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The physician assistant performed an endoscopic saphenous vein harvest in the right lower extremity. Concomitantly, a median
sternotomy was performed using a sternal saw. The left internal mammary artery was harvested in a pedicled fashion. Once
dissected, 5000 units of heparin were administered prior to distal division. There was excellent flow after distal division. The
LIMA was wrapped in a lidocaine soaked sponge for use at a later time. Hemostasis of the vascular bed was confirmed. The
mammary retractor was then removed and replaced with a sternal retractor.
After identification of the innominate vein, the pericardium was opened and a pericardial well was fashioned. Aortic
cannulation sutures were placed in the ascending aorta below the level of the innominate artery in preparation for arterial
cannulation. Right atrial cannulation sutures were then placed in the right atrial appendage and the right atrial-IVC junction in
preparation for bicaval venous cannulation. The patient was systemically heparinized with [UNITS] of heparin. The aortic
cannula was then inserted into the ascending aorta, de-aired, and secured. The venous cannulas were then placed through the
right atrial appendage into the SVC and through the right atrial-caval junction into the IVC. A retrograde cannula was then
placed into the coronary sinus without difficulty. A DLP vent was inserted into the ascending aorta. The patient was then
placed on cardiopulmonary bypass. Initial dissection of the interatrial groove was performed. The cross-clamp was applied;
antegrade and retrograde cardioplegia were given with immediate arrest of the heart. Cold topical solution was applied and
cardioplegia was given every 20 minutes for the remainder of the case.
The bypass began with the SVG to PDA anastomosis. The PDA was opened using a #15C scalpel. The anastomosis was
completed distally in an end-to-side fashion using a running #7-0 Prolene. Antegrade cardioplegia was then administered
through the graft, which was found to be patent and hemostatic. The proximal graft was then left free to cardioplegia. A suitable
site on the LAD was identified along its mid-portion. The LIMA graft was then trimmed to the appropriate length and clamped
with a bulldog. The anastomosis was completed in an end-to-side fashion using a running #7-0 Prolene. The bulldog clamp
was removed, and the graft was found to be patent and hemostatic.
To address the mitral valve, the interatrial groove was opened and the left atrium was entered sharply with a #15 blades
scalpel. This incision was then extended with Metzenbaum scissors. Cosgrove retractors were placed to better visualize the
mitral valve. There appeared to be normal valve leaflets but abnormal leaflet tethering in the subvalvular apparatus with
nonviable left ventricular muscle inferiorly. Consequently, the decision was made to replace rather than repair the valve, and
the anterior leaflet was excised while leaving the chordal attachments in place. The valve was then sized and a [SIZE] mm
[TYPE] [TISSUE/MECHANICAL] valve was selected. Sutures were placed through the annulus and brought to the sewing
ring of the valve, which was then tied down. The replacement valve appeared to be well-seated. It was tested and found to be
hemostatic. We therefore closed the atriotomy around the left ventricular vent with a single layer of running #3-0 Prolene, and
the vent was placed to suction to aid in de-airing.
The patient was allowed to rewarm. A site for the proximal bypass graft anastomosis was selected on the aorta. An aortotomy
for the proximal anastomosis of the saphenous vein graft was made with a #11-0 blade scalpel followed by an aortic punch to
enlarge the aortotomy, and the proximal anastomosis was completed using a running #5-0 Prolene.
A hot shot was given, and the cross-clamp was removed. Ventricular pacing wires were then placed and the patient was paced
at 80 beats per minute. Four chest tubes were placed: 2 in the mediastinum and 1 in each pleural space. The follow-up
transesophageal echocardiogram confirmed that there was no residual air in the heart and that the mitral valve had no
perivalvular leak. All vents were then removed, and the patient was subsequently weaned from bypass. The IVC and SVC
cannulas were removed. Protamine was given. The aortic cannula was removed. The cannulation sites were then tied down
and confirmed to be hemostatic. The patient’s sternum was then reapproximated with #6-0 stainless steel wires. We irrigated
the sternum with a solution of Betadine and Ancef. The fascia was closed with a running #1-0 Vicryl followed by a deep
dermal layer of running #2-0 Vicryl. The skin was closed in a running subcuticular fashion using #3-0 Monocryl. Bacitracin
was applied to the incision sites, which were then covered with sterile Primapore dressing.
