Pulmonary valve REPLACEMENT WITH BENTALL/AORTIC VALVE AND ROOT REPLACEMENT

Center for Minimally Invasive Surgery

Physician: Mark D. Plunkett, M.D.

Author: Heather Nolan, BA, AS


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


Chest X-Ray Electrocardiogram Echocardiogram Cardiac Catheterization


Surgeon 1

Surgeon 2Anesthesiologist

Echo Techs

Perfusionist

Scrub Tech 1

Scrub Tech 2


Anesthesia Workstation

Transesophageal Echocardiograph

Heart-lung Machine

Continue to Video Equipment


Back to Surgical Equipment

For more information:www.udmercy.edu/crna/agm/02.htm



For more information:www.med.yale.edu/intmed/cardio/imaging/techniques/echo_tee/index.html



For more information:www.surgeryencyclopedia.com/Fi-La/Heart-Lung-Machines.html


45° Laparascope (optional)

Camera Monitors


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


Small hemoclip appliers Medium hemoclip appliers Short yellow hemoclip appliers

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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

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Adson tissue forceps with teeth Gerald forceps Debakey forceps Scanlon smooth tip forceps Scanlon Debakey fine forceps

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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

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Beaver handle Knife handle

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Dandy nerve hook Dull nerve hook Sharp nerve hook Mid tip Janetta right angle hook

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1.0 dilator 1.5 dilator 2.0 dilator 2.5 dilator 3.0 dilator Joseph hook single prong Aortic arch dilator

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Spring Potts scissor flat handle Spring Potts scissor round handle Small Dietrich bulldog

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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

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CVD mosquito STR mosquito Jacobson mosquito

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Jacobs clamp Pennington clamp Right angle clamp Small tubing clamp Medium tubing clamp Peer towel clamps

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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

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1/4” malleable 5/8” malleable 3/8” malleable 1/2” malleable 3/4” malleable 1” malleable

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Boss pump suction tip Frazier suction tip Yankauer suction tip

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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


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


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



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



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



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



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



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


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


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 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


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



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


Thrombosis Valve malfunction/failure Root replacement malfunction/failure Infection Arrythmia Death

Documents

Pulmonary valve REPLACEMENT WITH BENTALL/AORTIC VALVE AND ROOT REPLACEMENT