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9. Biatrial Cox-Maze Ablation for Atrial Fibrillation
Mark J. Kearns, MD and Jamil Bashir, MD
Division of Cardiovascular Surgery, St. Paul’s Hospital
University of British Columbia Vancouver, BC, Canada
Essential Operative Steps
1. Right pulmonary veins bluntly dissected
2. Bipolar radiofrequency clamp device inserted around right pulmonary veins and ablation performed
3. Left pulmonary veins bluntly dissected
4. Clamp device used to ablate left pulmonary veins
5. Small incision at base of right atrial appendage
6. Clamp device used for ablation from atrial incision to superior cavoatrial junction along the atrial free wall
7. Vertical right atriotomy
8. Clamp device for ablation lines from posterior aspect of vertical atriotomy extending along superior and inferior vena
cavae, respectively
9. Cryoablation probe inserted through first (small) atrial incision, to create ablation line connecting the incision to the
tricuspid annulus (above the septal leaflet)
10. Cryoablation probe again used to connect anterior aspect of vertical atriotomy to tricuspid annulus (above the antero-
posterior commissure)
11. Left atrial appendage amputation
12. Clamp device to ablate between amputation site and left superior pulmonary vein
13. Standard left atrial incision
14. Clamp device to create adjoining ablation lines between superior and inferior pulmonary veins, respectively
15. Clamp device oriented from inferior aspect of left atriotomy towards mitral annulus around P2; ablation performed at
this site
16. Cryoablation probe used to extend above ablation line to the mitral annulus, both endocardially, and epicardially
(crossing the coronary sinus)
17. Closure of left atrial appendage amputation site
Potential Complications and Pitfalls
1. Friable atrial tissue, prone to injury
2. Injury to pulmonary arteries and veins
3. Inadequate hemostasis
4. Hemorrhage
5. Blood product transfusion and related adverse effects
6. Injury to conduction tissue and need for permanent pacemaker
7. Prolonged CPB and cross-clamp times
8. Failure to achieve lesion transmurality
9. Procedural failure
Template Dictation
Preoperative Diagnosis: [INDICATION—e.g. symptomatic AF, undergoing other cardiac operations; asymptomatic AF,
undergoing other cardiac operations and where the ablation can be performed with minimal additional risk.]
Postoperative Diagnosis: Same
Procedure(s) Performed: [X] and surgical AF ablation (DETAILS—e.g. cardiac incisions, energy source(s) used, extent of
lesion sets employed, whether testing for exit block was performed, and additional CPB and cross-clamp times required for
the ablation).
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] with a [DURATION] history of [COMPLAINTS—symptoms
accounted for by condition X, in addition to symptom burden associated with AF]. In addition to preoperative
investigations for condition X, include details regarding the type of AF (paroxysmal or persistent), and any past interventions
used to treat it (pharmacologic, cardioversion, electrophysiology ablation attempts).
Description of Procedure: [DETAILS of preparation for procedure X (the primary cardiac surgical indication)]. With the
arterial and bicaval cannulation sutures in place, heparin [UNITS] was administered intravenously. The patient remained in
[RHYTHM] and the absence of left atrial thrombus was confirmed by trans-esophageal echocardiography [for the patient in
AF at the time of surgery, document whether they were converted to normal sinus rhythm for the purpose of testing for exit
block]. The aorta and both cavae were cannulated in standard fashion. The superior and inferior vena cavae were freed
circumferentially, and ensnared with umbilical tapes just distal to both caval cannulation sites. Cardiopulmonary bypass was
then instituted at normothermia.
The right superior and inferior pulmonary veins were dissected circumferentially to allow the passage of a bipolar
radiofrequency clamp device [MANUFACTURER]. The jaws of the clamp were closed around both right-sided veins, and
ablation carried out as indicated by [MANUFACTURER]. The clamp was removed and cleaned with saline-soaked gauze.