All instrument, sponge, and needle counts were confirmed to be correct x 2 at the end of the operation. The patient was
transferred to the post-operative unit in critical condition.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of this procedure.
13. Coronary Artery Bypass Grafting with Aortic Valve Replacement
Michelle C. Ellis, MD and Jonathon W. Haft, MD
University of Michigan, Ann Arbor, MI
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, assess ascending aorta for plaque burden (consider epiaortic ultrasound or
alternative cannulation strategy)
7. Systemic heparinization (300u/kg)
8. Arterial cannulation
9. Venous cannulation
10. Cardioplegia cannula placement (antegrade via aortic root, retrograde via coronary sinus)
11. Check ACT (>350sec)
12. Initiate cardiopulmonary bypass
13. Aortic cross clamp
14. Antegrade cardioplegia +/- topical cooling, followed by retrograde cardioplegia
15. Assess and plan distal targets
16. Aortotomy, excision of aortic valve leaflets and debridement of the annulus
17. Choose prosthetic valve and size
18. Irrigate left ventricle and aortic root copiously while giving retrograde cardioplegia
19. Distal coronary anastomoses
20. Place annular sutures and implant valve
21. Close aortotomy
22. Proximal anastomoses
23. Retrograde hot shot/warm blood cardioplegia
24. Remove aortic cross clamp
25. Check for hemostasis
26. Temporary epicardial pacer wire placement
27. Wean from cardiopulmonary bypass
28. Protamine administration and decannulation
29. Assess hemostasis, place pleural/mediastinal tubes
30. Sternotomy closure
Potential Complications and Pitfalls
1. Stay midline during sternotomy
2. IMA injury
3. Cannulation complication (aortic dissection/disruption, inadequate anticoagulation)
4. Poor choice of aortic cannula/cross clamp location (too low/inadequate space for aortotomy and proximals, stroke
risk)
5. Insufficient myocardial protection (retrograde cannula malpositioned)
6. Coronary sinus injury
7. Quality/caliber of targets
8. Twisting, kinking, or inadequate length of graft
9. Valve-patient mismatch
10. Inadequate debridement of annulus
11. Poor seating of valve, occlusion of coronary ostia
12. Damage to prosthetic valve (commissure posts, leaflets) during suture tying
13. Inadequate de-airing prior to aortic root vent removal
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14. Perivalvular leak
15. Inadequate control of hemostasis prior to sternal closure
Template Dictation
Preoperative Diagnosis: [INDICATION exertional or unstable angina, dyspnea]
Postoperative Diagnosis: Same
Procedure(s) Performed:
1. Endoscopic vein harvesting
2. Coronary artery bypass grafting [DETAILS conduit used and targets]
3. Aortic valve replacement [PROSTHETIC IMPLANT info]
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] with [DURATION] history of [COMPLIANT: Exertional chest
pain, syncope]. Preoperative cardiac catheterization reveals [FINDINGS]. Preoperative cardiac echocardiography
demonstrates [FINDINGS]. The patient has chosen a [VALVE CHOICE: bioprosthetic to avoid lifelong warfarin, or a
mechanical prosthetic to reduce risks of future degenerative valve dysfunction].
Description of Procedure: The patient was taken to the operating room on [DATE] and was placed upon the operating room
table in the supine position. Swan Ganz catheter and radial artery lines were inserted. General endotracheal anesthesia was
administered. Preoperative transesophageal echocardiogram was then performed to evaluate cardiac and valve function. The
patient was prepped and draped in the usual sterile fashion.
The saphenous vein was endoscopically harvested from the lower extremity, length sufficient for X Number bypass grafts. The
tributaries of the vein were controlled with clips and silk ligatures. The access incision was closed in layers.
The chest was opened through a median sternotomy incision. The left pleural cavity was opened and the left internal mammary
artery was fully mobilized. The patient was heparinized systemically with 300 IU/kg after which, the internal mammary was
transected distally and prepared for anastomosis. The pericardium was opened. Pericardial stays were used for retraction. The
space between the aorta and pulmonary artery was exposed. Purse string sutures were placed in the [LOCATION: distal
ascending aorta or transverse aortic arch], right atrial appendage, and right atrium. A Prolene purse string suture was placed in
the right superior pulmonary vein. After ensuring adequate anticoagulation, arterial cannulation and dual-stage venous
cannulation was achieved. An antegrade cardioplegia catheter was placed in the ascending aorta. A retrograde cardioplegia
catheter was placed via the right atrium into the coronary sinus, positioning confirmed by transesophageal echocardiography
and pressure transduction. A left ventricular vent was placed via the right superior pulmonary vein. Cardiopulmonary bypass
was initiated. The aortic cross clamp was applied. Cardioplegia was administered in an antegrade fashion followed by
retrograde via the coronary sinus [NOTE: If there is significant aortic valve insufficiency, then antegrade cardioplegia may not
be delivered effectively]. A good diastolic arrest was achieved. The patient was cooled systemically to approximately 32
degrees Celsius.
