DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Severe aortic insufficiency.
2. Moderate to severe mitral regurgitation.
3. Left ventricular hypertrophy.
4. Left ventricular enlargement.
5. Congestive heart failure.
POSTOPERATIVE DIAGNOSES:
1. Severe aortic insufficiency.
2. Moderate to severe mitral regurgitation.
3. Left ventricular hypertrophy.
4. Left ventricular enlargement.
5. Congestive heart failure.
OPERATIONS PERFORMED:
SURGEON: John Doe, MD
ASSISTANT SURGEON: Jane Doe, MD
ANESTHESIA: General anesthesia with single-lumen tube endotracheal intubation was used.
COMPLICATIONS: Death.
SPECIMEN SENT: The body was referred to the medical examiner's office.
ESTIMATED BLOOD LOSS: Massive.
INDICATIONS: The patient was a (XX)-year-old woman known for chronic severe aortic insufficiency as well as mitral regurgitation, who had had multiple previous admissions for congestive heart failure. Cardiac catheterization showed severe aortic insufficiency, moderate tricuspid regurgitation, and moderate pulmonary hypertension with an end-diastolic pressure of 33 to 35 and pulmonary arterial pressures of 53/25. On admission, her brain natriuretic peptide was over 2400. She was deemed a candidate for surgery and was brought to the operating room with a plan for aortic valve replacement. Given that her mitral valve was normal but with dilated annulus, an annuloplasty was planned as well.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and positioned supine. Monitoring lines and leads were placed including temperature probe Foley catheter, radial arterial line, right internal jugular Cordis with Swan-Ganz catheter and transesophageal echo probe following the induction of general anesthesia with single-lumen tube endotracheal intubation. A median sternotomy was performed in standard fashion with scalpel to incise the skin followed by use of cautery to dissect through the subcutaneous tissue. Ostene, bone wax, tourniquet was used for hemostasis. The pericardium was opened in the midline, suspended circumferentially. The heart was a dilated hypertrophied heart, was quite large. The aorta and aortic root appeared to be normal in caliber. The left atrium was enlarged. The patient was heparinized and placed on ascending aortic and bicaval cannulation. The patient was put on cardiopulmonary bypass and cooled down to a temperature of 24 degrees.
With the aortic insufficiency, it was impossible to provide root cardioplegia. A cross-clamp was applied. The aorta was then opened transversely with a hockey stick incision and cardioplegia was instilled directly into the coronary ostia. Cold blood cardioplegia was used. Diastolic arrest with cardioplegic induction was prompt. Following administration of full induction dose, retrograde cardioplegia was provided. Slush was placed on the right ventricle. The left atrium was opened. Traction sutures were placed. The mitral valve was exposed. The heart was very large and thickened and made exposure of the anterior portion of the annulus challenging. Nonetheless, 11 pledgeted 2-0 Ethibond sutures were placed and passed through the annulus of a size 34 Physio ring. The annulus could have easily accommodated a size 40, the 34 therefore represented a downsizing, which was the desired effect.
Leaflet showed competency with static testing. The aortic valve was then excised with Metzenbaum scissors. Pledgeted commissural sutures were placed of 2-0 Ethibond. Additional 11 pledgeted sutures were then placed and passed through the sewing ring of a size 23 St. Jude Medical mechanical aortic valve. The pledgets had been oriented ventricularly. The valve was then secured in place. Leaflet motion was verified and found to be appropriate. It should be noted that throughout the annuloplasty and the valve implantation, antegrade cardioplegia was administered into the left main and right coronary ostia respectively every 20 minutes. The aortotomy was closed with a continuous running suture of 4-0 Prolene in two layers. Prior to this, the left atriotomy had been closed with a continuous running suture of 4-0 Prolene in two layers. These were both nonpledgeted sutures.
