DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Wide-open mitral regurgitation.
2. Tricuspid regurgitation.
3. Congestive heart failure.
4. History of pulmonary embolus x2.
5. Respiratory failure on intra-aortic balloon pump.
6. Possible pneumonia.
7. Atrial fibrillation.
POSTOPERATIVE DIAGNOSES:
1. Wide-open mitral regurgitation.
2. Tricuspid regurgitation.
3. Congestive heart failure.
4. History of pulmonary embolus x2.
5. Respiratory failure on intra-aortic balloon pump.
6. Possible pneumonia.
7. Atrial fibrillation.
8. No vegetations on mitral valve.
OPERATION PERFORMED: Urgent mitral valve replacement.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal and extracorporeal circulation and transesophageal echocardiography.
OPERATIVE FINDINGS: The mitral valve annulus was heavily calcified and acutely dilated. It was actually incised to 37, and we had no tissue valve in the hospital big enough to put in there. The only valve we had was actually probably bigger than 37; however, we had a size #37 St. Jude valve, mechanical, which we were able to use without putting too much tension on the annulus. The posterior chordae were fused into a large calcified mass in multiple areas, and also, in several areas, the anterior chordae were attenuated and ruptured. This valve was an unfixable valve in our hands certainly. There was also some tricuspid regurgitation seen at the beginning of the procedure, probably between 2 and 3+.
DESCRIPTION OF OPERATION: The patient was taken to the operating room, and suitable general endotracheal anesthesia was obtained. The patient was prepped and draped as a sterile field from chin to ankles. A midline sternal-splitting incision was made. Pericardium was opened and tagged back. The patient was given 4 mg/kg heparin. The patient was cannulated in the usual fashion. We attempted to put in retrograde cardioplegia; however, we could not get a pressure reading. It is possible that the orifice of the coronary sinus was so large that the balloon could not occlude it.
The patient was placed on extracorporeal circulation, cooled to 32 degrees centigrade, aorta cross-clamped, and 1200 mL of a 40-degree blood potassium cardioplegic solution was instilled on the right side of the aortic cross-clamp until electrical activity was achieved. Thereafter, every 20 or so minutes, we gave the patient another 500-1000 mL of cardioplegia antegrade to maintain electrical activity.
The left atrium was opened. It was a huge left atrium. The right atrium was pretty huge, and the right atrial valve was very thin. We excised the valve, great care being taken to account for pieces of calcium. The #37 mechanical St. Jude in place with interrupted horizontal sutures of 2-0 Dacron and found the valve to be working properly with Q-tips. The left atrium was closed with running 3-0 Prolene, care being taken to perform all the steps to remove air from the heart before cross clamping the patient.
We looked on TEE, and indeed, there was very little air. There was no mitral regurgitation any more. There was a reduced tricuspid regurgitation, probably in the neighborhood of 1 to 2+, and certainly, there was no indication at this time to do anything with the tricuspid valve. The patient was brought down smoothly off the pump, decannulated without incident. Protamine was given to neutralize the heparin. Two mediastinal tubes were placed in the anterior mediastinum, one going in to each chest. One bipolar ventricular wire was placed.
The patient actually came out of bypass in sinus rhythm, had been in atrial fibrillation at the beginning of the procedure. Protamine was given to neutralize the heparin after the patient had been decannulated, and the patient had had high INR, and we gave fresh frozen, and the hemostasis seemed to be relatively good. However, this patient certainly has a congested liver, and we have to watch what happens to his coagulation.
The sternum was closed with interrupted stainless steel wire #6. The presternal fascia was closed with running 0 Prolene. Subcutaneous tissue was thoroughly irrigated with antibiotic solution and closed with running 2-0 Dexon, and the skin was closed with skin clips. The patient’s PA pressures, at the end of the case, were a good deal lower than they had been preoperatively.
