TWilliam2019
Guru
1. Redo sternotomy with redo mitral valve replacement, 25 mm Mosaic bioprosthetic valve
2. Placement of left ventricular epicardial lead x2 with creation of a right subclavicular port pocket and tunneling for future use
3. Lysis of pericardial adhesions
4. Removal of sternal wires x10
5. TEE
6. Epiaortic ultrasound with visualization and interpretation
7. Rigid internal fixation of the sternum
8. Cardiopulmonary bypass with mild hypothermia
9. Limited reexploration of left pacemaker pocket
33430
33530
33202
76998 26
Indication:
80-year-old male presenting with fatigue, weakness, weight loss and found to have recurrent prosthetic mitral valve endocarditis as well as pacemaker lead infection. His mitral valve was originally replaced in 2012. He underwent placement of a pacemaker in 2014 and is fully pacemaker dependent. His most recent echo shows pacemaker lead vegetation as well as small vegetation on the bioprosthetic mitral valve. He has undergone pacemaker removal with laser lead extraction. He presents today for redo mitral valve replacement for prosthetic valve endocarditis.
Epiaortic ultrasound:
-There is no intramural or intraluminal disease that alter cannulation or cross clamp strategies. He had some scattered posterior calcifications which were identified on preoperative CT scan. No aneurysm was identified. Image was saved for permanent records.
Other intraoperative findings:
-Extensive adhesions involving the diaphragmatic surface, free wall the right ventricle, right atrium, and ascending aorta.
-Loss of temporary pacing via right IJ temporary atrial wire just prior to patient going on pump. Patient did have some intrinsic heartbeats that took over for a few seconds prior to initiation of cardiopulmonary bypass.
-Mitral valve was excised and had a small vegetation on one of the leaflets. This was submitted for routine, AFB, and fungal cultures. The remaining portions of the valve and leaflets were submitted to pathology.
-Mean gradient of new prosthetic valve: Less than 5 mmHg
-Epicardial leads: Serial #308086 with threshold of 1 V at 1 ms. R waves of 12 ms and 610 ohms. The epicardial lead with serial # had a threshold of 0.5 V at 1 ms. R waves at 9 mV and 553 ohms.
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 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.
Once pre-bypass TEE was performed by Dr. , midline sternal incision was made. The deep dermis and subcutaneous tissues were divided with electrocautery. The underlying sternal wires were identified. A total of 10 sternal wires were then cut and removed. Once this was completed, the redo oscillating saw was then used to transect the anterior table of the sternum. Bone hooks were used to elevate the xiphoid. The posterior table was then divided using the redo saw and reentry was completed safely. Using electrocautery, the anterior and posterior tables were cauterized. The left sternal table was then gently retracted and electrocautery was used to access the left pleural space and fully mobilized the left sternal table. The right sternal table was then mobilized in a similar fashion.
The sternal retractor was then placed. Dissection was then carried out along the diaphragmatic surface and adhesions were released with a combination of electrocautery and predominantly sharp dissection. The dissection was carried around the free wall the right atrium and stay sutures were placed in the pericardium to assist with retraction and visualization. Once the free wall the right atrium was released, dissection was carried up the ascending aorta. Once the ascending aorta was fully exposed, and epiaortic ultrasound was then used to evaluate the ascending aorta with findings as described above. The patient was heparinized and ACT was found to be therapeutic for the procedure. A total of 1 hour was spent performing lysis of adhesions.
The aorta was then cannulated with an 18 French cannula. Bicaval cannulation was performed using a 32 French cannula within the SVC and a 34 French cannula within the IVC. Upon cannulating the SVC, intermittent capture of the temporary atrial pacing wire was noted. It was suspected that the wire had come loose once the SVC cannula was placed. Shortly after cannulating the IVC, there was complete loss of temporary pacing. The patient was then placed on full bypass and systemically cooled to 32 °C.
