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Would it be endarterectomy?
Atherectomy of the ventricular aspect of the anterior mitral valve leaflet
Aortic valve findings:
-Normal coronary ostia, with the left main coronary artery arising from normal anatomical position with no ostial disease. The right coronary artery arose from normal anatomical position within the mid sinus. There is no ostial disease identified.
-The aortic valve was a bicuspid valve with a common raphae between the right and left cusps. There was severe calcification involving both leaflets and the annulus. The valve was asymmetric with a short right coronary annulus and a larger noncoronary annulus.
-There was severe calcification extending down the length of the anterior mitral leaflet on the ventricular aspect. Roughly a 2.5 x 1 x 0.5 cm bridge extended from the commissure between the left and noncoronary annulus to the coaptation zone of the anterior mitral valve leaflet. Atherectomy was performed and the mitral valve remained competent by final TEE.
Procedure in detail:
The patient had his history and physical updated prior to the procedure. He was transferred to the operating suite placed on the operating table where He underwent general anesthesia with endotracheal intubation. Monitoring lines and devices were 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 to confirm patient identity as well as the procedure to be performed. Antibiotics given prior to the incisions.
Pre-bypass TEE was performed with findings as described above. Midline sternal incision was made. The soft tissues were cauterized. Sternotomy was performed in the standard fashion. The patient was heparinized and ACT was found to be therapeutic for the procedure. Sternal retractor was placed. The pericardium was opened and teed off along the diaphragm. Stay sutures were placed to create a pericardial well. Epi-aortic ultrasound was used to evaluate the ascending aorta with findings as described. Once this was completed, central cannulation of the heart was performed. Reverse autologous priming the pump was performed. The patient was then placed on full bypass and systemically cooled to 33 °C. Antegrade needle was placed in the mid ascending aorta. The cross-clamp was placed and cold sanguinous antegrade cardioplegia was delivered to achieve ventricular fibrillation. Left ventricle was distended and therefore antegrade cardioplegia was discontinued and the needle vent was placed on high suction. An oblique aortotomy was then created using Metzenbaum scissors and direct ostial cardioplegia was delivered down the left main coronary artery as well as the right coronary artery to achieve full diastolic cardiac arrest.. Temperature probe was placed in the septum and ice was placed over the right ventricle.
The oblique aortotomy was then extended further with Metzenbaum scissors towards the noncoronary sinus. Pledgeted stay suture was then placed on the distal ascending aorta to assist with retraction and visualization. The aortic root was then evaluated with findings as described. The leaflet with the common raphae was essentially immobile. The noncoronary leaflet was heavily calcified. The aortic valve leaflets were then excised using Metzenbaum scissors. The annulus was then decalcified using rongeurs. After adequate decalcification of the annulus, the mitral valve leaflet was evaluated and there was a large and long bar of calcification extending along the posterior aspect of the anterior mitral valve leaflet to the level of the coaptation zone posteriorly. Rongeurs were then used to perform atherectomy of the anterior mitral valve leaflet. Once adequate decalcification was achieved, the Ellik evacuator was then placed to remove any micro calcific debris.
2-0 pledgeted Ethibond sutures were then placed in the subannular position in a circumferential fashion. The annulus was sized to a 25 mm Inspiris bioprosthetic valve. The sutures were placed through the sewing cuff of the bioprosthetic valve and the valve was parachuted into the supra annular position. It was then secured with the core-knot device. Throughout this portion of the procedure, CC, DO was responsible for following the suture, improving exposure, as well as removing blood from the field. The patient was then systemically rewarmed. The aortotomy was then closed in a 2 layered fashion using 4-0 Prolene.
The patient was placed in steep Trendelenburg and de-airing maneuvers were performed. After adequate de-airing, the needle vent was placed on high suction and the cross-clamp was removed. The heart regained a spontaneous sinus rhythm. The aortotomy was found to be hemostatic. Pacing wires were placed on the right ventricle and brought to the level of the skin. Lungs were ventilated. The heart was then weaned from bypass without difficulty. Final TEE was performed with findings as described. Protamine was then delivered to reverse the effects of heparin and the heart was decannulated in the usual fashion. All cannulation sites were oversewn with 4-0 Prolene.