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Operation:
#1. Right carotid artery endarterectomy with Hemashield patch
#2. Aortic valve replacement with 23 mm Intuity rapid deployment bioprosthetic valve
#3. Coronary artery bypass grafting ×1 with reverse saphenous vein graft to the right coronary artery
#4. Ascending aorta reconstruction with Hemashield patch
#5. Endoscopic vein harvest-left leg
#6. Temporary cardiopulmonary bypass with mild systemic hypothermia and cold sanguineous cardioplegia
#7. Transesophageal echocardiography independent interpretation ×2 (pre-bypass and post-bypass )
#8. Doppler ultrasound bypass graft interrogation ×2
#9. Epi-aortic ultrasound
#10. Doppler bypass graft interrogation ×1
#11. Post endarterectomy duplex analysis


Preoperative note:
Patient is a 77 y.o. caucasian male with critical right internal carotid artery stenosis, history of TIA-syncope, severe aortic valve stenosis and multivessel coronary artery disease now being taken to the operating room for high risk operative therapy. STS risk score is 7.64%.

Operative findings:
#1. TEE independent interpretation-pre bypass: The left ventricular size was increased and function wasnormal. The right ventricular size and function was normal. There was trace central mitral valve insufficiency with normal mitral valve leaflets. Aortic valve was a tricuspid valve with no incompetence in the long or short axis views. The atrial septum was intact.
#2. TEE independent interpretation- post bypass: The findings were identical to the pre-bypass independent interpretation.
#3. Operative findings: On opening the pericardium the right ventricle was significantly enlarged and globally hypokinetic. Palpation of the pulmonary arteries revealed normal pulmonary artery pressures. There was severe palpable calcific atherosclerosis involving the midpoint of the ascending aorta anteriorly. The aortic valve was a severely diseased tricuspid valve the right coronary artery was a severely calcified and diseased 2.0 mm vessel. The saphenous vein was a B quality vessel. The left ventricle was significantly enlarged grade 3/6 and hypertrophied grade 3/6. The left ventricle was enlarged grade 3/6 and hypertrophied grade 3/6. The right carotid bifurcation was extremely calcified and diseased extending into the proximal internal carotid artery.Very weak Doppler signals could be found coming beyond the stenosis.
#4. Doppler ultrasound bypass graft interrogation: RCA vein graft mean flow rate 124 mL/m with a PI of 1.0.
#5. Post endarterectomy duplex analysis Doppler velocity meters and centimeters per second are as follows: Common 30/0, bifurcation 32/0, external 40/0,internal 40/0
#6. Epi-aortic ultrasound: The ascending aorta was scanned in transverse and longitudinal planes from the sinotubular junction to the aortic arch. Severe dense calcification involving the midline anterior ascending aorta of the middle third of the ascending aorta. There were no mobile atheromas noted.


