgitation with flailed P2 segment of mitral
valve.
2. Tricuspid valve annular dilatation.
3. Recent atrial fibrillation.
4. Recent history of congestive heart failure.
PROCEDURE PERFORMED:
1. Minimally-invasive complex mitral valve repair:
A. Utilizing a 40-mm 3-D profile annuloplasty ring.
B. Reduction of P2 and P3 leaflet heights utilizing six
artificial Gore-Tex needle cords.
2. The second part of the procedure is a tricuspid valve repair
utilizing a 36-mm 3-D Contour annuloplasty ring.
3. Maze procedure utilizing radiofrequency energy.
4. Ligation of the left atrial appendage.
5. Direct repair of the left femoral artery.
OPERATING SURGEON:
Dr. - 1
ASSISTANT:
Dr. - 2, Dr. - 3
PROCEDURE IN DETAIL:
The patient was taken to the operating room and placed in a supine
position, prepped and draped in the usual fashion. A two-team
approach was utilized, with one team exposing the left femoral artery
and vein. Thereafter, the Seldinger technique was utilized to
cannulate these vessels. Thereafter, a 6-cm skin incision was formed
in the right lateral chest wall. The fourth-fifth interspace was
entered. Thereafter, a soft tissue retractor was placed and a rib
spreader. The pericardium was opened over the phrenic nerve and
tacked to the skin. Thereafter, a retrograde cardioplegia cannula was
inserted. We then instituted full cardiopulmonary bypass, and then
the superior and inferior vena cava were encircled with the vessel
loops. Thereafter, the aorta was cross clamped. Cold blood
cardioplegia was given, both in antegrade and retrograde fashion,
until obtaining adequate electromechanical arrest of the heart. Of
note, every 20 minutes, further doses of cardioplegia were given. We
then instituted full cardiopulmonary bypass. Thereafter, once we
instituted cardiopulmonary bypass, the aorta was cross clamped, and
cold blood cardioplegia given, both in antegrade and retrograde
fashion, until obtaining adequate electromechanical arrest of the
heart. Of note, every 20 minutes, further doses of cardioplegia were
given. Thereafter, after adequate electromechanical arrest of the
heart was obtained, a left lateral atriotomy was performed. Then, a
left-sided Maze procedure was performed with lesion patterns created
around the left and right pulmonary veins, that communicated with
each of the pulmonary veins in a box fashion. Then, encircling the
left atrial appendage, and from the left atrial appendage and the
left pulmonary veins, and then from the left pulmonary veins to the
midportion of the posterior leaflet of the mitral valve. Of note,
this was performed utilizing a Medtronic radiofrequency unipolar
device. Thereafter, the left atrial appendage was oversewn with a 4-0
Prolene suture in a two-layer closure. Then, directing our attention
to the mitral valve, it was noted that the patient had flailed P2
segment of the mitral valve, which is a large segment, and 2-0 Tevdek
sutures were placed circumferentially around the anulus. The anulus
was sized and noted to accommodate a 40-mm 3-D annuloplasty ring.
Thereafter, 4-0 Gore-Tex sutures were placed in the anterolateral and
posteromedial papillary muscles. These were exited through the free
edge of the P2 segment in a figure-of-eight fashion in three
different locations in the P2 segment. It was noted that the right
half of P2 was the flailed segment; the left half had elongated
chordae, but there were intact. Thereafter, once the 40-mm ring was
passed onto the operative field, the sutures were placed through the
ring, and the ring was seated onto the anulus, and the sutures were
tied down and transected. The final height of P2 was then assessed,
utilizing a saline test, injected saline into the left ventricular
cavity, and then once the height was assessed, then the cords were
tied down to the free edge of the leaflet. Then, at this point, a
saline test was then performed. Once again, in order to provide
long-term stability of the repair, a decision was made to perform an
Alfieri stitch utilizing 5-0 Prolene suture, approximating A2 and P2,
with a continuous
over-and-over suture line for approximately 0.5 cm in length.
Thereafter, the left atrium was partially closed, and then the venous
cannula was pulled into the inferior vena cava and snared, and then
the right atrium was immediately opened, and a pump suction was
placed into the superior vena cava, and this acted as drainage from
the superior vena cava. The left atriotomy was extended. An atrial
lift retractor was placed, and then 4-0 Tevdek sutures were placed
circumferentially around the anulus, avoiding the conduction system.
The 36-mm, 3-D Contour annuloplasty ring was passed onto from the
operative field. The sutures were placed through the ring, and the
ring was seated onto the anulus. The sutures were tied down and
transected. After the left atrium was closed with 4-0 Prolene suture
in a two-layer closure, then the remainder of the left atrium was
closed.
The patient was placed in Trendelenburg position. The aortic
cross-clamp was removed. Then, multiple de-airing maneuvers were
performed utilizing a THI needle in the root of the aorta. After
adequate deairing and adequate function of the valve, which was
evident by _____ the patient was weaned from cardiopulmonary bypass,
and after adequate function of both valves and adequate de-airing,
the patient was weaned from cardiopulmonary bypass. The venous
cannula was removed. The purse string suture was tied down. The
patient was given protamine, which he tolerated well. Then, the
arterial cannula was removed, and direct repair of the left femoral
artery was performed, approximating the intramammary tissue in a
two-layer closure. An On-Q system, the pacing wires, which was
placed in the inferior wall of the left ventricle, and a Blake chest
tube were all exited through the chest tube incision, and a
figure-of-eight suture was utilized to approximate the ribs. The
muscle, subcutaneous tissue, and skin were all closed in a routine
fashion. The patient tolerated the procedure well, with no
complication encountered.
Can some one please give me an insight on this report.
