TWilliam2019
Guru
any advice thanks in advance:
33025
33611
Procedure:
1. Pericardial window (Subxiphoid)
2. Median sternotomy
3. Repair of right ventricular free wall rupture
4. On-pump cardiopulmonary oxygenator
5. Left femoral artery cutdown
6. Trans-esophageal echocardiography with visualization and interpretation
Indications:
Mrs. who presented to hospital yesterday with altered mental status, sepsis and shock. She subsequently progressed to respiratory failure requiring intubation. Her recent hx is significant for NSTEMI 11 days ago with PCI to to the RCA and PPM placement 4 days following that. Her condition precipitously worsened this morning, requiring multiple inotropes and vasopressors. A bedside echocardiogram revealed a large pericardial effusion with tamponade. She was taken emergently to the operating room for the aforementioned procedures.
Anesthesia:
General
Estimated Blood Loss:
5 mL
Wound Classification:
Clean-contaminated
Findings:
Pre-bypass TEE: The left ventricle had depressed function. There was moderate global hypokinesis. There was severe mitral regurgitation. Right ventricular function was depressed and collapsed. There was no visible tricuspid regurgitation. There was mild aortic insuffiencey and no significant aortic stenosis. There was a large pericardial effusion with tamponade physiology.
Post-bypass TEE: On inotropes, showed vigorous right ventricular function. There was no tricuspid regurgitation. Left ventricular function was improved slightly, estimated to be 35-40%. There was persistent global hypokinesis. The pericardial effusion was confirmed evacuated.
Additional intraoperative findings: Approximately 600ml of bloody pericardial effusion drained upon pericardial window with evidence of continued active bleeding. The pericardial fluid was sent for culture. Upon sternotomy, there was significant epicardial fibrinous deposits. On the RV free wall and at two separate sites straddling the acute margin, were two areas of denuded ischemic myocardium that were actively bleeding. These two areas were repaired with two separate pieces of CorMatrix and fibrillar hemostatic agent.
Specimens:
Pericardial fluid for culture
Procedure Details:
The patient had their history and physical updated prior to the procedure. They were then transferred to the operating suite and placed on the operating table where general anesthesia was affected. Monitoring lines were placed by anesthesia. A surgical time-out was then performed to confirm patient identity as well as the surgery to be performed.
Next, a vertical sub-xiphoid incision was made. Dissection was carried down to the fascia with electrocautery. The abdominal fascia was incised. With my assistant elevating the xiphoid, I continued blunt dissection cephalad until the glistening anterior surface of the pericardium was encountered. The pericardium was grasped with a Kelly clamp, elevated away from the heart and incised sharply. There was a large and obviously bloody pericardial effusion present. Due to concern of a mechanical complication related to her recent MI, the decision was made to convert to a median sternotomy. With my assistant providing finger controlled drainage of the effusion in manner to optimize hemodynamics, I performed a left femoral artery cutdown to establish cardiopulmonary bypass.
Next, an approximate 4cm skin incision was made just inferior to the left inguinal ligament. Dissection was carried down tot he fascia with electrocautery. The fascia was incised, and with sharp dissection, the common femoral artery was identified and encircled with vessel loops. The patient was heparinized and ACT was found be therapeutic for cannulation and cardiopulmonary bypass. The common femoral vein and femoral artery were accessed directly with a 17 Fr arterial cannula and a 25 Fr multistage venous cannula which were de-aired and connected to the extracorporeal circuit. The patient was then placed on full cardiopulmonary bypass.
Next, I performed a midline sternal incision. With my assistant still controlling bleeding from the subxiphoid pericardotomy, I dissected down to the anterior sternal table with electrocautery, which was continued inferiorly into the superior aspect of the previous subxiphoid incision. The sternum was divided in the midline. The pericardium was then opened and teed off along the diaphragm. Stay sutures were placed to create a pericardial well. While on full bypass with vacuum assisted drainage, bleeding was controlled quite well. Next, with my assistant continually providing retraction and suctioning, a thorough and careful inspection of the epicardial surfaces commenced.
There was significant epicardial fibrinous debris across the majority of the right ventricular surface, acute margin of the heart, and the posterior apical septum. This was removed carefully and systematically with DeBakey forceps. On the right ventricular free wall, approximately 2cm cephalad to the apex, on either side of the true acute margin, there were two areas of denuded, cavitated epicardium and exposed myocardium that were actively bleeding when the heart was filled. Given the delicate nature of the surfaces and critical nature of the patient, the decision was made to perform a suture-less repair.
Again, with my assistant providing continual retraction and suctioning, fibrillar hemostatic agent was cut to length and placed within each of the aforementioned myocardial cavities. A single sheet of Cor-Matrix was then divided, and a separate piece applied directly to each of the two areas of epicardium with BioGlu. Direct pressure was held over each of the sites to ensure an adequate seal and exclusion of the ruptured and cavitated areas in question. The heat was then slowly weaned from cardiopulmonary bypass without difficulty. Hemostasis was verified.
Final TEE was performed with findings as described above. Protamine was delivered to reverse the effects of heparin. The left femoral artery and vein were decannulated. The left femoral arteriotomy was repaired primarily with running 6-0 Prolene. A 32 Fr chest tube was placed in the left and right pleural cavities, and two 32 Fr chest tubes were used to drain the mediastinum. Surgical hemostasis was verified.
Next, the sternum was reapproximated with #7 wires. The abdominal fascia was reapproximated with 0-looped PDS. My assistant then re-approximated the soft tissues with 0 Vicryl. Skin was closed with 4-0 Monocryl in a running subcuticular manner. The left femoral artery cutdown site was closed in a similar manner by my assistant. Dermabond was placed over the wounds.
At this stage, the procedure was discontinued. The patient was transferred to the cardiovascular recovery unit in critical condition.
