DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Atherosclerotic occlusive coronary artery disease with proximal disease, right coronary artery system.
2. Progression of rheumatic valvular disease with aortic stenosis, mitral stenosis with insufficiency in each valve.
3. Chronic atrial fibrillation.
4. Status post mitral valve commissurotomy.
5. Left ventricular hypertrophy.
POSTOPERATIVE DIAGNOSES:
1. Atherosclerotic occlusive coronary artery disease with proximal disease, right coronary artery system.
2. Progression of rheumatic valvular disease with aortic stenosis, mitral stenosis with insufficiency in each valve.
3. Chronic atrial fibrillation.
4. Status post mitral valve commissurotomy.
5. Left ventricular hypertrophy.
OPERATION PERFORMED:
1. Transesophageal echocardiogram with interpretation.
2. Redo sternotomy with redo mitral valve replacement.
3. Coronary artery revascularization x1 using the saphenous vein graft from the aorta to the right coronary artery.
4. Aortic valve replacement.
5. Left atrial maze procedure with endocardial ablation using radiofrequency and ligation of left atrial appendage with left atrial reduction procedure.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, PA-C
ANESTHESIA: General endotracheal anesthesia.
INDICATION FOR OPERATION: The patient is a (XX)-year-old gentleman with above-mentioned pathology. We discussed with the patient various options as well as the entirety of this procedure along with its risks and benefits. He consented to the procedure as planned.
DESCRIPTION OF OPERATION AND FINDINGS: The patient was brought to the operating room and placed in the supine position for redo sternotomy with redo mitral valve replacement and TEE. After general endotracheal anesthesia, the patient was prepped and draped in the usual fashion. Median sternotomy was utilized. Saphenous vein grafts were harvested from the lower extremities.
Median sternotomy was performed with oscillating saw. Once we entered the chest, intraoperative transesophageal echocardiogram was evaluated. Both the aortic and mitral valves were essentially where there was no movement and with severe AI and MR as well. The rest of the exam was unremarkable, other than chronic atrial fibrillation with a gigantic left atrium. The left atrium measured approximately 1.5 cm. At that point, we cannulated the aorta and right atrium and went on bypass. The patient was cooled systemically. Attention was then directed to the right coronary artery system. The aorta was cross-clamped. Antegrade and retrograde cardioplegia arrest was obtained. The patient was also cooled systemically.
The right coronary artery was opened up. It was approximately 2 mm. It was anastomosed with a saphenous vein graft with good flow following anastomosis. At that point, left atrium was opened. This is a massive left atrium.
At that point, we took approximately 2 cm coming down to approximately 1 cm width of the posterior left atrial surface. At that point, a radiofrequency ablation was also performed using the Cobra probe system.
We encircled both pulmonary veins as well as went up the mitral valve annulus and up to the left atrial appendage. The left atrial appendage was oversewn from the inside. At that point, we cut out the valve. It was necessary to cut out both anterior and posterior leaflets because the posterior leaflet was nonfunctional as well. Sewed a 27 mm pericardial valve into place. This seated nicely.
At that point, left atrial closure was then done. This was an extensive closure because of the width and extent of the left atrial resection. This was closed with two layers of running 4-0 Prolene suture. Once this completed, vent remained in the left atrium as we then went to the aorta. It was opened in tangential fashion. We cut out the aortic valve, which again was just a circle of calcified fibrotic material. Once this was cut out, now we carefully sewed a 23 mm supra-annular valve using ThermaFix valve in place without any difficulty.
At that point, the aorta was closed in two layers of running 4-0 Prolene suture. Once this was completed, the heart was deaired as the proximal anastomosis of the vein graft was sewn to the ascending aorta. It was done with running 5-0 Prolene suture. Clamp removed, the aorta was deaired, and satisfactory flow was obtained.
The patient was allowed to reperfuse for a brief period of time, was weaned off cardiopulmonary bypass uneventfully. Postoperative echocardiogram revealed good bioprosthetic valve function and aorta and mitral valve. The patient was in atrial ventricular mechanism as he was paced atrioventricularly sequentially.
At that point, adequate hemostasis was obtained. The patient’s chest was closed in the usual fashion with sternotomy wires. The fascia was closed with running Maxon suture, 0 Vicryl was used to close the subcutaneous tissue, 3-0 subcuticular Vicryl was utilized to close the skin. The patient tolerated the redo sternotomy with redo mitral valve replacement and TEE well and was taken to the CVR unit postoperatively in stable condition.