The patient was positioned head down. De-airing maneuvers were performed including a right superior pulmonary vein vent and an aortic root vent. The cross-clamp was removed and rewarming, which had been initiated with the implantation of the aortic valve, was continued. The patient was severely obese; therefore, rewarming was prolonged. At approximately 33 degrees, the heart began to fibrillate. Multiple shocks of 30 and then 50 joules were required as well as the administration of lidocaine and amiodarone. After approximately 20 minutes, the patient did assume a normal sinus rhythm. Cardiac output was very low. Dobutamine, epinephrine, Levophed and milrinone drips were instituted. Nonetheless, the blood pressure remained low, and the cardiac output remained very borderline.
Echocardiographic evaluation of the heart showed a functioning aortic valve that was competent, but continued regurgitation of the mitral valve. That was moderate to severe and was as bad as preoperatively. Blood pressures were in the 50s to 60s and was refractory to volume, pressors and inotropes. Cardiology was consulted and the opinion was rendered that the mitral regurgitation needed to be corrected. Prior to this consultation, however, an intra-aortic balloon pump had been placed. The attempt on the right leg, which is a former catheterization site, was unsuccessful. Therefore, access was gained on the left side and a balloon pump was introduced. Despite the balloon pump support, the patient's status remained borderline. I considered placing the patient on a ventricular assist device, but this was not currently available. In the patient's current situation, it was not tenable for departure from the OR.
After discussion with Cardiology, I reinstituted cardiopulmonary bypass, rearrested the heart, opened the left atrium and downsized the mitral valve further with a size 28 Cosgrove band. This was done by removing the Physio ring and the associated suture and pledget material and placing 5 simple 2-0 Ethibond sutures in the posterior annulus passing through the Cosgrove band and securing this in place and then closing the left atriotomy and once again weaning the patient from cardiopulmonary bypass. Tepid blood cardioplegia had been administered at 20-minute intervals following the induction dose. The patient's hemodynamic parameters remained unchanged following the second intervention with borderline blood pressure of 50 to 60 systolic and a cardiac index of approximately 1, despite all pharmacologic measures and balloon pump support.
Transesophageal echo now showed a normally functioning prosthetic aortic valve and a mitral valve with the band in place with only trivial mitral regurgitation. As the patient was still responsive, the boluses of epinephrine injected directly into the aortic root. The valvular findings remained consistent even in elevated systolic blood pressure. The patient clearly needed further support. I called Dr. Doe of (XX) Hospital and Dr. Doe advised me on his preferences for the Bio-Medicus centrifugal pump in terms of cannula positioning to facilitate his implantation of a temporary ventricular device once transfer to (XX) Hospital had been completed. He advised direct right atrial venous cannulation, pulmonary arterial cannulation, and left ventricular apical ascending aortic cannulation for the left-sided centrifugal pump. He suggested percutaneous style cannulation. I performed all these measures as directed. The superior vena cava and inferior vena caval cannulas were removed and replaced with a right atrial cannula.
A size 20 French EOPA cannula was placed into the pulmonary artery. A size 20 French EOPA cannulation was placed into the aortic cannulation site and a size 36 French venous cannula was placed into a cruciate incision in the apex of the left ventricle and secured in place with two circumferential pledgeted sutures of 2-0 Ethibond. Bio-Medicus support was instituted but flows remained low and, for the most part, remained at approximately 1 to 2 liters. Flows would improve with volume infusion by Anesthesia. Anesthesia had difficulty infusing adequate volume to maintain the patient's central venous pressure above 20, which seemed to provide better flows for the Bio-Medicus. As Anesthesia did not seem to be able to give fluids quickly enough through the Cordis, a side port was placed into the Bio-Medicus system on the right venous line. An infusion was made directly into the side port.