300-500 ml of retrograde cardioplegia was administered in 20 minute intervals throughout the period of the aortic occlusion.
The aorta was then opened revealing a [DETAILS: heavily calcified tricuspid valve, with/without fused right and left
leaflets]. The aortic valve was then excised, the annulus debrided of any remaining calcium deposits and the left ventricle
copiously irrigated with cold saline. The annulus was sized. A Xmm prosthetic [IMPLANT type: Trifecta, MagnaEase, St.
Jude mechanical] aortic valve was selected.
The epicardial vessels were identified and incised. The distal anastomoses were accomplished next. Individual segments of
reverse saphenous vein were sewn to the [TARGETS: diagonal, obtuse marginal, posterolateral branch of the circumflex
artery, distal right coronary or posterior descending] artery respectively. Each of these anastomoses were carried out with
running sutures of 7-0 Prolene. The anastomoses were tested for patency and hemostasis with gentle syringe infusion. The left
internal mammary artery was then brought through a window in the pericardium and was sewn to the left anterior descending
vessel with a running suture of 7-0 Prolene. The proximal clamp on the internal mammary was briefly removed to confirm both
patency and hemostasis of this anastomosis.
Pledgeted 2-0 Ethibond sutures were placed circumferentially along the aortic valve annulus with pledgets oriented
[DETAILS: on the ventricular side for bioprosthetics, on the aortic side for mechanical prosthetics]. Sutures were then passed
through the sewing ring, the valve lowered into position and tied securely in place. The valve was inspected to be certain it
was well seated and the coronary ostia were unobstructed. The aortotomy was closed with a continuous running suture of 5-0
Prolene. The vein grafts were cut to the appropriate length and spatulated. X number of aortic tissue buttons were excised and
used as X proximal anastomoses for the saphenous grafts, which were carried out with running sutures of 5-0 Prolene.
A terminal dose of warm blood cardioplegia (the hot shot) was administered retrograde and the aortic cross clamp was then
released. The heart was de-aired using the left ventricular vent and the ascending aortic vent. Temporary pacing wires were
placed on the surface of the [LOCATION: right atrium, right ventricle].
With the patient fully re-warmed, the heart resumed good contractility and resumed a [TYPE: normal spontaneous or paced]
rhythm. The lungs were inflated. [DETAILS: Inotropes were initiated if the ventricular function was impaired or the cross
clamp period was prolonged]. The patient was weaned from cardiopulmonary bypass. Transesophageal echocardiography
revealed a well seated valve with no insufficiency and acceptable gradients. The left chest was aspirated. Protamine was
administered and decannulation was accomplished. Hemostasis was achieved from all sites, including the skin fat, the
mammary bed, cannulation sites, and all proximal and distal anastomotic sites. The entire wound was inspected for hemostasis
and was felt to be adequate. [NUMBER] mediastinal tube and [NUMBER] left pleural tube were placed.
The incision was then closed in layers with #5 stainless steel wires used to approximate the sternum, 2-0 PDS suture used to
approximate the fascia, 2-0 monocryl to approximate the subcutaneous tissue, and 4-0 monocryl subcuticular closure used to
approximate the skin. Sterile dressings were applied. The patient tolerated the procedure well and transferred to the ICU in
stable condition.
All sponge, instrument, and needle counts were correct at the completion of the case.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of this procedure.