Next the left superior and inferior pulmonary veins were identified and dissected circumferentially. The ablation clamp was
carefully positioned around both veins, closed and ablation was performed as previously described. [Document whether exit
block at the pulmonary veins was tested for, to ensure completeness of the ablation]. The patient was then cooled to 34
degrees Celsius, and both caval tapes were snared securely using rubber tourniquets.
A small incision was made at the base of the right atrial appendage and the clamp device was inserted. The clamp was
oriented towards the junction of the right atrium and superior vena cava, along the right atrial free wall. The clamp was closed,
and ablation carried out at this site. A vertical right atriotomy was performed approximately 2cm from the first free wall
ablation. The clamp was then used to perform two ablation lines, orthogonal to the right atriotomy incision, starting from its
base and oriented superiorly and inferiorly along both cavae, respectively. Next, a cryoablation device was inserted through
the small incision at the base of the right atrial appendage. The probe was oriented to create an endocardial line of ablation
from its entry point to the tricuspid annulus (above the septal leaflet). Following copious saline irrigation to remove the
cryoablation probe safely, it was repositioned to join the anterior aspect of the vertical right atriotomy with the tricuspid
annulus above its antero-posterior commissure. An endocardial line of ablation was created at this site, and the probe was
removed as described previously.
Cannulation sutures were placed in the aorta proximal to the arterial cannulation site, and an antegrade cardioplegia/venting
catheter was introduced and secured in place. Cardiopulmonary bypass flows were reduced, and the ascending aorta was
clamped prior to the resumption of full flow. Cold blood cardioplegia [VOLUME] was administered down the antegrade
cannula to achieve complete electro-mechanical cardiac arrest. Once arrest was achieved, the left atrial appendage was
identified and amputated. The bipolar radiofrequency clamp device was introduced through the appendectomy and oriented
towards left superior pulmonary vein. The clamp was closed and a line of ablation was created joining the left atrial
appendage base with the left superior pulmonary vein.
A standard left atrial incision was performed next, and the bipolar clamp device was used to create two adjoining ablation
lines across the superior and inferior pulmonary veins, respectively. From the inferior aspect of the left atriotomy, the clamp
device was used to create a line of ablation oriented towards the mitral annulus, in the region of the P2. A cryoablation probe
was used to fully extend this lesion down to the mitral annulus both endocardially, and epicardially, crossing the coronary
sinus. The site of left atrial appendage amputation was then closed in two layers using 5-0 prolene suture.
[DETAILS of the remainder of the cardiac operation (procedure X), including: closure of cardiac incisions, re-warming,
de-airing, weaning from cardiopulmonary bypass, heparin reversal and hemostasis, drains left in situ, atrial and
ventricular pacing wires, sternal and soft tissue closure, and details regarding patient stability and level of
pharmacologic support at the end of the case].
Instrument, sponge, and needle counts were correct. The patient was transferred to the cardiac surgical intensive care unit in
stable condition.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of the case.
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10. Coronary Artery Bypass Grafting with Cardiopulmonary Bypass
Damien J. LaPar, MD, MSc and Gorav Ailawadi MD
University of Virginia, Charlottesville, VA
Essential Operative Steps
1. Lines and Monitoring
2. General endotracheal anesthesia
3. Intraoperative transesophageal echocardiogram
4. Median sternotomy
5. Conduit choice and LIMA harvest
6. Open pericardium, pericardial well, survey ascending aorta for plaque burden (consider epiaortic ultrasound),
cannulation and proximal anastomosis sites.
7. Systemic heparinization (400 u/kg)
8. Arterial cannulation
9. Venous cannulation
10. Myocardial protection cannula placement (DLP in aortic root, +/-retrograde cannula in coronary sinus)
11. Check ACT (>400 sec)
12. Initiate CPB
13. Aortic cross clamp (reduce CPB flow rate, apply cross clamp, increase CPB flow to 2.0-2.5L/min/m2)
14. Antegrade cardioplegia (1200 ml) and topical cooling with ice for cardiac arrest (+/- retrgrograde cardioplegia)
15. Distal anastomoses (start with right side for instillation of cardioplegia down completed vein graft for better right
heart myocardial protection).
