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23. Mitral Valve Replacement
Franjo Siric, MD and A. Marc Gillinov, MD
Cleveland Clinic, Cleveland, OH
Essential Operative Steps
1. Lines and Monitoring
2. General endotracheal anesthesia
3. Intraoperative transesophageal echocardiogram
4. Median sternotomy
5. Open pericardium, elevation of the right side of the pericardium with stay sutures, survey ascending aorta for plaque
burden and cannulation site
6. Systemic heparinization (400 U/Kg)
7. Aortic cannulation
8. Venous cannulation- Bicaval
9. Aortic root vent
10. Check ACT (>480 sec)
11. Initiate cardiopulmonary bypass
12. Maintain normothermia
13. Aortic cross clamp
14. Antegrade cold blood cardioplegia (1000-1200 ml)
15. Dissect Sondergaard’s groove
16. Standard left atriotomy
17. Expose and assess the mitral valve (fill left ventricle with cold saline to identify the mechanism of regurgitation)
18. Excise portion of anterior leaflet, preserving subvalvular apparatus
19. Size valve
20. Place annular valve sutures (pledgits on the left atrial side)
21. Implant valve
22. Check valve struts with a dental mirror
23. Left atriotomy closure
24. De-airing maneuvers
25. Remove aortic cross clamp
26. Check for hemostasis
27. Place epicardial atrial and ventricular pacing wires
28. Wean from cardiopulmonary bypass
29. Evaluate mitral valve with transesophageal echocardiogram
30. Venous decannulation
31. Ensure adequate de-airing of the heart prior to removal of aortic root vent
32. Protamine administration for heparin reversal
33. Aortic decannulation
34. Assess hemostasis
35. Sternotomy closure
Potential Complications and Pitfalls
1. Stay midline during sternotomy
2. Avoid injury to the innominate vein while making pericardial well
3. Cannulation catastrophe (aortic dissection/hematoma, right atrial tear)
4. Poor choice of location of aortic cannula/cross clamp (risk of stroke)
5. Injury of the pulmonary artery during cross clamp application
6. Insufficient myocardial protection and cardiac arrest (cross clamp not across, aortic regurgitation with secondary
ventricular distension)
7. Feel the left ventricle during administration of antegrade cardioplegia to ensure absence of ventricular distension and
uniform cooling of the ventricle with cardioplegia
8. Poor venous drainage (incorrect choice of cannula size, advancing the two-stage cannula too far in so it is obstructing
hepatic veins)
9. Failure to dissect Sondergaard’s groove
10. Improper dissection of the Sondergaard’s groove with inadvertent opening of the right atrium close to the inferior
vena cava
11. Opening the left atrium close to the right superior pulmonary vein with subsequent difficulty in exposing the mitral
valve
12. Retractor injury with subsequent shearing tear of the left atrial wall edges which complicates closure
13. Failure to recognize important vital structures in relation to the mitral valve: atrioventricular node, coronary sinus,
aortic valve and circumflex coronary artery
14. Improper placement of the annular sutures with misidentification of the mitral annulus and subsequent placement of
the sutures in the left atrial wall
15. Deep placement of annular sutures with subsequent injury to the circumflex coronary artery in a left dominant system
16. LVOT obstruction by the valve strut
17. Improper de-airing prior to removal of aortic root vent
18. Lifting the heart with the prosthesis in place causing AV disruption
19. Inadequate control of hemostasis prior to sternal closure/bleeding from cannulation sites
20. Improper closure of sternotomy
Template Dictation
Preoperative Diagnosis: Severe mitral valve regurgitation/stenosis
Postoperative Diagnosis: Same
Procedure(s) Performed:
1. Intraoperative transesophageal echocardiography
2. Mitral valve replacement
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [G ENDER] with [DURATION] history of [COMPLAINT –e.g. increasingly
shortness of breath]. Preoperative transthoracic echocardiography reveals [FINDINGS - e.g. severe mitral valve regurgitation
and stenosis due to advanced rheumatic disease].
Description of the Procedure: After satisfactory general endotracheal anesthesia was induced, a right internal jugular central
venous line, pulmonary artery catheter and brachial arterial lines were inserted. Transesophageal echocardiogram was
performed to evaluate the mitral valve and cardiac function. The patient was prepped and draped in the supine position.
