Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4110_Библиотеки_им_академика_М_И_Перельмана

heart was decompressed. It is our hope that with time his ventricular function will improve. We removed the first venous

cannula and repaired the atrial appendage with 2-0 nonabsorbable suture. Considerable time was taken to try to improve

Dr. [BLANK] was present and scrubbed for [BLANK] elements of this procedure.

3. Intraop TEE

8. Systemic heparin

13. Lift the apex of heart and identify the apex

Potential Complications and Pitfalls

1. Stay midline during sternotomy

2. The tunneler for the driveline has potential to hit bowel, liver, vessels, etc.

3. Fragile LV apex that can tear

4. Outflow graft too long/short

5. Pump sitting in a poor position

6. Cannot adequately deair the pump

7. Bleeding

8. RV failure

9. Suction event

Template Dictation

Postoperative diagnosis: same

therapy or bridge to transplant)

Assistants: [BLANK]

timeout was performed. Patient was in supine position. General anesthesia was obtained. A right internal jugular central

Patient was prepped and draped in normal fashion.

The HVAD ring was then sewn on to this region with a 12 pledgeted 2-0 Ethibond sutures. Subsequently, a circular

that our inflow cannula would be unobstructed. At this time, the LVAD pump was placed in and secured. The heart was then

placed back into the pericardium and the driveline of the device was brought out through the right upper quadrant of the

abdomen. At this time, we checked the inflow cannula position and it was positioned perfectly, directed toward the mitral.

Subsequently, the outflow graft was measured to the ascending aorta and cut to length. A partial cross-clamp was placed over

the ascending aorta and after aortotomy was created, the graft was sewn on with 4-0 Prolene suture in an end-to-side fashion.

A deairing vent was placed in the ascending aorta. The partial cross-clamp was then removed. The heart was gradually de-

aired. We gradually increased the flow on the HVAD and came off cardiopulmonary bypass.

We were able to achieve flows of over 5 L/min and the right ventricular function was excellent. Postop TEE demonstrated no

All instruments, sponges and needles counts were confirmed to be correct x 2 at the end of the case.

3. Intraop TEE

8. Create tunnel for driveline with endoscopic tunneler

13. Initiate CPB (CI 2.2)

25. Come off bypass and turn on pump and titrate to appropriate flows

26. Decannulate

1. Stay midline during sternotomy

2. The tunneler for the driveline has potential to hit bowel, liver, vessels, etc.

3. Need to create pocket large enough and lateral enough to sit properly

4. Fragile LV apex that can tear

5. Bleeding from the pump pocket

7. Pump sitting in a poor position. Inflow cannula not directing towards the mitral valve

11. Suction event

Preoperative Diagnosis: [Indication: e.g. Ischemic cardiomyopathy]

Postoperative Diagnosis: Same

Estimated blood loss: [BLANK]

Specimen: [LV core]

Indication(s) for Procedure: [AGE] year old [GENDER] with [DURATION] history of [COMPLAINT]. Preoperative

workup showed severe cardiomyopathy and end-stage systolic and diastolic congestive heart failure. Patient is status

[INTERMACS LEVEL] with [JUSTIFICATION OF STATUS]. Patient taken to the OR today for implantation of LVAD

venous line, pulmonary artery catheter and radial arterial line were inserted. Transesophageal echocardiogram was performed.

Patient was prepped and draped in normal fashion.

was placed in the ascending aorta and 2-stage venous cannula was inserted in the right atrial appendage. Once ACT was >480,

secured with plastic tapes. The body of the pump was then placed in the previously created pump pocket. The driveline was

exited initially through a right upper quadrant and subsequently into the left upper quadrant in a double tunneling technique.

placed and the aortotomy was performed. The outflow graft was sewn in an end-to-side fashion with 4-0 Prolene suture.

3. Intraoperative transesophageal echocardiogram

8. Placement of stabilizers

13. Doppler flow check of anastamosis

Potential Complications and Pitfalls

1. Incorrect rib space for entry

4. Phrenic nerve injury when opening pericardium

5. Insufficient graft length

6. Subclavian vein injury

7. Kinking of graft

8. Fibrillation

9. Need to go on CPB

Procedure(s) Performed: Minimally invasive directed coronary artery bypass [DETAILS – e.g. LIMA to LAD]

Secondary Surgeon: [BLANK]

Assistants: [BLANK]

Anesthesia: [BLANK]

Indication(s) for Procedure: [AGE] year old [GENDER] with [DURATION] history of symptomatic coronary artery

Description of Procedure: The patient was taken to the operating room on [DATE]. An appropriate review was performed

verifying the patient’s identity and planned procedure. While supine on the operating room table, general endotracheal

anesthesia was administered without difficult. Single right-sided lung ventilation was achieved with a [double-lumen tube or