16. Proximal anastomoses
17. Antegrade warm blood cardioplegia “hot shot” administration for rewarming
18. Remove aortic cross clamp
19. Check for hemostasis
20. Arterial and ventricular pacer wire placement
21. Chest tube placement
22. Wean from CPB
23. Venous decannulation
24. Protamine administration for heparin reversal (test dose first)
25. Aortic decannulation
26. Assess hemostasis
27. Sternotomy closure
Potential Complications and Pitfalls
1. Stay midline during sternotomy
2. Avoid injury to innominate vein while making pericardial well
3. Avoid IMA injury
4. Cannulation catastrophe (Aortic dissection/ bleeding, Right atrial tear)
5. Poor choice of location of aortic cannula/ crossclamp (leading to stroke)
6. Insufficient myocardial protection and cardiac arrest (cross clamp not across, aortic insufficiency, insufficient venous
drainage)
7. Coronary sinus injury with retrograde cardioplegia cannulation
8. Difficulty finding coronary arteries, including intramyocardial vessels
9. Injury to coronary artery/ posterior wall while opening coronaries
10. Opening coronary proximal to lesion
11. Kinking of bypass grafts and/or insufficient graft length resulting in tension of graft
12. Improper deairing prior to removal of aortic root vent
13. Bleeding from distal anastomoses
14. Inadequate control of hemostasis prior to sternal closure/ bleeding from cannulation sites.
Template Dictation
Preoperative Diagnosis: [INDICATION – e.g. Unstable angina, 90% stenosis LAD, 80% proximal PDA]
Postoperative Diagnosis: Same
Procedure(s) Performed: Coronary artery bypass grafting (DETAILS – e.g. LIMA to LAD, SVG to PDA)
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
EBL: [ml]
Products: [FFP/Platelets/PRBCs]
CPB Time: [Minutes]
Aortic Cross Clamp Time: [Minutes]
Indication(s) for Procedure: [AGE] year old [GENDER] with [DURATION] history of [COMPLAINT – e.g. increasingly
worse chest pain and shortness of breath]. Preoperative coronary catheterization reveals [FINDINGS - e.g. 90% stenosis of
LAD and 80% stenosis of proximal PDA with estimated ejection fraction of 50-55%].
Description of Procedure: The patient was taken to the operating room on [DATE]. The patient’s identity and planned
procedure verified, and the patient was placed on the operating room table in the supine position. General anesthesia was
obtained. A right internal jugular central venous line and pulmonary artery catheter and radial arterial line were inserted.
Preoperative transesophageal echocardiogram was then performed to evaluate cardiac function and valve function. We then
proceeded to prep and drape the chest, abdomen, groins, and lower extremities in sterile fashion. A time out was performed.
Median sternotomy was then performed. Simultaneous to this, a right lower extremity endoscopic saphenous vein harvest was
performed, performed by physician's assistant. After performing the sternotomy, we then proceeded to harvest the left internal
mammary artery in a pedicled fashion. Once dissected, 5000 units of heparin were administered prior to distal division.
Hemostasis of the LIMA bed was confirmed. Following harvest of the LIMA, the IMA retractor was removed and a
sternotomy retractor placed. After identification of the innominate vein, the pericardium was opened and a pericardial well
was created. The aortic cannulation sutures were then placed in the ascending aorta below the level of the innominate artery.
The right atrial cannulation sutures were then placed within the right atrium. A total of [UNITS] of systemic heparin was
administered. The aortic cannula was then inserted, secured and de-aired. Venous cannula was then placed and secured in the
right atrium. A retrograde cannula was placed through the right atrium. A DLP vent was then inserted into the ascending aorta
for administration of antegrade cardioplegia. The aortic cross-clamp was placed. Antegrade cardioplegia was administered
and there was rapid arrest of the heart followed by retrograde cardioplegia. Ice was applied to the heart.
