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Center for Minimally Invasive Surgery
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 pressuresFor 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 palpitationsFor 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
Surgeon 1
Surgeon 2Anesthesiologist
Echo Techs
Perfusionist
Scrub Tech 1
Scrub Tech 2
Center for Minimally Invasive Surgery
Anesthesia Workstation
Transesophageal Echocardiograph
Heart-lung Machine
Continue to Video Equipment
Center for Minimally Invasive Surgery
Back to Surgical Equipment
For more information:www.udmercy.edu/crna/agm/02.htm
Center for Minimally Invasive Surgery
Back to Surgical Equipment
For more information:www.med.yale.edu/intmed/cardio/imaging/techniques/echo_tee/index.html
Center for Minimally Invasive Surgery
Back to Surgical Equipment
For more information:www.surgeryencyclopedia.com/Fi-La/Heart-Lung-Machines.html
Center for Minimally Invasive Surgery
45° Laparascope (optional)
Camera Monitors
Center for Minimally Invasive Surgery
Hemoclip appliers + Vascular clamps + Forceps + Needle holders + Handles + Nerve hooks + Penfield Tourniquets Dilators + Spring instruments + Retractors + Defibrillator paddles Mosquitos + Hemostats
Kellys, Tonsils, Kockers, Allis Clamps + Scissors + Sponge sticks Tubing clamps Wire cutter Malleables + Weitlanders Suction tips + Suction tube Tube holder Cross-clamp Sternal wire (needle included)
Click on + for individual instruments
Continue to Procedure Steps
Center for Minimally Invasive Surgery
Small hemoclip appliers Medium hemoclip appliers Short yellow hemoclip appliers
Back to Instruments
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
Back to Instruments
Center for Minimally Invasive Surgery
Adson tissue forceps with teeth Gerald forceps Debakey forceps Scanlon smooth tip forceps Scanlon Debakey fine forceps
Back to Instruments
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
Back to Instruments
Center for Minimally Invasive Surgery
Beaver handle Knife handle
Back to Instruments
Center for Minimally Invasive Surgery
Dandy nerve hook Dull nerve hook Sharp nerve hook Mid tip Janetta right angle hook
Back to Instruments
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
Back to Instruments
Center for Minimally Invasive Surgery
Spring Potts scissor flat handle Spring Potts scissor round handle Small Dietrich bulldog
Back to Instruments
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
Back to Instruments
Center for Minimally Invasive Surgery
CVD mosquito STR mosquito Jacobson mosquito
Back to Instruments
Center for Minimally Invasive Surgery
Jacobs clamp Pennington clamp Right angle clamp Small tubing clamp Medium tubing clamp Peer towel clamps
Back to Instruments
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
Back to Instruments
Center for Minimally Invasive Surgery
1/4” malleable 5/8” malleable 3/8” malleable 1/2” malleable 3/4” malleable 1” malleable
Back to Instruments
Center for Minimally Invasive Surgery
Boss pump suction tip Frazier suction tip Yankauer suction tip
Back to Instruments
Center for Minimally Invasive Surgery
Make sternotomy incision (more)
Place heart on cardiopulmonary bypass (more)
Add cardioplegic agent (more)
Expose and remove aortic valve
Size aortic replacement valve (more)
Expose and remove pulmonic valve
Size pulmonic valve replacement (more)
Attach aortic valve and root replacement to heart (more)
Expose left coronary artery
Expose and trim native aortic root
Attach pulmonary homograft (more)
Attach coronary arteries to aortic root replacement (more)
Attach aortic root replacement to ascending aorta (more)
Take heart off cardiopulmonary bypass (more)
Close (more)
Continue to Post-Operative Care
Center for Minimally Invasive Surgery
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
Back to Procedure Steps
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
Back to Procedure Steps
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
Back to Procedure Steps
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
Back to Procedure Steps
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
Back to Procedure Steps
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) (more) 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
Back to Procedure Steps
Center for Minimally Invasive Surgery
Use pledgetted sutures Run end one of suture through the annulus starting from under the
annulus 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 Tie sutures in place
Back toBentall Steps
(animation)
PledgettNeedle
AnnulusSuture
Center for Minimally Invasive Surgery
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
Back toBentall Steps
Center for Minimally Invasive Surgery
Replacement valves can be biological or mechanical
Back to Procedure Steps
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 valveMechanical 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
Back to Procedure Steps
Center for Minimally Invasive Surgery
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