DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Status post surgical revascularization of heart with left internal mammary artery graft, left anterior descending coronary artery and aortocoronary bypass x4. Now, presents with chest pain. CT scan demonstrates type I aortic dissection.
POSTOPERATIVE DIAGNOSIS: Type I aortic dissection involving the ascending aorta.
OPERATION PERFORMED: Type I aortic dissection, resection and reconstruction with 26 mm Hemashield graft and reimplantation of saphenous vein grafts, utilizing cardiopulmonary bypass.
SURGEON: John Doe, MD
DESCRIPTION OF OPERATION: After general endotracheal anesthesia was established, a femoral heart line was placed in the right common femoral artery for hemodynamic monitoring purposes. The patient had the left common femoral artery exposed and vessel loops placed around it. The chest was reopened, sternal wire was removed and the heart was dissected from the adhesions. Systemic heparinization was given through right atrial appendage and cardiopulmonary bypass was established through the femoral artery and the two-stage cannula in the right atrium. The patient was cooled, aortic cross-clamps applied and retrograde cardioplegia was injected as well as antegrade cardioplegia.
With the heart arrested, the aorta was opened and the dissection was found to be just proximal to the area of cannulation and involving vein graft take-off sites. Thus, the aorta was resected and the vein grafts were preserved and the proximal anastomosis was able to be created with an outer rim of Teflon reinforcement and a 26 mm Hemashield graft and 3-0 Prolene suture. This was completed. The anastomosis was tested, felt to be hemostatic and reinforced as needed. Additional cardioplegia was given throughout the procedure. The proximal anastomosis was then constructed just above the sinuses of Valsalva in the coronary artery take-offs, and this was again done with 3-0 Prolene suture with Hemashield graft and Teflon reinforcement. This was checked for hemostasis and additional cardioplegia was given. Antegrade cardioplegia catheter was placed into the graft and then the 3 vein grafts were individually anastomosed to the segment of Hemashield graft utilizing Concept cautery to create the ostomies and then 6-0 Prolene suture to construct the anastomoses.
Warm infusion of cardioplegia was given and the heart returned to sinus rhythm spontaneously, and the patient was ultimately able to be weaned from cardiopulmonary bypass. Total pump time was 75 minutes. Cross-clamp time was 95 minutes. The cannula was removed, the cannula sites were reinforced and protamine was utilized to reverse the effects of heparin. The femoral artery was repaired with 6-0 Prolene suture in a running continuous fashion. The temporary pacing wires were placed into the right ventricle and two 36 French chest tubes were placed. Hemostasis was gained. The patient was stabilized after weaning from cardiopulmonary bypass, hemostasis was retained and the chest was then closed with a #7 sternal wire. There was prior fracture in the sternum on the right side, which was repaired with a lateral sternal wire. The wound and subcutaneous tissues were closed with absorbable suture. The patient was then transferred to the intensive care unit hemodynamically stable, having received blood with the procedure, as well as platelets and fresh frozen plasma, cryoprecipitate. The patient had sinus rhythm, good cardiac output and no active bleeding.