After administering [BLANK] mL of cardioplegia, a suitable site on the [TARG ET – e.g. posterior descending coronary
artery] was located. Using a #15C blade, the artery was opened. A saphenous vein graft was trimmed, splatulated and a
running #7-0 Prolene suture was used to create an end-to-side anastomosis. Antegrade cardioplegia was then administered
through the SVG and hemostasis and flow through the graft was confirmed. A suitable site on the [TARGET – e.g. left
anterior descending coronary artery] was identified along the mid portion. Using a #15C scalpel blade, the artery artery
was opened. The LIMA was then trimmed to an appropriate length and spatulated. A bulldog was placed on the LIMA. We
then performed the distal LIMA anastomosis using running #7-0 Prolene in an end-to-side fashion. We then tested the
anastomosis by removing the bulldog clamp to confirm patency of the graft and hemostasis. An adequate length of the
[LEFT/RIGHT] sided saphenous vein graft to the PDA was then assessed by briefly filling the heart and measuring its length
to the aortic root. The vein was trimmed proximally and spatulated. The heart was then drained, and the site for proximal
anastomosis was selected. A #11 blade was used to create an aortotomy and an aortic punch was then used to enlarge the
aortotomy, and the proximal anastomosis was completed using running #6-0 Prolene.
Once the proximal anastomosis was complete, hot shot cardioplegia was administered and the patient was rewarmed. The
bulldog was removed from the LIMA. The aortic cross-clamp was then removed. A total of [NUMBER] chest tubes were
placed in the [LEFT/RIGHT] pleural space, and [N UM B E R ] chest tubes were placed in the mediastinum.
[ATRIAL/VENTRICULAR] pacing wires were then inserted and tested for appropriate capture. The heart was de-aired,
and the DLP vent was removed and cannulation sutures tied down. The patient was weaned from cardiopulmonary bypass.
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The venous cannula was removed, and the cannulation sutures were tied down. A test dose of protamine was administered
and the patient was monitored for adverse reaction before the protamine was resumed. The aortic cannula was then removed,
and the cannulation sutures tied down. Adequate hemostasis was then confirmed within the mediastinum and left chest wall
LIMA harvest site. The sternum was then closed with a total of [NUMBER] stainless steel sternal wires. The wound was
irrigated with Betadine saline and antibiotic saline. The fascia was then closed with #1 Vicryl suture in running fashion. The
deep dermal layer was then closed with #2- 0 Vicryl suture in running fashion. The skin and subcuticular layer was closed
with #3-0 Monocryl in running fashion. The skin of the wound was cleansed with sterile saline and dressed with antibiotic
ointment and a Primapore dressing.
All instrument, sponge and needle counts were confirmed to be correct x 2 at the end of the operation. The patient was
subsequently transferred to the postoperative cardiac surgical intensive care unit in critical condition.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of this procedure.
11. Coronary Artery Bypass Grafting with Mammary and Vein Grafts -
Off Pump
Uthman Aluthman, M.D, and Teresa M. Kieser, MD
Libin Cardiovascular Institute of Alberta, Division of Cardiac Surgery, University of Calgary, Calgary, Alberta, Canada
Essential Operative Steps
1. Lines and Monitoring
2. General endotracheal anesthesia
3. Intraoperative transesophageal echocardiogram
4. Median sternotomy
5. Conduit choice and LIMA harvest
6. Open pericardium, pericardial well, survey ascending aorta for plaque burden (consider epiaortic ultrasound).
7. Systemic heparinization
8. OctoBase retractor, Trendelenberg position of OR table +/-lateral rotation of OR table to expose distal target
without hypotension; placement of posterior pericardial sutures and/or pericardial sling to position/elevate heart for
optimal exposure for distal anastomosis; Octopus tissue stabilizer to stabilize the anastomotic site, possible use of
Starfish heart positioner to aid in exposure of target site and improve hemodynamics during anastomosis completion,
possible placement of temporary atrial +/- ventricular pacing wires to stabilize rhythm and/or to counteract
bradycardia especially if performing RCA distal anastomosis, placement of proximal snare (retracto-tape) on native
coronary artery to control bleeding during performance of distal anastomosis; use of intra-coronary shunt for signs of
ischemia or for better visibility; use of blower-mister for accurate visualization during performance of distal
anastomosis.