After placing the heart on full bypass, further takedown of adhesions was performed to free up the anterior heart. Once this was completed, the superior and inferior vena cava were dissected out and umbilical tapes were placed for future isolation. An antegrade cardioplegia vent was placed in the ascending aorta. The cross-clamp was then placed and cold sanguinous antegrade cardioplegia was delivered to achieve full diastolic cardiac arrest. Temperature probe was placed in the septum and ice was placed over the right ventricle.
The superior and inferior vena cava were then snared. A direct left atriotomy to Waterston's groove was then performed and self-retaining retractors were then placed to expose the prosthetic mitral valve. Once adequate visualization was achieved, a 15 blade scalpel was used to dissect out the prosthetic valve from the endocardium. All previous titanium clips were removed and Metzenbaums were also used to release the prosthetic valve from the mitral annulus. The mitral valve was then removed and inspected. There was a small to moderate size vegetation on mitral valve leaflet. This leaflet was excised and submitted for routine, AFB, and fungal cultures. The remainder of the prosthetic valve was submitted to pathology.
Betadine was then placed around the annulus of the mitral valve. At this point, the self-retaining doctors were removed and the heart was gently retracted to expose the lateral portion of the left ventricle. At this time, the epicardial leads with serial numbers and serial # were placed on the left ventricle. One was positioned closer to the base and approximately a centimeter and 1/2 to 2 cm away, the second lead was placed at mid ventricle. It should be noted that coronary ultrasound was used to ensure there was no coronaries within the chosen placement region for the leads.
The heart was then dropped back into the pericardial well and the self-retaining retractors were then replaced to expose the mitral annulus. 2-0 pledgeted Ethibond sutures were then placed circumferentially around the mitral annulus in an everting fashion. The mitral annulus was sized to a 25 mm mosaic bioprosthetic valve. The sutures were placed through the sewing cuff of the valve and the valve was parachuted into the supra annular position. The valve was then secured using the cor-knot device. The patient was then systemically rewarmed.
The valve was tested with no obvious evidence of paravalvular leaks. The valve appeared competent. The left atriotomy was then closed using 4-0 Prolene in a running fashion. The snares were released and de-airing maneuvers were performed. The patient was then placed in steep Trendelenburg and de-airing maneuvers were performed a second time. The cross-clamp was then removed. Given the patient is in complete heart block and we lost the temporary atrial lead, ventricular pacing wires were placed on the right ventricle by the level of the skin. The heart was paced at 90 bpm. Lungs were ventilated. The heart was then weaned from bypass without difficulty. Final TEE was performed with findings as described above. Once completed, protamine was delivered to reverse the effects of heparin. The heart was decannulated and all cannulation sites were oversewn with 4-0 Prolene. Temporary atrial pacing wires were also placed on the free wall the right atrium and brought up to the level of the skin.
Once hemostasis was achieved, the retractor was removed. A small incision was made in the right subclavicular region using a 15 blade scalpel. This incision measured approximately 2 cm in size. The left ventricular epicardial leads were then tunneled through the right pleural space and positioned in the subcutaneous tissue beneath the right clavicle. This incision was closed with 2-0 Vicryl and a running 4-0 Monocryl for subcuticular closure. 28 French angled chest tubes were placed in bilateral pleural cavities. A third 28 French angled chest tube was placed along the diaphragm. A 32 French straight chest tube was placed in the mediastinum. The sternum was reapproximated with #7 wires. At the mid sternal body, a square plate was placed and secured with 14 mm anchoring screws x4. The superior abdominal fascia was reapproximated with 0 Ethibond. Soft tissues were reapproximated with 0 Vicryl. The skin was closed with 4-0 Monocryl in a running subcuticular manner. Dermabond was placed over the wounds.
At the initial portion of the procedure, the patient's left pacemaker pocket dressing was removed and appeared to have a fair amount of purulent material. Decision was made to reexplore the left pacemaker pocket. A small stab incision was made and extended approximately 2 cm. Fortunately, there was no further evidence of purulent drainage within the port pocket. It was reapproximated with interrupted 3-0 Prolene in a vertical mattress fashion.