A standard median sternotomy was performed and sternal retractor was placed. We opened the pericardium in an inverted T-
shape fashion and pericardial stay sutures were placed on the right side. Heparin was given systemically and an aortic cannula
was inserted through two pursestring sutures in the distal ascending aorta, secured and de-aired. Bicaval cannulation. An
aortic root cardioplegia/vent was then inserted. After confirming ACT of more than 480 seconds, cardiopulmonary bypass was
commenced at 2.4 L/min per m
2
. We maintained normothermia during perfusion. The aorta was cross clamped. After
administering 750ml of Buckberg cardioplegia antegrade we administered 500ml of cardioplegia in the retrograde fashion.
Thereafter cold blood cardioplegia was given retrograde very 15 to 20 minutes. Simultaneously we developed Sondergaard’s
groove between left and right atrium and opened the left atrium about 1-2cm away from the orifice of right upper pulmonary
vein to decompress it. A self-retracting Cosgrove retractor was applied to sternal retractor. Once cardioplegia was given, the
self-retracting arms of Cosgrove retractor were placed starting cranially to visualize the mitral valve. Once we confirmed that
the valve could not be repaired we incised the anterior leaflet in its mid-portion. Before we cut it all out we started placing
everting, interrupted #2-0 ethibond pledgeted stitches on anterior annulus gently lifting the anterior leaflet to facilitate
visualization. We made our way to both commissures, detached the remainder of the anterior mitral leaflet and divided it in the
middle and brought the segments to the left and right to preserve chordae. Preserved portions of the anterior leaflet were sewn
to the annulus towards the left and right commissures, away from central portion of the inflow, with double armed interrupted
#2-0 ethibond pledgeted mattress stitches. Appropriately sized [Valve type and size] valve was selected and sutures were
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placed through sewing cuff orienting the struts in a way to avoid obstructing the left ventricular outflow tract. Atrial closure
was completed after deairing. Retrograde and antegrade hot-shot was given and the aortic crossclamp was released. Following
thorough deairing we removed the aortic vent. The IVC cannula was removed while still on partial bypass, the cannulation site
was reinforced and CPB weaned off. Ventricular and atrial pacing wires were placed. Every attempt was made not to lift the
heart with the bioprosthesis in place given the possibility of posterior LV wall rupture. 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. Adequate hemostasis was then confirmed within the mediastinum. The sternum was then closed with a total of
[NUMBER] stainless steel sternal wires. The wound was irrigated with antibiotic solution. 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.
24. Minimally Invasive Mitral Surgery
Brian Solomon, MD and Eugene Grossi, MD
New York University Langone Medical Center, New York, NY
Essential Operative Steps
1. Lines and Monitoring
2. General endotracheal anesthesia +/- Right Lung Isolation
3. Intraoperative trans-esophageal echocardiogram (Evaluation of Aortic atherosclerotic disease)
4. Femoral vessel dissection and palpation of cannulation sites
5. Purse-string of femoral artery and vein
6. Right anterior thoracotomy – 4
th
intercostal space
7. Chest wall retraction, soft tissue retractor, and exposure
8. Open pericardium, survey ascending aorta and right atrium
9. Carbon dioxide line
10. Systemic heparinization (100 u/kg)
11. Femoral arterial cannulation
12. Long venous cannulation through femoral vein – placement under TEE guidance
13. Lines tested
14. Check ACT (>450 sec)
15. Initiate CPB
16. Myocardial protection cannula placement (DLP in aortic root, +/-retrograde cannula in coronary sinus)
17. Flexible aortic cross clamp placed (reduce CPB flow rate, apply cross clamp, increase CPB flow to 2.0-
2.5L/min/m2)