Description of operation:
Patient was placed on the operating table in the supine position and adequate general anesthesia was administered monitoring the arterial pressure, CVP with flow track measurements, bladder temperature, and electrocardiogram. A transesophageal echocardiographic probe was placed by anesthesia and findings are described above. The entire right neck, chest, abdomen, and legs were prepped in a sterile manner. BB, PA-C functioned as the first assistant for the right carotid artery endarterectomy providing suctioning, exposure, and following sutures. A skin incision was made following the anterior border of the right neck and deepened down through the platysma. The facial vein was doubly ligated and divided. The common, internal, and external carotid arteries were dissected out. 10,000 units of heparin were administered. A satisfactory ACT greater than 250 seconds the vessels were occluded. The common carotid arteriotomy was performed and extended onto the internal carotid artery beyond the disease endpoint. An indwelling shunt was then placed in the usual manner. The endarterectomy was then performed in the usual standardized manner removing all the obstruction. Following endarterectomy the arteriotomy was closed using a Hemashield platinum patch and running 7-0 Prolene. Before placing the final sutures the shunt was removed flushing sequence was carried out and final sutures were then placed, tied and cut. Forward flow was reestablished. Protamine was administered and hemostasis was obtained. Duplex analysis findings are described above. A sterile sponge was placed over the artery and then a Tegaderm patch was placed over this. BB, PA-C also was responsible for the endoscopic vein harvest from the left leg. A small transverse incision was placed directly over the saphenous vein in the left lower leg and using the Guidant endoscopic vein harvesting device the vein was then mobilized. Individual branches of the vein were divided using the hemo-pro unit. The vein was then doubly ligated divided, excised and prepared on the back table in the usual manner. The wound was closed in layers. A primary median sternotomy was performed and the pericardium was opened and marsupialized. JB, PA-C was first assistant and responsible for assistance with cannulation of the heart, suctioning, providing exposure, and following sutures. Pursestring sutures were placed, heparin was administered, and following satisfactory ACT aortic and right atrial cannulation were effected and cardiopulmonary bypass was established. The aorta was crossclamped and cold sanguinous antegrade cardioplegia was administered and diastolic arrest ensued. Additional myocardial preservation was achieved using retrograde cardioplegia and direct coronary ostial cardioplegia. The usual aortic root aortotomy was performed and the aortic valve was carefully and meticulously excised. Annular debridement was carried out. The right coronary bypass graft was then performed using longitudinal arteriotomy and end to side anastomosis of saphenous vein with running 7-0 Prolene. Hand injection of cardioplegia was satisfactory. The proximal coronary anastomosis was constructed using a 4.0 mm punch and running 6-0 Prolene. This was a technically difficult anastomosis due to the significant calcification which was located in the mid ascending aorta anteriorly. Stay sutures were placed and the aortic root and the aortic annulus was sized to a 23 mm Intuity prosthetic rapid deployment valve. Three guide sutures were placed in the nadir of each sinus based on 120°spacing. The Intuity bioprosthetic valve was prepared on the back table and placed within the delivery holder. It was brought into the wound and the guide sutures were passed accordingly. The valve was then lowered in position and once satisfactory seating was identified guide sutures were tied and cut using the core knot device. The balloon expansion device was inflated to 4.5 atm for 10 seconds. The balloon was then deflated and the delivery system was removed from the operative field. Internal visualization of the valve seating with a dental mirror demonstrated excellent seating of the prosthesis. Rewarming was carried out. The area of the aortotomy near the proximal coronary anastomosis was noted to be torn from a stay suture. Due to the large amount of calcium in the region it was necessary to reconstruct this part of the arteriotomy with a Hemashield patch and running 5-0 Prolene. This resulted in an a satisfactory area which allowed closure of the aortotomy in the usual manner. Volume was infused into the patient and air was evacuated from the left side of the heart and ascending aorta. Throughout the entire open part of the procedure the pericardial well was flooded with carbon dioxide at 10 L/m. Strong suction was then placed in the needle vent and the aortic cross-clamp was released. Spontaneous sinus rhythm ensued. Temporary pacing wires were placed. Following satisfactory rewarming cardiopulmonary bypass was gradually discontinued until satisfactory ejection was occurring and aggressive de-airing maneuvers were carried out in the usual standardized manner under TEE surveillance. Following satisfactory de-airing maneuvers cardiopulmonary bypass was completely discontinued in a gradual manner and satisfactory hemodynamics in rhythm ensued. Protamine was administered and decannulation was effected and hemostasis was obtained. With satisfactory rhythm and hemodynamics and hemostasis the chest was closed in layers. JB, PA-C was responsible for the sternal wound closure. A sterile Dermabond dressing was applied. The right neck incision was closed in layers. JB PA-C was responsible for the neck wound closure. A sterile Dermabond dressing was applied. The patient was then transported to the CVRU in stable hemodynamic condition.

are these correct?
33405
33510 51
35301
33858
76998 26 59
93314 26

THANKS
 
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