2. Placement of left ventricular epicardial lead x2 with creation of a right subclavicular port pocket and tunneling for future use
3. Lysis of pericardial adhesions
4. Removal of sternal wires x10
5. TEE
6. Epiaortic ultrasound with visualization and interpretation
7. Rigid internal fixation of the sternum
8. Cardiopulmonary bypass with mild hypothermia
9. Limited reexploration of left pacemaker pocket
33430
33530
33202
76998 26
Indication:
80-year-old male presenting with fatigue, weakness, weight loss and found to have recurrent prosthetic mitral valve endocarditis as well as pacemaker lead infection. His mitral valve was originally replaced in 2012. He underwent placement of a pacemaker in 2014 and is fully pacemaker dependent. His most recent echo shows pacemaker lead vegetation as well as small vegetation on the bioprosthetic mitral valve. He has undergone pacemaker removal with laser lead extraction. He presents today for redo mitral valve replacement for prosthetic valve endocarditis.
Epiaortic ultrasound:
-There is no intramural or intraluminal disease that alter cannulation or cross clamp strategies. He had some scattered posterior calcifications which were identified on preoperative CT scan. No aneurysm was identified. Image was saved for permanent records.
Other intraoperative findings:
-Extensive adhesions involving the diaphragmatic surface, free wall the right ventricle, right atrium, and ascending aorta.
-Loss of temporary pacing via right IJ temporary atrial wire just prior to patient going on pump. Patient did have some intrinsic heartbeats that took over for a few seconds prior to initiation of cardiopulmonary bypass.
-Mitral valve was excised and had a small vegetation on one of the leaflets. This was submitted for routine, AFB, and fungal cultures. The remaining portions of the valve and leaflets were submitted to pathology.
-Mean gradient of new prosthetic valve: Less than 5 mmHg
-Epicardial leads: Serial #308086 with threshold of 1 V at 1 ms. R waves of 12 ms and 610 ohms. The epicardial lead with serial # had a threshold of 0.5 V at 1 ms. R waves at 9 mV and 553 ohms.
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 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.
Once pre-bypass TEE was performed by Dr. , midline sternal incision was made. The deep dermis and subcutaneous tissues were divided with electrocautery. The underlying sternal wires were identified. A total of 10 sternal wires were then cut and removed. Once this was completed, the redo oscillating saw was then used to transect the anterior table of the sternum. Bone hooks were used to elevate the xiphoid. The posterior table was then divided using the redo saw and reentry was completed safely. Using electrocautery, the anterior and posterior tables were cauterized. The left sternal table was then gently retracted and electrocautery was used to access the left pleural space and fully mobilized the left sternal table. The right sternal table was then mobilized in a similar fashion.
The sternal retractor was then placed. Dissection was then carried out along the diaphragmatic surface and adhesions were released with a combination of electrocautery and predominantly sharp dissection. The dissection was carried around the free wall the right atrium and stay sutures were placed in the pericardium to assist with retraction and visualization. Once the free wall the right atrium was released, dissection was carried up the ascending aorta. Once the ascending aorta was fully exposed, and epiaortic ultrasound was then used to evaluate the ascending aorta with findings as described above. The patient was heparinized and ACT was found to be therapeutic for the procedure. A total of 1 hour was spent performing lysis of adhesions.
The aorta was then cannulated with an 18 French cannula. Bicaval cannulation was performed using a 32 French cannula within the SVC and a 34 French cannula within the IVC. Upon cannulating the SVC, intermittent capture of the temporary atrial pacing wire was noted. It was suspected that the wire had come loose once the SVC cannula was placed. Shortly after cannulating the IVC, there was complete loss of temporary pacing. The patient was then placed on full bypass and systemically cooled to 32 °C.