18. Antegrade cardioplegia (20 cc/kg initial dose) and (+/- retrogrograde cardioplegia)
19. Incision in Sondergaard’s groove. Intra-atrial septal retractor blade and handle placed.
20. Valve inspected. Saline distention test. Reconciliation with TEE pathology
21. Triangular resection of posterior leaflet, re-approximation with primary sutures
22. Valve measured along base and size of anterior leaflet
23. Ethibond sutures placed in posterior annulus from anterior to posterior trigone
24. Sutures passed through annuloplasty band
25. Annuloplasty band seated along annulus and secured
26. Saline distention test
27. Left ventricular vent placed
28. Closure of atriotomy – 2 rows running 4-0 prolene
29. Cross-clamp removed with root and LV vents on suction
30. Heart defibrillated
31. De-airing confirmed with TEE
32. Removal of vents and over-sewing of vent sites, tying LA closure sutures
33. Temporary epicardial pacer wire placement
34. Removal of arterial and venous cannulae
35. Reversal of heparinization
36. Hemostasis obtained
37. Blake drain placed in pericardium
38. Loose closure of pericardium
39. Pleural chest tube placement
40. Intercostal block
41. Closure of thoracotomy and groin incision
Potential Complications and Pitfalls
1. Entering incorrect intercostal space – resulting in poor exposure
2. Avoid injury to IMA when performing thoractomy
3. Avoid damage to femoral vessels or profunda when dissection groin vessels
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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 completely across aorta, unrecognized aortic
insufficiency, insufficient venous drainage)
7. Coronary sinus injury with retrograde cardioplegia cannulation – if used
8. AV groove dissociation if dissecting posterior annulus
9. Incomplete coaptation of valve with residual mitral insufficiency
10. Valve sutures placed excessively deep, risking damage to circumflex artery
11. Valve sutures placed excessively deep, risking damage to conduction system / AV block
12. Valve sutures placed too deep causing injury to left cusp aortic valve – resultant aortic insufficiency
13. Mitral annular calcification with resultant annular disruption for valve sutures
14. Postoperative systolic anterior motion of the anterior mitral leaflet.
15. Bleeding
Template Dictation
Preoperative Diagnosis: [INDICATIO N – e.g. Mitral Valve Insufficiency, Mitral Valve Prolapse, Ischemic Mitral Valve
Disease]
Postoperative Diagnosis: Same
Procedure(s) Performed: Minimally invasive mitral valve repair (DETAILS – e.g. resection of posterior leaflet prolapse,
suture valvuloplasty, annuloplasty with #30 Medtronic Future band).
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] with [DURATIO N] history of [CO MPLAINT –e.g. congestive
heart failure and shortness of breath]. Preoperative evaluation revealed [PRE-OPERATIVE FINDINGS - e.g. torn chordae
in the posterior mitral valve leaflet and severe mitral valve insufficiency with normal ventricular size and function, but
pulmonary hypertension in response to exercise].
Operative Findings: Fibroelastic deficiency of the valve with ruptured chordae in the P2 segment of the posterior leaflet. Left
ventricular systolic function was normal.
Wound Classification: Clean.
Specimens: Segment of posterior mitral valve leaflet was sent to Pathology.
Implant: Mitral valve annuloplasty – [Make, Model, Size, Serial Number]
Pump Data:
Cross-clamp time: [TIME]
Bypass time: [TIME]
Blood: None
Description of Procedure: The patient was taken to the operating room and general anesthesia was induced without
hemodynamic change. A central venous catheter and an arterial pressure measuring lines were placed. Trans-esophageal
echocardiography was performed and pre-operative pathology was confirmed. TEE was used to monitor throughout the case.
Patient was prepped and draped in the usual sterile fashion. Evaluation confirmed that patient was good candidate for
retrograde arterial perfusion. A 4 cm transverse small incision was made in the right groin, inferior to the inguinal ligament.
The common femoral artery and vein were exposed. The artery was palpated. It was noted to be soft, without visible or
palpable calcifications. A purse-string suture was then placed in the anterior wall of the femoral vein. An 8 cm right anterior
thoracotomy incision was performed at the level of the 4
th
intercostal space, adjacent to the right sternal border. The fourth
intercostal space was entered using electrocautery. A skin retractor was secured within the incision and a soft tissue retractor
placed in the intercostal space using the [Color] blades, to expose the underlying pericardium. The pericardium was
visualized and opened, exposing the lower ascending aorta and right-sided cardiac structures. The field was flooded with
carbon dioxide throughout the case to minimize intracardiac air.
The patient was systemically heparinized. Next, an arterial cannula was placed in the right common femoral artery over a
guidewire, using the modified Seldinger technique, within the arterial purse-string. A long venous cannula was placed through
a purse-string suture in the right common femoral vein, also using the modified Seldinger technique. The long venous cannula
was positioned in the right atrium with the tip in the superior vena cava, confirmed by echocardiography. The cannulae were
attached to cardiopulmonary bypass and the lines tested. Cardiopulmonary bypass was begun and the patient was systemically
cooled to 32 degrees centigrade. A cardioplegia catheter was placed into the aortic root. The ascending aorta was occluded
with a flexible cross-clamp through the thoracotomy. Cardioplegia was then re-injected part way through the cross-clamp time
and myocardial protection was excellent.