The patient was severely coagulopathic at this point. The ACTs were running greater than 999, despite no heparin being administered. Copious amounts of blood products had been administered through the course of the day and clotting factors were also administered in massive quantities. Nonetheless, the patient continued to ooze despite my best efforts from every cut surface, and despite the application of multiple pledgeted 4-0 Prolene sutures both in the chest and in the groin incision, where a cut down had been performed, on the right side, to facilitate the failed intra-aortic balloon pump placement. During the course of trying to stabilize the patient, so that she could be transferred to the intensive care unit, the groin incision was closed in layers to better achieve hemostasis using continuous running suture of 2-0 Vicryl in 2 layers followed by closure of the skin with skin staples. However, the patient remained in hemodynamically moribund situation. Bio-Medicus flow peak near 4 liters, which would have provided an adequate cardiac index of 2 for this patient. These indices were not durable, and the patient's CVP would wane. Blood was essentially being drained by the Cell Saver, washed and reintroduced back into the patient by Anesthesia as well as blood products, but the reinfusion was not enough to maintain Bio-Medicus flow.
There was no discrete source of bleeding. We spent several hours trying to support the patient, correct the coagulopathy and support her hemodynamically. Several hours went by, where the heart continued to maintain a spontaneous rhythm and the kidneys continued to produce urine. We had now been in the operating room for 20 hours. We had tried all measures conceivable to support the patient hemodynamically but could not get improvement in flows or in blood pressure. Now, the systolic blood pressure had been in the 30s to 40s for several hours; this with balloon augmentation. The bleeding remained diffuse and substantial. Blood gases did not show acidosis. Cerebral saturation was extremely low and had been for several hours at about 15%. At this time, I felt it was worth to try and transport the patient to the intensive care unit with a sump in place connected to the Cell Saver with a goal of trying to continue the resuscitation in the intensive care unit; although, I strongly felt that after 5 hours of sub 40 systolic blood pressures and very low cerebral oxygenation and now declining urine output, that these gestures were futile. The sternal retractor was removed. All the Bio-Medicus support tubing was brought out into the field inferiorly. A clear plastic sheeting was then anastomosed to the edges of the sternotomy when the patient underwent ventricular fibrillation. The patient expired.
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PREOPERATIVE DIAGNOSES:
1. Severe aortic insufficiency.
2. Moderate to severe mitral regurgitation.
3. Left ventricular hypertrophy.
4. Left ventricular enlargement.
5. Congestive heart failure.
POSTOPERATIVE DIAGNOSES:
1. Severe aortic insufficiency.
2. Moderate to severe mitral regurgitation.
3. Left ventricular hypertrophy.
4. Left ventricular enlargement.
5. Congestive heart failure.
OPERATIONS PERFORMED:
SURGEON: John Doe, MD
ASSISTANT SURGEON: Jane Doe, MD
ANESTHESIA: General anesthesia with single-lumen tube endotracheal intubation was used.
COMPLICATIONS: Death.
SPECIMEN SENT: The body was referred to the medical examiner's office.
ESTIMATED BLOOD LOSS: Massive.
INDICATIONS: The patient was a (XX)-year-old woman known for chronic severe aortic insufficiency as well as mitral regurgitation, who had had multiple previous admissions for congestive heart failure. Cardiac catheterization showed severe aortic insufficiency, moderate tricuspid regurgitation, and moderate pulmonary hypertension with an end-diastolic pressure of 33 to 35 and pulmonary arterial pressures of 53/25. On admission, her brain natriuretic peptide was over 2400. She was deemed a candidate for surgery and was brought to the operating room with a plan for aortic valve replacement. Given that her mitral valve was normal but with dilated annulus, an annuloplasty was planned as well.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and positioned supine. Monitoring lines and leads were placed including temperature probe Foley catheter, radial arterial line, right internal jugular Cordis with Swan-Ganz catheter and transesophageal echo probe following the induction of general anesthesia with single-lumen tube endotracheal intubation. A median sternotomy was performed in standard fashion with scalpel to incise the skin followed by use of cautery to dissect through the subcutaneous tissue. Ostene, bone wax, tourniquet was used for hemostasis. The pericardium was opened in the midline, suspended circumferentially. The heart was a dilated hypertrophied heart, was quite large. The aorta and aortic root appeared to be normal in caliber. The left atrium was enlarged. The patient was heparinized and placed on ascending aortic and bicaval cannulation. The patient was put on cardiopulmonary bypass and cooled down to a temperature of 24 degrees.