Thanks,
valve.
2. Tricuspid valve annular dilatation.
3. Recent atrial fibrillation.
4. Recent history of congestive heart failure.
PROCEDURE PERFORMED:
1. Minimally-invasive complex mitral valve repair:
A. Utilizing a 40-mm 3-D profile annuloplasty ring.
B. Reduction of P2 and P3 leaflet heights utilizing six
artificial Gore-Tex needle cords.
2. The second part of the procedure is a tricuspid valve repair
utilizing a 36-mm 3-D Contour annuloplasty ring.
3. Maze procedure utilizing radiofrequency energy.
4. Ligation of the left atrial appendage.
5. Direct repair of the left femoral artery.
OPERATING SURGEON:
Dr. - 1
ASSISTANT:
Dr. - 2, Dr. - 3
PROCEDURE IN DETAIL:
The patient was taken to the operating room and placed in a supine
position, prepped and draped in the usual fashion. A two-team
approach was utilized, with one team exposing the left femoral artery
and vein. Thereafter, the Seldinger technique was utilized to
cannulate these vessels. Thereafter, a 6-cm skin incision was formed
in the right lateral chest wall. The fourth-fifth interspace was
entered. Thereafter, a soft tissue retractor was placed and a rib
spreader. The pericardium was opened over the phrenic nerve and
tacked to the skin. Thereafter, a retrograde cardioplegia cannula was
inserted. We then instituted full cardiopulmonary bypass, and then
the superior and inferior vena cava were encircled with the vessel
loops. Thereafter, the aorta was cross clamped. Cold blood
cardioplegia was given, both in antegrade and retrograde fashion,
until obtaining adequate electromechanical arrest of the heart. Of
note, every 20 minutes, further doses of cardioplegia were given. We
then instituted full cardiopulmonary bypass. Thereafter, once we
instituted cardiopulmonary bypass, the aorta was cross clamped, and
cold blood cardioplegia given, both in antegrade and retrograde
fashion, until obtaining adequate electromechanical arrest of the
heart. Of note, every 20 minutes, further doses of cardioplegia were
given. Thereafter, after adequate electromechanical arrest of the
heart was obtained, a left lateral atriotomy was performed. Then, a
left-sided Maze procedure was performed with lesion patterns created
around the left and right pulmonary veins, that communicated with
each of the pulmonary veins in a box fashion. Then, encircling the
left atrial appendage, and from the left atrial appendage and the
left pulmonary veins, and then from the left pulmonary veins to the
midportion of the posterior leaflet of the mitral valve. Of note,
this was performed utilizing a Medtronic radiofrequency unipolar
device. Thereafter, the left atrial appendage was oversewn with a 4-0
Prolene suture in a two-layer closure. Then, directing our attention
to the mitral valve, it was noted that the patient had flailed P2
segment of the mitral valve, which is a large segment, and 2-0 Tevdek
sutures were placed circumferentially around the anulus. The anulus
was sized and noted to accommodate a 40-mm 3-D annuloplasty ring.
Thereafter, 4-0 Gore-Tex sutures were placed in the anterolateral and
posteromedial papillary muscles. These were exited through the free
edge of the P2 segment in a figure-of-eight fashion in three
different locations in the P2 segment. It was noted that the right
half of P2 was the flailed segment; the left half had elongated
chordae, but there were intact. Thereafter, once the 40-mm ring was
passed onto the operative field, the sutures were placed through the
ring, and the ring was seated onto the anulus, and the sutures were
tied down and transected. The final height of P2 was then assessed,
utilizing a saline test, injected saline into the left ventricular
cavity, and then once the height was assessed, then the cords were
tied down to the free edge of the leaflet. Then, at this point, a
saline test was then performed. Once again, in order to provide
long-term stability of the repair, a decision was made to perform an
Alfieri stitch utilizing 5-0 Prolene suture, approximating A2 and P2,
with a continuous
over-and-over suture line for approximately 0.5 cm in length.
Thereafter, the left atrium was partially closed, and then the venous
cannula was pulled into the inferior vena cava and snared, and then
the right atrium was immediately opened, and a pump suction was
placed into the superior vena cava, and this acted as drainage from
the superior vena cava. The left atriotomy was extended. An atrial
lift retractor was placed, and then 4-0 Tevdek sutures were placed
circumferentially around the anulus, avoiding the conduction system.
The 36-mm, 3-D Contour annuloplasty ring was passed onto from the
operative field. The sutures were placed through the ring, and the
ring was seated onto the anulus. The sutures were tied down and
transected. After the left atrium was closed with 4-0 Prolene suture
in a two-layer closure, then the remainder of the left atrium was
closed.
The patient was placed in Trendelenburg position. The aortic
cross-clamp was removed. Then, multiple de-airing maneuvers were
performed utilizing a THI needle in the root of the aorta. After
adequate deairing and adequate function of the valve, which was
evident by _____ the patient was weaned from cardiopulmonary bypass,
and after adequate function of both valves and adequate de-airing,
the patient was weaned from cardiopulmonary bypass. The venous
cannula was removed. The purse string suture was tied down. The
patient was given protamine, which he tolerated well. Then, the
arterial cannula was removed, and direct repair of the left femoral
artery was performed, approximating the intramammary tissue in a
two-layer closure. An On-Q system, the pacing wires, which was
placed in the inferior wall of the left ventricle, and a Blake chest
tube were all exited through the chest tube incision, and a
figure-of-eight suture was utilized to approximate the ribs. The
muscle, subcutaneous tissue, and skin were all closed in a routine
fashion. The patient tolerated the procedure well, with no
complication encountered.
Can some one please give me an insight on this report.
Thanks,