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14. DeVega Tricuspid Valve Repair
Mathéau A Julien, MD, PhD and Duc Thinh Pham, MD
Tufts Medical Center, Boston, MA
Essential Operative Steps
1. Lines and Monitoring
2. General endotracheal anesthesia
3. Intraoperative transesophageal echocardiogram
4. Median sternotomy
5. Open pericardium, pericardial well, survey ascending aorta for plaque burden
6. Systemic heparinization (400 u/kg)
7. Arterial cannulation
8. Dual stage venous cannulation
9. Restriction of SVC and IVC return into the operative field with Rummels
10. Myocardial protection cannula placement (DLP in aortic root)
11. Check ACT (>400 sec)
12. Initiate CPB
13. Aortic cross clamp (reduce CPB flow rate, apply cross clamp, increase CPB flow to
14. 2.0-2.5L/min/m2)
15. Antegrade cardioplegia (1200 ml) and topical cooling with for cardiac arrest
16. Check for PFO once right atrium opened
17. During suturing, take up a segment of annular tissue with each bite, but leave only a small space between each bite
18. Use of a tricuspid valve annuloplasty calibrator in order to narrow the annulus to the desired size
19. Testing tricuspid valve competence by distending the right ventricle using a Robinson catheter
20. Antegrade warm blood cardioplegia “hot shot” administration for rewarming
21. Remove aortic cross clamp
22. Closure of right atriotomy
23. Check for hemostasis
24. Arterial and ventricular pacer wire placement
25. Drainage tube placement
26. Wean from CPB
27. Venous decannulation
28. Protamine administration for heparin reversal (test dose first)
29. Aortic decannulation
30. Assess hemostasis
31. Sternotomy closure
Potential Complications and Pitfalls
1. Stay midline during sternotomy
2. Avoid injury to innominate vein while making pericardial well
3. Cannulation catastrophe (aortic dissection/ bleeding)
4. Poor choice of location of aortic cannula/ crossclamp (leading to stroke)
5. SA node or right phrenic nerve injury during SVC isolation/cannulation
6. Inadvertent azygous vein rather than SVC cannulation
7. Excessive bleeding or cardiac manipulation during IVC cannulation
8. Inadvertent hepatic vein rather than IVC cannulation
9. Insufficient myocardial protection
10. Insufficient venous drainage
11. Failure to address PFO
12. Injury to tricuspid valve leaflets
13. Failure to improve degree of tricuspid regurgitation
14. Insufficient de-airing prior to removal of aortic root vent
15. Inadequate control of hemostasis prior to sternal closure/ bleeding from one of numerous cardiotomies
Template Dictation
Preoperative Diagnosis: Tricuspid Valve Insufficiency
Postoperative Diagnosis: Same
Procedure(s) Performed: DeVega Tricuspid Valve Repair
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] mild functional tricuspid regurgitation by echocardiography.
While the annular dilatation of moderate to severe tricuspid regurgitation should be managed with a ring-reinforced
annuloplasty, the suture annuloplasty technique of DeVega was chosen and has successfully been employed for the repair of
mild regurgitation. Of note, this technique is becoming of more historical interest, due to compelling evidence suggesting a
higher recurrence rate.
Description of Procedure: After informed consent was obtained, the patient was brought to the operating room and placed in
the supine position. General endotracheal anesthesia was induced. A central venous catheter, Swan-Ganz catheter, radial
arterial catheter, and Foley catheter were inserted. The patient was prepped and draped in the usual sterile manner. A median
sternotomy was performed. The heart was then exposed and marsupialized by supporting the right side of the pericardium. The
SVC and IVC were each looped using umbilical tape on a Rummel tourniquet. The patient was systemically heparinized, and
cardiopulmonary bypass lines were brought up. Double pursestring sutures were placed in the ascending aorta, and it was
cannulated in the usual fashion. The venous line was Y'ed for SVC and IVC cannulation, and after placing single pursestring
sutures, these were cannulated as well, using right-angle cannulas. Once a therapeutic ACT was achieved the patient was
placed on cardiopulmonary bypass and kept warm.