With the aortic insufficiency, it was impossible to provide root cardioplegia. A cross-clamp was applied. The aorta was then opened transversely with a hockey stick incision and cardioplegia was instilled directly into the coronary ostia. Cold blood cardioplegia was used. Diastolic arrest with cardioplegic induction was prompt. Following administration of full induction dose, retrograde cardioplegia was provided. Slush was placed on the right ventricle. The left atrium was opened. Traction sutures were placed. The mitral valve was exposed. The heart was very large and thickened and made exposure of the anterior portion of the annulus challenging. Nonetheless, 11 pledgeted 2-0 Ethibond sutures were placed and passed through the annulus of a size 34 Physio ring. The annulus could have easily accommodated a size 40, the 34 therefore represented a downsizing, which was the desired effect.
Leaflet showed competency with static testing. The aortic valve was then excised with Metzenbaum scissors. Pledgeted commissural sutures were placed of 2-0 Ethibond. Additional 11 pledgeted sutures were then placed and passed through the sewing ring of a size 23 St. Jude Medical mechanical aortic valve. The pledgets had been oriented ventricularly. The valve was then secured in place. Leaflet motion was verified and found to be appropriate. It should be noted that throughout the annuloplasty and the valve implantation, antegrade cardioplegia was administered into the left main and right coronary ostia respectively every 20 minutes. The aortotomy was closed with a continuous running suture of 4-0 Prolene in two layers. Prior to this, the left atriotomy had been closed with a continuous running suture of 4-0 Prolene in two layers. These were both nonpledgeted sutures.
The patient was positioned head down. De-airing maneuvers were performed including a right superior pulmonary vein vent and an aortic root vent. The cross-clamp was removed and rewarming, which had been initiated with the implantation of the aortic valve, was continued. The patient was severely obese; therefore, rewarming was prolonged. At approximately 33 degrees, the heart began to fibrillate. Multiple shocks of 30 and then 50 joules were required as well as the administration of lidocaine and amiodarone. After approximately 20 minutes, the patient did assume a normal sinus rhythm. Cardiac output was very low. Dobutamine, epinephrine, Levophed and milrinone drips were instituted. Nonetheless, the blood pressure remained low, and the cardiac output remained very borderline.
Echocardiographic evaluation of the heart showed a functioning aortic valve that was competent, but continued regurgitation of the mitral valve. That was moderate to severe and was as bad as preoperatively. Blood pressures were in the 50s to 60s and was refractory to volume, pressors and inotropes. Cardiology was consulted and the opinion was rendered that the mitral regurgitation needed to be corrected. Prior to this consultation, however, an intra-aortic balloon pump had been placed. The attempt on the right leg, which is a former catheterization site, was unsuccessful. Therefore, access was gained on the left side and a balloon pump was introduced. Despite the balloon pump support, the patient's status remained borderline. I considered placing the patient on a ventricular assist device, but this was not currently available. In the patient's current situation, it was not tenable for departure from the OR.
After discussion with Cardiology, I reinstituted cardiopulmonary bypass, rearrested the heart, opened the left atrium and downsized the mitral valve further with a size 28 Cosgrove band. This was done by removing the Physio ring and the associated suture and pledget material and placing 5 simple 2-0 Ethibond sutures in the posterior annulus passing through the Cosgrove band and securing this in place and then closing the left atriotomy and once again weaning the patient from cardiopulmonary bypass. Tepid blood cardioplegia had been administered at 20-minute intervals following the induction dose. The patient's hemodynamic parameters remained unchanged following the second intervention with borderline blood pressure of 50 to 60 systolic and a cardiac index of approximately 1, despite all pharmacologic measures and balloon pump support.