9. Distal anastomosis (es)
10. Proximal anastomosis
11. Check for hemostasis
12. Arterial and ventricular pacer wire placement
13. Chest tube placement
14. Protamine administration for heparin reversal (test dose first)
15. Assess hemostasis
16. Sternotomy closure
Potential Complications and Pitfalls
1. Stay midline during sternotomy
2. Avoid injury to innominate vein while making pericardial well
3. Avoid IMA injury
4. Difficulty finding coronary arteries, including intramyocardial vessels
5. Specific to off-pump: during performance of distal anastomosis- signs of ischemia, hypotension, hemodynamic
compromise, and ventricular arrhythmia/fibrillation during performance of distal anastomosis, necessitating urgent
conversion to on-pump CABG; suboptimal bypass requiring revision/redo of bypass
6. Injury to coronary artery/ posterior wall while opening coronaries
7. Opening coronary proximal to lesion
8. Kinking of bypass grafts and/or insufficient graft length resulting in tension of graft
9. Bleeding from distal anastomoses
10. Inadequate control of hemostasis prior to sternal closure/ bleeding from cannulation sites.
Template Dictation
Preoperative Diagnosis: [BLANK]
Post-operative Diagnosis: Same
Procedure(s) Performed: Elective double coronary artery bypass grafting (CABG) off pump, left internal mammary artery
(LIMA) to left anterior descending artery (LAD), Great Saphenous Vein Graft (GSVG) to marginal artery.
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Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [NAME] is a [AGE]-year-old [GENDER] with [DURATION] history of [COMPLAINT].
Preoperative coronary catheterization reveals [BLANK finding]. ECHO intraoperatively [BLANK finding]
Operative Findings: The patient had reasonable LAD and marginal artery to bypass and excellent conduits of left internal
mammary artery and saphenous vein from the left lower leg. Heart function was normal without any regional wall motion
abnormalities seen on the trans-esophageal echo. She/He did have 1 unit of PRBC’s.
Description of Procedure: Under general anesthesia and endotracheal intubation, a right internal jugular central venous line,
pulmonary artery catheter and radial arterial line were inserted. Chest, groins and lower extremities was prepped and draped
in the usual sterile fashion. The chest was opened via midline sternotomy. The left internal mammary artery was taken down
via the skeletonized technique with the use of the Harmonic scalpel and the Bugge retractor. Simultaneous to this, a left lower
extremity greater saphenous vein was harvested by open technique, performed by a physician’s assistant. Once all conduits
were harvested and hemostasis maintained, 300 IU/Kg of heparin were administered achieving ACT around 400.
The Bugge retractor used to harvest the LIMA was exchanged for the Octobase retractor. The patient was placed in deep
Trendelenburg position, and with a heart sling attached to the posterior pericardium 1 cm away from the border of the left
atrium and 2/3 from the inferior vena cava and 1/3 the distance from the left inferior pulmonary vein, the heart was elevated.
The LIMA was brought through the hole in the pericardium. The Octopus tissue stabilizer was used to stabilize the site of the
LIMA to LAD anastomosis. A retracto-tape was placed on the LAD proximal to the location of the anastomosis. LIMA was
trimmed to an appropriate length and spatulated. Using a # 15 scalpel blade, LAD was opened and a 1.5 mm shunt was inserted
into the LAD. A running #7-0 Prolene suture was used to create an end-to-side anastomosis. The systolic blood pressure was
kept above 100 with 0.4 mg norepinephrine and the end-tidal CO2 was carefully monitored to avoid drops of more than 2-3
mmHg. This anastomosis was hemostatic and transit-time flow was used to check the flow, resistance (Pulsatility Index) and
diastolic filling and found to be adequate. Using the previously placed proximal snare to occlude the LAD, we tested for
competitive flow, which there was none because the LAD had a 90% stenosis. The heart was placed in the neutral position and
transit-time flows were re-measured and were found to be good.