An aortic root vent / antegrade cardioplegia DLP cannula was placed in the proximal ascending aorta. The aorta was
crossclamped, and cardioplegia given antegrade into the aortic root. After there was good cardiac arrest, the superior and
inferior vena caval tapes were snared down. The operative field was flooded with carbon dioxide. The right atrium was then
opened. No atrial septal defect was identified. Attention was then turned to the tricuspid valve. The valve leaflets were thin
and pliable, and the pathology was limited to dilatation of the annulus. To fashion the DeVega annuloplasty, a double-armed 2-
0 pledgeted Prolene suture was used. Starting at the commissure between the septal and anterior leaflets of the tricuspid valve,
sequential stitches were taken through the tricuspid valve annulus, leaving only a small space between each bite and taking up a
segment of annular tissue with each bite. The suture line was completed at the septal-posterior leaflet commissure. The
opposite needle was then used to make a second row of suture in the floor of the atrium just outside the annulus of the tricuspid
valve. This stitch was also completed at the septal-posterior leaflet commissure. Both needles were passed through a free
Teflon pledget. With the aid of a tricuspid valve annuloplasty calibrator, the suture was tightened in order to narrow the
annulus to the desired size. Afterwards, tricuspid valve competence was tested by distending the right ventricle using a
Robinson catheter. The right atriotomy was then closed with a double-layer running Prolene suture
The patient was successfully weaned off of cardiopulmonary bypass. The heart was deaired and decannulated. The heparin
was reversed with protamine. Two temporary right atrial and right ventricular epicardial pacing wires were placed. The
pericardial cavity was copiously irrigated, hemostasis was assured, and two mediastinal drainage tubes were placed. The
sternum was reapproximated with wires. The rectus and pectoralis fascia were closed with 0 Vicryl. The subcutaneous tissue
was closed with 2-0 Vicryl, and the skin was closed with 3-0 Monocryl. All wounds were sterilely dressed. Instrument and
sponge counts were correct. The patient tolerated the procedure well and was sent to the critical care unit in stable condition.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of this procedure.
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15. Donor Heart Procurement
Alexandra Tuluca, MD and Hari Mallidi, MD, FRCSC
Baylor College of Medicine/ Texas Heart Institute, Houston, TX
Essential Operative Steps
1. Final checklist at the site:
1. ABO compatibility
2. Serology (HIV, HCV, HbsAg and CMV)
3. Laboratory findings (Troponin, Na, ABG)
4. ECG ( look for Atrial fibrillation, bundle or AV blocks and signs of hypertrophy, long QT)
5. Echocardiography (valvular abnormalities, LV and RV function, wall motion, wall thickness)
6. Chest X-ray
7. Coronary angiogram (if performed)
8. Medications during ICU course (especially catecholamine requirements)
2. Median sternotomy
3. Dissect and remove thymus, open pericardium longitudinally, create pericardial well
4. Expose the great vessels, Aorta with the arch branch vessels
5. Visual inspection and palpation of the heart for injury and lesions; Palpate LM coronary (behind the PA) and branch
coronary arteries for evidence of calcification
6. Dissect SVC and IVC circumferentially; Ligate and divide the azygous vein
7. Separate aorta and pulmonary artery
8. Insert cardioplegia cannula in ascending aorta
9. Systemic heparin (300 units/kg)
10. Ligate the SVC above the azygous vein
11. Cross-clamp the aorta
12. Incise IVC supradiaphragmatic - check with liver team
13. Vent the heart (pulmonary vein, main PA or LA appendage - if heart-lung block)
14. Arrest the heart with cardioplegia solution and copious topical cooling
15. Divide SVC and IVC
16. Incise the pulmonary veins/ left atrium
17. Divide the aorta (usually distal arch, with preservation of the arch vessels) and the PA as long as possible; If
harvesting for complex congenital transplant divide the PA at branch PA level
18. Remove the heart and inspect again for lesions, contusions, etc.
19. Store in sterile bag ( 3 bag method, first with cold perfusion solution, outer two with ice water)
Potential Complications and Pitfalls
1. Forgetting to heparinize
2. Allowing ventricular distention
3. Back-walling aorta with cardioplegia needle or angiocath thereby failing to administer cardioplegia
4. Allowing to aortic root pressure to get too high when administering cardioplegia
5. Caution to stay supradiaphragmatic when dividing the IVC
6. Not enough length on the SVC, IVC or the great vessels
7. Injuring RA / Dome of LA when preserving RSPV for lung team
8. Injuring the coronary sinus during IVC transection
9. Failure to identify structural abnormalities
10. Failure to adequately cool and preserve the heart
Template Dictation
Preoperative Diagnosis: N/A
Postoperative Diagnosis: Same
Procedure(s) Performed: Donar heart procurement
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: N/A
Description of Procedure: The donor is positioned supine and prepped and draped in standard sterile fashion from chin to
knees. A standard median sternotomy is performed. The thymus is removed and the pericardium is opened longitudinally in a
reverse-T along the diaphragm. A pericardial well is created and the great vessels are exposed. The heart is visually
inspected and palpated to identify myocardial contusions, coronary atherosclerosis or previous infarction.