[radial/axillary/femoral/brachial] arterial line were placed. A pulmonary artery catheter [was/was not] placed.

performed. A [BLANK] cm anterolateral skin incision was made in the [4

th

th

Dissection was carried down to the intercostal space with minimal division of the pectoralis muscle. The thoracic cavity was

descending artery was identified and location of acceptable target was decided upon. There was adequate length of the

LIMA. A coronary artery stabilizing device was then placed through a small port incision in the chest to stabilize the LAD

target. [Proximal LAD occlusion was achieved with a 4-0 felt-pledgeted suture / An arteriotomy was performed in the

hemostasis was achieved. A total of [BLANK] chest tubes were placed in the left pleural space and [BLANK] chest tube(s)

were placed in the mediastinum. [Atrial/Ventricular] pacing wires were placed in the standard fashion. The thoracotomy

was reapproximated with rib sutures and prior to closure the left lung was observed to reinflate completely and imposed

3. Intraoperative transesophageal echocardiogram

4. Upper hemisternotomy (to level of right 4

intercostal space and taken transversely through this space)

5. Open pericardium, pericardial well, survey ascending aorta for plaque burden (consider epiaortic ultrasound)

11. Initiate CPB

12. Aortic cross clamp (reduce CPB flow rate, apply cross clamp, return to full CPB flow)

17. Aortic valve replacement

19. Warm blood cardioplegia “hot shot” administration for rewarming

20. Remove aortic cross clamp

21. Deairing

22. Placement of pacing wires (ventricular +/- atrial)

23. Chest tube placement while on CPB

1. Make sure that the sternotomy is absolutely midline and that the midline sternotomy is not carried beyond the level of

2. Care must be taken not to cut too deeply when the sternotomy is continued into the right fourth intercostal space to

3. Care must be taken when bringing up the pericardium and reopening the retractor, as sudden retraction with elevated

cardiac structures could impede venous return causing a sudden drop in cardiac output.

4. Cannulation catastrophe (Aortic dissection/bleeding, Right atrial tear)

5. Insufficient myocardial protection and cardiac arrest (cross clamp not across, aortic insufficiency, insufficient venous

9. Deep debridement in the area below the junction of the right and non-coronary cusps in the membranous septum or

10. Not capturing debris during procedure or forcing debris into the left ventricle while the aortic root is flushed with

saline, this debris may embolize and lead to stroke

12. Not recognizing bleeding from aortotomy (particularly at extremes of aortotomy)

13. Inadequate control of hemostasis prior to sternal closure/ bleeding from cannulation sites.

14. Placement of the drains while the heart is full; this must be done on bypass with the heart decompressed or injury to

the heart can occur.

Template Dictation

Preoperative Diagnosis: [INDICATION – e.g. Severe AR, Severe AS]

Postoperative Diagnosis: Same

Secondary Surgeon: [BLANK]

Anesthesia: [BLANK]

Indication(s) for Procedure: [AGE] year old [GENDER] with [DURATION] history of [COMPLAINT – e.g. chest pain,

syncope and shortness of breath]. The preoperative echocardiography revealed [FINDINGS - e.g. severe AS, mean

gradient across aortic valve(mmHg), peak jet velocity(m/s), Aortic valve area (cm²), severe AR , LV end-diastolic

disease].

obtained. A right internal jugular central venous line and pulmonary artery catheter and radial arterial line were inserted.

External defibrillator pads were attached. Preoperative transesophageal echocardiogram was performed to evaluate cardiac

function and valve function. The patient’s chest, abdomen, groins, and lower extremities were prepped and draped in standard

sterile fashion. A time out was performed.

An antegrade cardioplegia/vent cannula was placed in ascending aorta and a retrograde cardioplegia catheter was placed in

the coronary sinus via the right atrium under TEE guidance. [Alternative: this catheter can be placed by the anesthesiologists

via the transjugular route prior to the incision). [A right superior pulmonary vein or a left atrial dome vent can be placed.]

and posteriorly. [Additional [ml] of cardioplegia was delivered directly into the [right and/or the left] coronary arteries.] The

aortic valve was exposed, examined and found to be [trileaflet, bileaflet, heavily calcified, etc.]. The valve was excised and

valve. A series of [2-0, type of suture] pledgetted valve sutures were placed around the annulus with the pledgets on the

[aortic or ventricular] side. The valve sutures were taken sequentially around the sewing ring of the [company name] valve

visualized to be [e.g., well away] from the valve annulus and posts. The aortic root and aorta were again irrigated with normal

saline. The aortotomy was closed with two layers of running 4-0 prolene and the aorta was deaired.

reversed with protamine. Hemostasis was obtained and the wounds were closed in standard fashion. The patient tolerated the

Dr. [BLANK] was present and scrubbed for [BLANK] elements of this procedure.