The patient was placed deeper in the Trendelenberg position and the OR table was rotated toward the surgeon’s side; the heart
sling was repositioned so as to expose the later wall of the left ventricle. The reversed saphenous vein was gently distended to
check for leaks. The marginal artery was identified and the Octopus tissue stabilizer was used to stabilize the intended
location of the distal anastomosis. A proximal snare and intracoronary shunt was used as for the LIMA-LAD anastomosis, and
the saphenous vein to marginal artery anastomosis was performed using continuous 7.0 Prolene. The heart and patient were
then both placed in neutral position.
The proximal saphenous vein to ascending aorta anastomosis was then completed using the Heartstring device so as to avoid
any clamping of the ascending aorta. The anastomosis was performed using 6-0 Prolene and was hemostatic. Transit-time flow
was then used to measure graft flow, resistance and diastolic filling and found to be adequate.
Protamine was given to reverse the heparin. Both graft flows were checked again with transit-time flow. Blake drains were
placed in the left pleural cavity and in the anterior and posterior mediastinum. Pacing wires were placed in the surface of the
right atrium and right ventricle and tested for appropriate capture.
The sternum was closed with #5 stainless steel sternal wires x 8. The fascia was closed with #0 Ethibond, the subcutaneous
layers with #2-0 Vicryl and the skin with #3-0 Monocryl in running fashion.
All instruments, sponge and needle counts were confirmed to be correct x2 at the end of operation. The patient tolerated the
procedure well and was taken to the cardiovascular intensive care unit in stable condition on low dose Dopamine and IV
nitroglycerin.
The total OR time: [BLANK]
ECHO findings: [BLANK]
Transit time flows were as follows: LIMA to LAD: [BLANK] mL per minute/PI [BLANK]/DF [BLANK%]; with proximal
snare was [BLANK] mL per minute/PI [BLANK]/DF [BLANK%]. Post Protamine: [BLANK] (ml/min)/ PI [BLANK] /DF
[BLANK].
The SVG to Marginal artery: [BLANK] mL per minute/PI [BLANK]/DF [BLANK%]; with proximal snare was [BLANK] mL
per minute/PI [BLANK]/DF [BLANK%]. Post Protamine: [BLANK] (ml/min)/ PI [BLANK] /DF [BLANK]
Dr. [BLANK] was present and scrubbed for [BLANK] elements of this procedure.
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12. Coronary Artery Bypass Grafting + Mitral Valve Repair VS
Replacement
Kenan W Yount MD MBA and Leora T Yarboro MD
University of Virginia, Charlottesville, VA
Essential Operative Steps
1. Lines & monitoring (e.g., large bore central +/- pulmonary artery catheter; arterial)
2. Intraoperative transesophageal echocardiogram (i.e., assess for mechanism)
3. Median sternotomy
4. Conduit harvests (e.g., endoscopic saphenous vein harvest, LIMA harvest)
5. Open pericardium, pericardial well, survey ascending aorta for plaque burden (consider epiaortic ultrasound),
cannulation, proximal anastomosis sites
6. Systemic heparinization
7. Arterial cannulation
8. Bicaval cannulation
9. Myocardial protection and vent placement (DLP in aortic root, retrograde cannulation in coronary sinus)
10. Check ACT
11. Initiate CPB
12. Initial interatrial groove dissection
13. Aortic cross-clamp (reduce CPB flow rate, apply cross-clamp, increase CPB flow)
14. Anterograde +/- retrograde cardioplegia +/- topical cooling for cardiac arrest
15. Distal anastomoses (consider starting with right side for instillation of cardioplegia down completed vein graft for
better right myocardial protection).