After placing the heart on full bypass, further takedown of adhesions was performed to free up the anterior heart. Once this was completed, the superior and inferior vena cava were dissected out and umbilical tapes were placed for future isolation. An antegrade cardioplegia vent was placed in the ascending aorta. The cross-clamp was then placed and cold sanguinous antegrade cardioplegia was delivered to achieve full diastolic cardiac arrest. Temperature probe was placed in the septum and ice was placed over the right ventricle.
The superior and inferior vena cava were then snared. A direct left atriotomy to Waterston's groove was then performed and self-retaining retractors were then placed to expose the prosthetic mitral valve. Once adequate visualization was achieved, a 15 blade scalpel was used to dissect out the prosthetic valve from the endocardium. All previous titanium clips were removed and Metzenbaums were also used to release the prosthetic valve from the mitral annulus. The mitral valve was then removed and inspected. There was a small to moderate size vegetation on mitral valve leaflet. This leaflet was excised and submitted for routine, AFB, and fungal cultures. The remainder of the prosthetic valve was submitted to pathology.
Betadine was then placed around the annulus of the mitral valve. At this point, the self-retaining doctors were removed and the heart was gently retracted to expose the lateral portion of the left ventricle. At this time, the epicardial leads with serial numbers and serial # were placed on the left ventricle. One was positioned closer to the base and approximately a centimeter and 1/2 to 2 cm away, the second lead was placed at mid ventricle. It should be noted that coronary ultrasound was used to ensure there was no coronaries within the chosen placement region for the leads.
The heart was then dropped back into the pericardial well and the self-retaining retractors were then replaced to expose the mitral annulus. 2-0 pledgeted Ethibond sutures were then placed circumferentially around the mitral annulus in an everting fashion. The mitral annulus was sized to a 25 mm mosaic bioprosthetic valve. The sutures were placed through the sewing cuff of the valve and the valve was parachuted into the supra annular position. The valve was then secured using the cor-knot device. The patient was then systemically rewarmed.
The valve was tested with no obvious evidence of paravalvular leaks. The valve appeared competent. The left atriotomy was then closed using 4-0 Prolene in a running fashion. The snares were released and de-airing maneuvers were performed. The patient was then placed in steep Trendelenburg and de-airing maneuvers were performed a second time. The cross-clamp was then removed. Given the patient is in complete heart block and we lost the temporary atrial lead, ventricular pacing wires were placed on the right ventricle by the level of the skin. The heart was paced at 90 bpm. Lungs were ventilated. The heart was then weaned from bypass without difficulty. Final TEE was performed with findings as described above. Once completed, protamine was delivered to reverse the effects of heparin. The heart was decannulated and all cannulation sites were oversewn with 4-0 Prolene. Temporary atrial pacing wires were also placed on the free wall the right atrium and brought up to the level of the skin.
Once hemostasis was achieved, the retractor was removed. A small incision was made in the right subclavicular region using a 15 blade scalpel. This incision measured approximately 2 cm in size. The left ventricular epicardial leads were then tunneled through the right pleural space and positioned in the subcutaneous tissue beneath the right clavicle. This incision was closed with 2-0 Vicryl and a running 4-0 Monocryl for subcuticular closure. 28 French angled chest tubes were placed in bilateral pleural cavities. A third 28 French angled chest tube was placed along the diaphragm. A 32 French straight chest tube was placed in the mediastinum. The sternum was reapproximated with #7 wires. At the mid sternal body, a square plate was placed and secured with 14 mm anchoring screws x4. The superior abdominal fascia was reapproximated with 0 Ethibond. Soft tissues were reapproximated with 0 Vicryl. The skin was closed with 4-0 Monocryl in a running subcuticular manner. Dermabond was placed over the wounds.
At the initial portion of the procedure, the patient's left pacemaker pocket dressing was removed and appeared to have a fair amount of purulent material. Decision was made to reexplore the left pacemaker pocket. A small stab incision was made and extended approximately 2 cm. Fortunately, there was no further evidence of purulent drainage within the port pocket. It was reapproximated with interrupted 3-0 Prolene in a vertical mattress fashion.