DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Mitral valve disease, primarily regurgitation.
2. Cardiomyopathy with left ventricular dysfunction.
POSTOPERATIVE DIAGNOSES:
1. Mitral valve disease, primarily regurgitation.
2. Cardiomyopathy with left ventricular dysfunction.
OPERATIONS PERFORMED:
1. Mitral valve repair.
2. Excision of left atrial appendage.
3. Epicardial left ventricular lead implant.
SURGEON: John Doe, MD
SEDATION: General.
SPECIMEN REMOVED: Left atrial appendage.
ESTIMATED BLOOD LOSS: Minimal.
COMPLICATIONS: None.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and positioned supine for mitral valve repair and above procedures. Preoperative intravenous antibiotics were given. Routine preparations were made including a peripheral arterial line, as well as a pulmonary artery catheter demonstrating normal pulmonary artery pressures. Induction of general anesthetic was well tolerated. Oral endotracheal tube was placed without difficulty.
Under sterile prep and drape, a mid sternotomy was performed. The pericardium was opened. The ascending aorta was without palpable plaques. Sinus rhythm was present. Contractility of the right heart was good.
A transesophageal echo probe had been introduced, which demonstrated left ventricular dysfunction with global hypokinesis and an ejection fraction of less than 35%. Examination of the mitral valve demonstrated prolapse of the anterior leaflet with no restriction of the posterior leaflet as previously thought. Regurgitant jet was along the entire area of coaptation, moderate, with a more significant pronounced jet at the A2-A3 junction directed posteriorly.
The patient was placed on cardiopulmonary bypass and cooled to 30 degrees centigrade following a total heparin dose. Antegrade as well as retrograde cold blood cardioplegia technique was employed following application of the aorta cross-clamp. Liberal doses of cardioplegia were delivered thereafter.
Left atrial appendage was excised, no mural thrombus, and sent this specimen to pathology. The excised stump was oversewn flush in a 2-layer fashion. Epicardial bipolar left ventricular lead was screwed in adjacent to the oversewn left atrial appendage stump. A 35 cm lead was taken through the transverse sinus and later tunneled over the pectoral fascia below the left clavicle, exiting the mediastinum to the jugular notch.
Mitral valve was explored through a standard left atrial cardiotomy. Immediately apparent was a billowy, prolapsing anterior leaflet compromising the majority of the surface area of the overall mitral valve. Indeed, a more pronounced prolapse was present at the A2-A3 juncture; however, no chordal fractures were noted.
Testing demonstrated leakage along the entire line of coaptation; however, most pronounced was this previously-described specific area at A2-A3. Anterior leaflet was mildly plicated several millimeters, primarily at the A2-A3 region. A 32 mm annuloplasty ring was sutured in place following careful sizing and suture placement.
Additional saline testing now revealed no regurgitation along the line of coaptation with the exception of the A2-A3 area, which still had slight leakage. Further examination, however, revealed no additional treatment option other than perhaps triangular resection, which I chose not to do for fear of significantly distorting the anterior leaflet.
The left atrial cardiotomy was closed in a 2-layer fashion. Heart was vigorously de-aired, supported on cardiopulmonary bypass until sinus rhythm returned and weaned off cardiopulmonary bypass with no difficulty. Total pump time was 120 minutes. Ischemic cross-clamp time was 90 minutes. Protamine and blood products were given. Hemostasis was obtained.
Re-examination of the transesophageal echo demonstrates trace mitral regurgitation along the entire length of coaptation, other than at A2-A3, which has a 1 to 2+ narrow jet, now directed anteriorly. Pressure was increased to 140 to 150 systolic, with no increase in the mitral regurgitation. Considerable oozing was present, which improved but not stopped with the blood products. Closure of the sternum, however, resulted in hemostasis.
The patient was transferred to the cardiovascular intensive care unit in stable condition.