33025
33611
Procedure:
1. Pericardial window (Subxiphoid)
2. Median sternotomy
3. Repair of right ventricular free wall rupture
4. On-pump cardiopulmonary oxygenator
5. Left femoral artery cutdown
6. Trans-esophageal echocardiography with visualization and interpretation
Indications:
Mrs. who presented to hospital yesterday with altered mental status, sepsis and shock. She subsequently progressed to respiratory failure requiring intubation. Her recent hx is significant for NSTEMI 11 days ago with PCI to to the RCA and PPM placement 4 days following that. Her condition precipitously worsened this morning, requiring multiple inotropes and vasopressors. A bedside echocardiogram revealed a large pericardial effusion with tamponade. She was taken emergently to the operating room for the aforementioned procedures.
Anesthesia:
General
Estimated Blood Loss:
5 mL
Wound Classification:
Clean-contaminated
Findings:
Pre-bypass TEE: The left ventricle had depressed function. There was moderate global hypokinesis. There was severe mitral regurgitation. Right ventricular function was depressed and collapsed. There was no visible tricuspid regurgitation. There was mild aortic insuffiencey and no significant aortic stenosis. There was a large pericardial effusion with tamponade physiology.
Post-bypass TEE: On inotropes, showed vigorous right ventricular function. There was no tricuspid regurgitation. Left ventricular function was improved slightly, estimated to be 35-40%. There was persistent global hypokinesis. The pericardial effusion was confirmed evacuated.
Additional intraoperative findings: Approximately 600ml of bloody pericardial effusion drained upon pericardial window with evidence of continued active bleeding. The pericardial fluid was sent for culture. Upon sternotomy, there was significant epicardial fibrinous deposits. On the RV free wall and at two separate sites straddling the acute margin, were two areas of denuded ischemic myocardium that were actively bleeding. These two areas were repaired with two separate pieces of CorMatrix and fibrillar hemostatic agent.
Specimens:
Pericardial fluid for culture
Procedure Details:
The patient had their history and physical updated prior to the procedure. They were then transferred to the operating suite and placed on the operating table where general anesthesia was affected. Monitoring lines were placed by anesthesia. A surgical time-out was then performed to confirm patient identity as well as the surgery to be performed.
Next, a vertical sub-xiphoid incision was made. Dissection was carried down to the fascia with electrocautery. The abdominal fascia was incised. With my assistant elevating the xiphoid, I continued blunt dissection cephalad until the glistening anterior surface of the pericardium was encountered. The pericardium was grasped with a Kelly clamp, elevated away from the heart and incised sharply. There was a large and obviously bloody pericardial effusion present. Due to concern of a mechanical complication related to her recent MI, the decision was made to convert to a median sternotomy. With my assistant providing finger controlled drainage of the effusion in manner to optimize hemodynamics, I performed a left femoral artery cutdown to establish cardiopulmonary bypass.
Next, an approximate 4cm skin incision was made just inferior to the left inguinal ligament. Dissection was carried down tot he fascia with electrocautery. The fascia was incised, and with sharp dissection, the common femoral artery was identified and encircled with vessel loops. The patient was heparinized and ACT was found be therapeutic for cannulation and cardiopulmonary bypass. The common femoral vein and femoral artery were accessed directly with a 17 Fr arterial cannula and a 25 Fr multistage venous cannula which were de-aired and connected to the extracorporeal circuit. The patient was then placed on full cardiopulmonary bypass.
Next, I performed a midline sternal incision. With my assistant still controlling bleeding from the subxiphoid pericardotomy, I dissected down to the anterior sternal table with electrocautery, which was continued inferiorly into the superior aspect of the previous subxiphoid incision. The sternum was divided in the midline. The pericardium was then opened and teed off along the diaphragm. Stay sutures were placed to create a pericardial well. While on full bypass with vacuum assisted drainage, bleeding was controlled quite well. Next, with my assistant continually providing retraction and suctioning, a thorough and careful inspection of the epicardial surfaces commenced.
There was significant epicardial fibrinous debris across the majority of the right ventricular surface, acute margin of the heart, and the posterior apical septum. This was removed carefully and systematically with DeBakey forceps. On the right ventricular free wall, approximately 2cm cephalad to the apex, on either side of the true acute margin, there were two areas of denuded, cavitated epicardium and exposed myocardium that were actively bleeding when the heart was filled. Given the delicate nature of the surfaces and critical nature of the patient, the decision was made to perform a suture-less repair.
Again, with my assistant providing continual retraction and suctioning, fibrillar hemostatic agent was cut to length and placed within each of the aforementioned myocardial cavities. A single sheet of Cor-Matrix was then divided, and a separate piece applied directly to each of the two areas of epicardium with BioGlu. Direct pressure was held over each of the sites to ensure an adequate seal and exclusion of the ruptured and cavitated areas in question. The heat was then slowly weaned from cardiopulmonary bypass without difficulty. Hemostasis was verified.
Final TEE was performed with findings as described above. Protamine was delivered to reverse the effects of heparin. The left femoral artery and vein were decannulated. The left femoral arteriotomy was repaired primarily with running 6-0 Prolene. A 32 Fr chest tube was placed in the left and right pleural cavities, and two 32 Fr chest tubes were used to drain the mediastinum. Surgical hemostasis was verified.
Next, the sternum was reapproximated with #7 wires. The abdominal fascia was reapproximated with 0-looped PDS. My assistant then re-approximated the soft tissues with 0 Vicryl. Skin was closed with 4-0 Monocryl in a running subcuticular manner. The left femoral artery cutdown site was closed in a similar manner by my assistant. Dermabond was placed over the wounds.
At this stage, the procedure was discontinued. The patient was transferred to the cardiovascular recovery unit in critical condition.