16. Interatrial groove dissection and retractor (e.g., Cosgrove) insertion
17. Inspect valve for pathology and mechanism; decide on repair vs. replacement
18. Leaflet excision with chordal sparing (or valve leaflet repair/resection); careful debridement
19. Sutures through annulus and through replacement valve (or annuloplasty ring)
20. Close atriotomy +/- leave left ventricular vent
21. Proximal anastomoses
22. Antegrade warm blood cardioplegia “hot shot” administration for rewarming
23. Remove aortic cross-clamp
24. Check for hemostasis
25. Temporary pacing wire placement
26. Chest tube placement
27. Wean from CPB
28. Venous decannulation
29. Protamine administration for heparin reversal (test dose, first)
30. Aortic decannulation
31. Assess hemostasis
32. Sternotomy closure
Potential Complications and Pitfalls
1. Entry
1. Midline during sternotomy
2. Innominate vein injury while making pericardial well
2. Harvest
1. LIMA injury during harvest
2. Heparinization during LIMA and saphenous harvest
3. Cannulation
1. Aortic dissection with arterial cannula insertion
2. Aortic cannulation and cross-clamp site selection (to avoid stroke)
3. Right atrial or caval tear with bicaval venous cannula insertion
4. Coronary sinus injury with retrograde cannula insertion
4. Protection
1. Inadequate myocardial protection and cardiac arrest (e.g., cross-clamp not across, aortic insufficiency,
insufficient venous drainage)
2. Ordering of bypass grafts
5. Bypass Grafting
1. Difficulty finding coronary arteries (e.g., intramyocardial segments)
2. Posterior injury during opening of coronary arteries
6. Mitral
1. Consider approach (e.g., generally interatrial, but may require transeptal if atria are not enlarged)
2. Decision to repair or replace mitral valve
3. Careful leaflet excision and annular debridement if calcified (e.g., to avoid stroke from embolization, to avoid
risk of AV dissociation)
4. Careful placement and tying of sutures (e.g., to avoid perivavular leak, to avoid injury to surrounding structures)
5. Adequate venting +/- Valsalva to de-air during atriotomy closure
7. Closure & Decannulation
1. Kinking of bypass grafts and/or insufficient graft length resulting in graft tension after completion of proximal
anastomosis
2. Avoid excessive manipulation of the heart (e.g., to prevent AV dissociation—generally why distal bypasses are
completed before mitral in addition to augmenting myocardial protection)
3. Inspecting postoperative TEE for residual regurgitation
4. Improper de-airing prior to vent removal
5. Bleeding from atriotomy site, anastomotic sites, cannulation sites
6. RIMA injury during sternal wire placement
Template Dictation
Preoperative Diagnoses: [INDICATION – e.g. severe mitral regurgitation, coronary artery disease, congestive heart failure]
Postoperative Diagnoses: Same
Procedure(s) Performed:
1. Coronary artery bypass grafting x [NUMBER], [DETAILS – e.g., LIMA to LAD, SVG to PDA
2. Mitral valve [REPAIR/REPLACEMENT] with a [NUMBER] mm [TYPE O F VALVE OR ANNULOPLASTY
RING]
3. [SIDE] endovascular vein harvest
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] with a [DURATION] history of [COMPLAINT – e.g., increasing
worse chest pain and shortness of breath]. [HE/SHE] was found to have severe mitral insufficiency on a recent
echocardiogram and a preoperative coronary catheterization revealed multi-vessel coronary artery disease with [FINDINGS –
e.g., 90% stenosis of LAD and 80% stenosis of the proximal PDA with an estimated ejection fraction of 35%]. After a
discussion of the risks and benefits, the patient was consented for coronary artery bypass grafting with a mitral valve repair
versus replacement; should replacement be necessary, the patient had a stated preference of receiving a
[TISSUE/MECHANICAL] valve.
Description of the Procedure: The patient was correctly identified in the holding area and brought to the operative suite
where [HE/SHE] was placed supine on the operative table. The patient’s identity and planned procedure were verified. After
adequate induction of general anesthesia, the patient was intubated with a single-lumen endotracheal tube. A right internal
jugular central venous line with a pulmonary artery catheter was placed as well as a radial arterial line, Foley catheter, and
transesophageal echocardiogram probe. A preoperative transesophageal echocardiogram was performed to evaluate cardiac
function and valve function. The patient’s chest, abdomen, groins, and lower extremities were then prepped and draped in the
usual sterile fashion. A time-out was completed.
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