Transcript Pulmonary Valve Replacement with Bentall/Aortic Valve and Root
Physician: Mark D. Plunkett, M.D.
Author: Heather Nolan, BA, AS Center for Minimally Invasive Surgery
For Aortic Root Repair/Replacement Aortic root aneurysm Aortic dissection affecting both root and valve Symptoms: cough, diastolic murmur, dysphasia, dyspnea on exertion, fatigue, palpitations, and widened pulse pressures For Aortic Valve Repair/Replacement Aortic valve stenosis Aortic valve insufficiency Aortic regurgitation Symptoms: angina, dizziness, fainting, fatigue, shortness of breath, swelling of ankles and legs, arrhythmia, and palpitations For Pulmonary Valve Repair/Replacement Pulmonary valve stenosis Pulmonary valve insufficiency Pulmonic regurgitation Symptoms: dyspnea, angina, cyanosis, congestive heart failure, fatigue, fluid retention, cough, cardiomegaly, and syncope Center for Minimally Invasive Surgery
Chest X-Ray Electrocardiogram Echocardiogram Cardiac Catheterization Center for Minimally Invasive Surgery
Anesthesiologist Echo Techs Surgeon 2 Scrub Tech 2 Surgeon 1 Scrub Tech 1 Perfusionist Center for Minimally Invasive Surgery
Anesthesia Workstation
Transesophageal Echocardiograph
Heart-lung Machine Center for Minimally Invasive Surgery
For more information: www.udmercy.edu/crna/a gm/02.htm
Center for Minimally Invasive Surgery
For more information: www.med.yale.edu/intmed/cardio/imaging/ techniques/echo_tee/index.html
Center for Minimally Invasive Surgery
For more information: www.surgeryencyclopedia.
com/Fi-La/Heart-Lung Machines.html
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Camera Monitors 45 ° Laparascope (optional) Center for Minimally Invasive Surgery
Click on + for individual instruments
Vascular clamps
Needle holders
Penfield Tourniquets
Defibrillator paddles
Hemostats Kellys, Tonsils, Kockers, Allis
Sponge sticks Tubing clamps Wire cutter
Weitlanders Suction tips
Suction tube Tube holder Cross-clamp Sternal wire (needle included) Center for Minimally Invasive Surgery
Small hemoclip appliers Medium hemoclip appliers Short yellow hemoclip appliers Center for Minimally Invasive Surgery
Left blue titanium vascular clamp Right blue titanium vascular clamp Deborah Castaneda clamp Castaneda anastomosis clamp Derra partial occlusion clamp Cooley derra clamp Debakey anastamosis clamp Debakey general purpose clamp Straight Debakey bulldog clamp Debakey spoon perivascular clamp Debakey multipurpose clamp Debakey acutely curved clamp Angled Debakey Center for Minimally Invasive Surgery
Adson tissue forceps with teeth Gerald forceps Debakey forceps Scanlon smooth tip forceps Scanlon Debakey fine forceps Center for Minimally Invasive Surgery
Castro round handle locking needle holder Non-locking castro round handle needle holder Fine tip Scanlon needle holder Sarot needle holder Creelewood needle holder Small Berry needle holder Center for Minimally Invasive Surgery
Beaver handle Knife handle Center for Minimally Invasive Surgery
Dandy nerve hook Dull nerve hook Sharp nerve hook Mid tip Janetta right angle hook Center for Minimally Invasive Surgery
1.0 dilator 1.5 dilator 2.0 dilator 2.5 dilator 3.0 dilator Joseph hook single prong Aortic arch dilator Center for Minimally Invasive Surgery
Spring Potts scissor flat handle Spring Potts scissor round handle Small Dietrich bulldog Center for Minimally Invasive Surgery
Kirkland retractor ALM retractor Finochetto retractor Morse retractor Chest retractor Ragnell retractor Sharp Senn retractor Short sharp rake Vein retractor Army-Navy retractor Ankenney retractor Touffier retractor Dr. Salley retractor Center for Minimally Invasive Surgery
CVD mosquito STR mosquito Jacobson mosquito Center for Minimally Invasive Surgery
Jacobs clamp Pennington clamp Right angle clamp Small tubing clamp Medium tubing clamp Peer towel clamps Center for Minimally Invasive Surgery
STR Mayo scissors CVD Mayo scissors Metz scissors Curved fine Cooley scissors Curved heavy Cooley scissors Demartel scissors Jamison black handle supercut scissors Straight Mayo Harrington scissors Wire scissors Pump line scissors Center for Minimally Invasive Surgery
1/4” malleable 5/8” malleable 3/8” malleable 1/2” malleable 3/4” malleable 1” malleable Center for Minimally Invasive Surgery
Boss pump suction tip Frazier suction tip Yankauer suction tip Center for Minimally Invasive Surgery
Make sternotomy incision (
Place heart on cardiopulmonary bypass (
) Add cardioplegic agent (
Expose and remove aortic valve Size aortic replacement valve (
) Expose and remove pulmonic valve
Size pulmonic valve replacement ( more )
Attach aortic valve and root replacement to heart (
) Expose left coronary artery Expose and trim native aortic root Attach pulmonary homograft (
Attach coronary arteries to aortic root replacement (
) Attach aortic root replacement to ascending aorta (
Take heart off cardiopulmonary bypass (