The heart mobilization begins by dissecting the SVC from the right atrium to the innominate vein. The azygous vein is ligated in
the process and the SVC is encircled with heavy ligature. The IVC is mobilized circumferentially. Next, the aorta is separated
from the pulmonary artery and isolated with umbilical tape. A cardioplegia cannula is inserted in the ascending aorta through a
purse-string suture and secured with a Rommel tourniquet.
Once the abdominal organs and lungs are mobilized and prepared for explanation, the patient is administered 300 units/kg of
heparin intravenously. Anesthesia is asked to pull back any venous neck lines they may have and the SVC is ligated as distal as
possible. The IVC is incised and blood allowed to drain into the pericardium. The heart is further vented by incising a
pulmonary vein (or alternatively, the left atrial appendage if lungs or a heart-lung block is being harvested). The aortic cross-
clamp is applied just proximal to the takeoff of the innominate artery and the heart is arrested with a single flush (1000ml or
10mL/kg for larger donors) of cold crystalloid cardioplegia solution. Watch at this time for appropriate aortic root distention,
quick cessation of electrical activity and left ventricular relaxation without distention. Rapid cooling of the heart is achieved
with copious topical cold saline solution in the pericardial well. The cardioplegia cannula can now be removed and the purse-
string tied.
The IVC is fully transected. The heart is wrapped in an ice-soaked lap pad and the apex of the heart is elevated. The remaining
pulmonary veins are divided from inferior to superior, followed by branch pulmonary arteries. If lungs are also harvested, the
main PA is divided close to the bifurcation and adequate left atrial cuffs must be negotiated. The aorta and the SVC are divided
last with more than adequate length.
The donor heart is then placed in a sterile bag with perfusion solution, then two additional outer bags with sterile ice water.
The organ is then placed in a cooler with ice and transported to the recipient hospital.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of this procedure.
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16. Hemiarch Replacement with DHCA – Aneurysm
Thomas J Zeyl MD and Tomas D Martin MD
University of Florida, Gainesville, FL
CAVEAT: Aortic surgery, including that of the arch, may vary from institution to institution. Cannulation strategies and
cerebral protection can be completed differently. Strategies such as right axillary cannulation for antegrade cerebral protection
and bypass, or retrograde cannulation for cerebral protection are both valid methods. The described procedure omits these
techniques.
Essential Operative Steps
1. Appropriate patient identification
2. Lines and Monitoring
3. General endotracheal anesthesia
4. Intraoperative transesophageal echocardiogram
5. Median sternotomy
6. Dissect prepericardial fat/thymus to expose innominate vein
7. Open pericardium, pericardial well, survey ascending aorta/arch for pathology and potential cannulation site
8. Systemic heparinization
9. Arterial cannulation
10. Venous cannulation
11. Retrograde cannula in coronary sinus
12. Check ACT (>400 sec)
13. Initiate CPB and cooling
14. LV vent placement
15. Aortic cross clamp
16. Antegrade cardioplegia if no associated AI via a slotted cardioplegia needle, then retrograde cardioplegia
17. Aortotomy with resection of ascending aorta to sinotubular junction.
18. Once electrocerebral silence and adequate temperature, place patient in trendelenberg, turn cardiopulmonary bypass
off and remove aortic cannula and cross clamp.
19. Complete resection of aorta into the arch and as far as needed to get to normal aorta, create beveled graft with side-
arm
20. Distal anastomosis
21. Reperfusion through side-arm on graft
22. Rewarm
23. Proximal anastomosis to sinotubular junction
24. Deairing via root with slotted needle, retrograde cardioplegia
25. Remove aortic cross clamp
26. Check for hemostasis
27. Atrial and ventricular pacer wire placement
28. Chest tube placement
29. Check for air, remove LV vent, then wean from CPB
30. Remove root vent and venous cannulas
31. Protamine administration for heparin reversal
32. Ligate graft side-arm
33. Assess hemostasis
34. Sternotomy closure
Potential Complications and Pitfalls
1. Stay midline during sternotomy
2. Avoid injury to innominate vein and aneurysmal aorta during initial dissection/creation of pericardial well
3. Cannulation catastrophe (Aortic dissection/ bleeding, Right atrial tear)
4. Coronary sinus injury with retrograde cardioplegia cannulation
5. Poor choice of location of aortic cannula/ crossclamp (leading to stroke)
6. Inadequate cerebral protection (prolonged ischemic time prior to reperfusion)
7. Inadequate deairing prior to removal of aortic root vent
8. Acquired coagulopathy and bleeding
Template Dictation
Preoperative Diagnosis: [INDICATION – e.g. size and extent of aneurysmal disease]
Postoperative Diagnosis: Same
Procedure(s) Performed: Ascending Aorta with Hemiarch Replacement with DHCA using a [DETAILS – Size of Graft]
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] with a history of [DISEASE – size of aneurysmal disease, and or
rate of growth of aneurysm]. Preoperative CT scan revealed [FINDINGS]
Description of Procedure: The patient was taken to the operating room and [HIS/HER] identity and planned procedure
verified. The patient was placed on the operating room table in the supine position and general anesthesia was obtained.