In the event of concurrent aortic insufficiency: The heart became somewhat distended, due to a degree of aortic
insufficiency. A small atriotomy incision was made and under direct vision, a retrograde cardioplegia catheter was placed in
the coronary sinus. The atriotomy was closed and cardioplegia was reinitiated with retrograde cardioplegia.
An incision was made in the left atrium posterior to the interatrial septum in Sondergaard’s groove. Septal retractor blade was
placed nicely exposing the mitral valve. It was secured to a “iron intern” retractor through a 0.5 cm separate incision placed
just medial to the thoracotomy. The valve was carefully inspected, comparing all leaflet to P1. Valve were inspected for
deformity, coaptation, ruptured chordae, and prolapse. Cold saline was gently instilled into the left ventricle and the valve
was assessed for regurgitation. The following findings were observed: [Findings - e.g. - P2 segment of the posterior leaflet
had several ruptured chordae and was flail in its midportion, with intact chordae on each side]. The decision was made to
repair the mitral valve.
In the event of a mitral valve repair: The flail leaflet was excised in a triangular V-type fashion. A primary repair was
performed with figure-of-eight 4-0 Ethibond sutures. The mitral valve was measured using mitral valve sizing tools. It was
measured from along the anterior leaflet from anterior to posterior commissure and a [size] annuloplasty ring was selected.
Next, 2-0 Ethibond sutures were placed in each trigone. Additional 2-0 Ethibond sutures were placed along the annulus
posteriorly. The sutures were placed through the sewing ring of the annuloplasty. The annuloplasty device was seated on the
mitral valve annulus and each suture was tied using [extracorporeal knot pusher or Core Knot] and cut.
In the event of a mitral valve replacement: The mitral valve was measured using mitral valve sizing tools. It was measured
from along the anterior leaflet from anterior to posterior commissure and a [size] mitral valve prosthesis was selected. The
anterior leaflet of the mitral valve was excised sharply from the posterior to anterior commissure. The posterior leaflet was
left in situ to protect the AV groove. Next, 2-0 Ethibond sutures were placed in each trigone. Additional 2-0 Ethibond sutures
were placed along the annulus posteriorly. Finally 2-0 Ethibond sutures were placed along anterior annulus. The sutures were
placed through the sewing ring of the valve prosthesis. The prosthesis was seated on the mitral valve annulus and each suture
was tied using [extracorporeal knot pusher or Core Knot] and cut.
Gentle distention of the left ventricle with cold saline revealed a competent valve in all zones. A vent was placed through the
atriotomy incision across the valve and the left ventricle. The atriotomy incision was closed with double layer of 4-0 prolene.
With the left ventricular vent and the aortic root vent on suction, the cross-clamp was removed and the heart re-perfused. It
was subsequently defibrillated and returned to normal sinus rhythm. The vents remained on suction until all micro-bubbles
were cleared from the circulation and cardiac tone returned. This was confirmed on echocardiography. The vents were then
removed. The vent sites were securely sutured with 4-0 prolene.
Temporary right atrial and right ventricular pacemaker wires were placed on the heart. Left ventricular function was
[description of EF] and the echocardiogram confirmed no residual mitral valve insufficiency. The venous cannula was
removed and bleeding was controlled by tying the purse-string suture in the anterior wall of the femoral vein. It was then
oversewn with 5-0 prolene. After obtaining proximal and distal control of the femoral artery with vascular clamps, the arterial
cannula was removed. The arteriotomy was then closed with a running 5-0 prolene suture. Distal pulses were confirmed and
the femoral artery was palpated to assure no residual thrill in the artery. Heparin was reversed with protamine.
Hemostasis was obtained at all operative site. A 24 Fr Blake drain was placed within the pericardium. The pericardium was
partially closed over the ascending aorta and the right atrium. A 28 Fr straight chest tube was placed in the right pleural cavity.
An intercostal block was performed using 0.25% Marcaine. The intercostal space was then closed with blunt #2 Vicryl
sutures. The fascia was closed in 3 layers with vicryl suture. The skin was then closed with 4-0 monocryl sutures in a running
subcuticular fashion. The groin incision was also closed in layers with vircyl and monocryl suture. The patient was brought to
the recovery room in stable condition without complication.