Transesophageal echo now showed a normally functioning prosthetic aortic valve and a mitral valve with the band in place with only trivial mitral regurgitation. As the patient was still responsive, the boluses of epinephrine injected directly into the aortic root. The valvular findings remained consistent even in elevated systolic blood pressure. The patient clearly needed further support. I called Dr. Doe of (XX) Hospital and Dr. Doe advised me on his preferences for the Bio-Medicus centrifugal pump in terms of cannula positioning to facilitate his implantation of a temporary ventricular device once transfer to (XX) Hospital had been completed. He advised direct right atrial venous cannulation, pulmonary arterial cannulation, and left ventricular apical ascending aortic cannulation for the left-sided centrifugal pump. He suggested percutaneous style cannulation. I performed all these measures as directed. The superior vena cava and inferior vena caval cannulas were removed and replaced with a right atrial cannula.
A size 20 French EOPA cannula was placed into the pulmonary artery. A size 20 French EOPA cannulation was placed into the aortic cannulation site and a size 36 French venous cannula was placed into a cruciate incision in the apex of the left ventricle and secured in place with two circumferential pledgeted sutures of 2-0 Ethibond. Bio-Medicus support was instituted but flows remained low and, for the most part, remained at approximately 1 to 2 liters. Flows would improve with volume infusion by Anesthesia. Anesthesia had difficulty infusing adequate volume to maintain the patient's central venous pressure above 20, which seemed to provide better flows for the Bio-Medicus. As Anesthesia did not seem to be able to give fluids quickly enough through the Cordis, a side port was placed into the Bio-Medicus system on the right venous line. An infusion was made directly into the side port.
The patient was severely coagulopathic at this point. The ACTs were running greater than 999, despite no heparin being administered. Copious amounts of blood products had been administered through the course of the day and clotting factors were also administered in massive quantities. Nonetheless, the patient continued to ooze despite my best efforts from every cut surface, and despite the application of multiple pledgeted 4-0 Prolene sutures both in the chest and in the groin incision, where a cut down had been performed, on the right side, to facilitate the failed intra-aortic balloon pump placement. During the course of trying to stabilize the patient, so that she could be transferred to the intensive care unit, the groin incision was closed in layers to better achieve hemostasis using continuous running suture of 2-0 Vicryl in 2 layers followed by closure of the skin with skin staples. However, the patient remained in hemodynamically moribund situation. Bio-Medicus flow peak near 4 liters, which would have provided an adequate cardiac index of 2 for this patient. These indices were not durable, and the patient's CVP would wane. Blood was essentially being drained by the Cell Saver, washed and reintroduced back into the patient by Anesthesia as well as blood products, but the reinfusion was not enough to maintain Bio-Medicus flow.
There was no discrete source of bleeding. We spent several hours trying to support the patient, correct the coagulopathy and support her hemodynamically. Several hours went by, where the heart continued to maintain a spontaneous rhythm and the kidneys continued to produce urine. We had now been in the operating room for 20 hours. We had tried all measures conceivable to support the patient hemodynamically but could not get improvement in flows or in blood pressure. Now, the systolic blood pressure had been in the 30s to 40s for several hours; this with balloon augmentation. The bleeding remained diffuse and substantial. Blood gases did not show acidosis. Cerebral saturation was extremely low and had been for several hours at about 15%. At this time, I felt it was worth to try and transport the patient to the intensive care unit with a sump in place connected to the Cell Saver with a goal of trying to continue the resuscitation in the intensive care unit; although, I strongly felt that after 5 hours of sub 40 systolic blood pressures and very low cerebral oxygenation and now declining urine output, that these gestures were futile. The sternal retractor was removed. All the Bio-Medicus support tubing was brought out into the field inferiorly. A clear plastic sheeting was then anastomosed to the edges of the sternotomy when the patient underwent ventricular fibrillation. The patient expired.
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