Close (
) Center for Minimally Invasive Surgery
Continue to Post-Operative Care
Make incision along sternal midline using scalpel Cauterize any bleeding vessels Use sternal saw to cut sternum Apply bone paste to cut edge of sternum Place sterile towels on cut edge of sternum Use retractors to access surgical area Center for Minimally Invasive Surgery
Put purse string suture into superior vena cava Thread suture through tourniquet and secure with hemostat Cut vein wall Insert bypass cannula into vein Cinch tourniquet and secure with hemostat Repeat above to inferior vena cava Repeat for aorta Attach retrograde cardioplegia Cross-clamp aorta Connect cannulae to bypass tubing Center for Minimally Invasive Surgery
Uncinch tourniquet of superior vena cava Remove cannula while simultaneously tightening purse string sutures Add 6 knots to purse string suture Repeat for inferior vena cava Repeat for aorta Center for Minimally Invasive Surgery
For Antegrade Cardioplegia Once aortic valve is removed, administer cardioplegic agent at the aortic root Repeat approximately every 20-30 minutes For Retrograde Cardioplegia use purse string sutures to place retrograde cannula in coronary sinus Cardioplegic agent is administered continuously Remove cannula, close purse strings, tie off suture Antegrade versus Retrograde Considerations Size of anatomy Length of procedure Access to coronary sinus and aortic root Center for Minimally Invasive Surgery
Replacement valve sizes range from 16-33 mm These sizes are measured as the external diameter of the prosthetic valve with the sewing ring compressed Use a valve sizing tool (pictured) to get optimal size Match the replacement size to the native valve Error on the large side to get the largest possible diameter for maximal blood flow Check valve function prior to placement Center for Minimally Invasive Surgery
Replacement includes valve and root When removing native aorta/aortic root detach the coronary ostia (opening) from the aorta leaving a small rim of aortic tissue (Note: this is deemed the “button”) Size aortic replacement device (valve and root combination) Suture the device to the aortic annulus (fibrous tissue ring surrounding the opening to the aorta) (
) Cut two holes in the root replacement for the coronary ostia using a thermal cutter or blade
Suture the coronary ostia to the root replacement ( more
) Trim the root replacement to size Suture root replacement to native ascending aorta
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Use pledgetted sutures Run end one of suture through the annulus starting from under the annulus (animation) Run end one of suture through device’s sewing ring starting from under the device Repeat with end two so that pledgett is up against underside of annulus Alternate suture colors to allow for easier manipulation and tying of the device to the annulus Push device into the annulus using previously placed suture to guide the device into place Needle Tie sutures in place Pledgett Annulus Center for Minimally Invasive Surgery Suture
Use a teflon strip for reinforcement Place ostia within pre-cut opening in an end-to-side manner Use a running stitch to secure ostia to device Center for Minimally Invasive Surgery
Replacement valves can be biological or mechanical Biological Replacement Valves A homograft, or allograft, comes from a human donor (pictured-in forceps) A xenograft comes from animal tissue Another option for aortic valve replacement is a pulmonary autograft in which the aortic valve is replaced with the patient’s native pulmonary valve Mechanical Replacement Valves Are manmade and come in a variety of designs and materials Biological Versus Mechanical Considerations Biologic valves reduce the risk of associated clots but are not as durable Mechanical valves theoretically will last forever; however, there is an increased risk of clotting on the prostheses which can lead to stroke
Center for Minimally Invasive Surgery
Place external pacemaker leads Check pacemaker leads and pacing Place chest tube drainage cannulae Prepare exposed sternal bone for closure using bone paste and electrocautery Use sternal wires with the attached needle to close the sternum Twist sternal wires together (twist number varies but 3-4 is recommended for optimal strength) Bend exposed metal ends of sternal wire toward sternum Close fascia Close skin
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Connect patient to ventilator Monitor ECG, oxygen saturation, blood pressures, and blood gases Check urinary output and chest tube output Prior to discharge: wean off ventilator, train patient on incentive spirometer, anticoagulation therapy, diet as tolerated, and ambulation Center for Minimally Invasive Surgery
Thrombosis Valve malfunction/failure Root replacement malfunction/failure Infection Arrythmia Death Center for Minimally Invasive Surgery