Hemodynamic catheters were inserted and transesophageal echocardiogram was performed to evaluate cardiac and valve
function. The patient was prepped and draped in the usual sterile fashion. The chest was entered via standard median
sternotomy. The heart was exposed, and the ascending aorta was inspected and showed [OPERATIVE FINDINGS]. The
patient was systemically heparinized with a total of [UNITS] of systemic heparin. Epiaortic ultrasound was performed to
assess the aortic wall. The aortic cannulation sutures were then placed in the ascending aorta below the level of the
innominate artery take off. The right atrial cannulation sutures were then placed in the right atrium. The retrograde cardioplegia
sutures were placed in the right atrium and the left ventricular vent sutures were placed in the right superior pulmonary vein.
The ACT and systemic pressure was confirmed and the aortic cannula was then inserted, secured and de-aired. Venous cannula
was then placed and secured in the right atrium. A retrograde catheter was placed into the coronary sinus and secured. The
patient was placed on cardiopulmonary bypass and eventually cooled to [TEMP] degrees centigrade and electrocerebral
silence. Upon fibrillation, a vent was placed in the left ventricle via the right superior pulmonary vein. The aortic cross-clamp
was placed and antegrade cardioplegia was administered upon which there was rapid arrest of the heart. This was followed by
retrograde cardioplegia. The aorta was opened just proximal to the cross clamp and the ascending aorta was resected to just
superior to the sinotubular junction with visualization of the right and left coronary ostia. Once the patient reached
approximately [TEMP] degrees centigrade and electrocerebral silence, [HE/SHE] was placed in Trendelenburg position and
the pump was turned off. The aortic cannula and cross clamp were removed. The ascending aorta was transected cephalad and
the aorta was resected all the way up into the aortic arch, including all diseased aorta in the arch, until there was noted to be
relatively normal sized aorta. A [SIZE] side-arm graft was chosen and beveled to fit the transverse arch. The graft was sewn
end-to-end to the underneath side of the aortic arch utilizing a running 3-0 Prolene suture. Upon completion of the anastomosis,
bioglue was utilized on the graft to cover needle holes. The side-arm was then connected to the arterial line through a regular
tubing connector. After de-airing the graft, the graft was clamped and reperfusion was begun. A cross clamp was applied
proximal to the joining of the side-arm. Cerebral ischemia time was [TIME] minutes. Rewarming was begun. The graft was
cut to the appropriate length and anastomosed end-to-end to the proximal aorta utilizing a running 3-0 Prolene suture. This was
done right at the sinotubular junction. Upon completion bioglue was placed on the graft to cover suture holes. The heart was
de-aired in the routine fashion utilizing active suction in the aortic root and the left ventricle and retrograde cardioplegia was
given. The crossclamp was removed. The patient was rewarmed to [TEMP] degrees.
Atrial and ventricular pacing wires were then inserted and tested for appropriate capture. A [NUMBER] chest tube was
placed in the mediastinum and large Blake drains in the [LEFT/RIGHT] pleural space. The heart was de-aired, and the LV
vent was removed after minimal air was seen by echo. The patient was weaned from cardiopulmonary bypass. The venous
cannula was removed, and the cannulation sutures were secured. Protamine was administered and the patient was monitored
for adverse reactions. Coagulopathy was assessed and hemostasis secured. The aortic side-arm was clamped and cut. The
remaining stub of the side-arm was closed with a 3-0 Prolene suture and 2 large clips placed at the base. The operative field
was thoroughly inspected for bleeding.
Once adequate hemostasis was achieved, the sternum was closed with a total of [NUMBER] stainless steel sternal wires
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