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Dr. [BLANK] was present and scrubbed for [BLANK] elements of this procedure.
25. Mitral Valve Repair for Bileaflet Prolapse
Sameh M. Said, MD, and Hartzell V. Schaff, MD
Mayo Clinic, Rochester, MN
Essential Operative Steps
1. Lines and Monitoring
2. General endotracheal anesthesia
3. Intraoperative transesophageal echocardiogram
4. Median sternotomy
5. Open pericardium, elevation of the right side of the pericardium with stay sutures, survey ascending aorta for plaque
burden and cannulation site
6. Systemic heparinization (400 U/Kg)
7. Aortic cannulation
8. Venous cannulation-single two-stage right atrial cannula
9. Aortic root vent/cardioplegia needle
10. Check ACT (>400 sec)
11. Initiate cardiopulmonary bypass
12. Maintain normothermia
13. Aortic cross clamp (reduce pump flow rate, apply cross clamp, increase pump flow rate to 2.0-2.5 L/min/m
2
)
14. Antegrade cold blood cardioplegia (1000-1200 ml)
15. Dissect Waterston’s groove
16. Standard left atriotomy
17. Expose and assess the mitral valve (fill left ventricle with cold saline to identify the mechanism of regurgitation)
18. Triangular excision or plication of the prolapsed posterior leaflet
19. The remaining edges of the posterior leaflets are sewn together in two layers with 4-0 Prolene suture or plication
with figure of-eight 4-0 Prolene
20. For anterior leaflet repair, artificial chordae (Gore-Tex) are used to correct prolapse
21. Posterior annuloplasty band (63 mm in length) is placed from trigone-to-trigone secured with interrupted 2-0
Ethibond, usually 7 or 8 sutures
22. The mitral valve is checked with cold saline injection into the left ventricle, ensure aortic root vent is off
23. Left atriotomy closure
24. De-airing maneuvers
25. Lowering pump flow rate and removal of aortic cross clamp
26. Check for hemostasis
27. Placement of epicardial atrial and ventricular pacing wires
28. Chest tube placement
29. Wean from cardiopulmonary bypass
30. Evaluate mitral valve with transesophageal echocardiogram
31. Venous decannulation
32. Ensure adequate de-airing of the heart prior to removal of aortic root vent
33. Protamine administration for heparin reversal
34. Aortic decannulation (systolic blood pressure 90-100 mmHg)
35. Assess hemostasis
36. Sternotomy closure
Potential Complications and Pitfalls
1. Stay midline during sternotomy
2. Avoid injury to the innominate vein while making pericardial well
3. Cannulation catastrophe (aortic dissection/hematoma, right atrial tear)
4. Poor choice of location of aortic cannula/cross clamp (risk of stroke)
5. Injury of the pulmonary artery during cross clamp application
6. Insufficient myocardial protection and cardiac arrest (cross clamp not across, aortic regurgitation with secondary
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ventricular distension)
7. Feel the left ventricle during administration of antegrade cardioplegia to ensure absence of ventricular distension and
uniform cooling of the ventricle with cardioplegia
8. Poor venous drainage (incorrect choice of cannula size, advancing the two-stage cannula too far in so it is obstructing
hepatic veins)
9. Failure to dissect Waterston’s groove
10. Improper dissection of the Waterston’s groove with inadvertent opening of the right atrium close to the inferior vena
cava
11. Opening the left atrium close to the right superior pulmonary vein with subsequent difficulty in exposing the mitral
valve
12. Retractor injury with subsequent shearing tear of the left atrial wall edges which complicates closure
13. Failure to recognize important vital structures in relation to the mitral valve: atrioventricular node, coronary sinus,
aortic valve and circumflex coronary artery
14. Excessive excision of the prolapsed leaflet tissue which may compromise the repair
15. Poor judgement of the neochordal length with either persistence of leaflet prolapse or poor leaflet coaptation
16. Improper placement of the annuloplasty sutures with misidentification of the mitral annulus and subsequent placement
of the sutures in the left atrial wall
17. Deep placement of annuloplasty sutures with subsequent injury to the circumflex coronary artery in a left dominant
system
18. Improper de-airing prior to removal of aortic root vent
19. Failure to recognize systolic anterior motion (SAM) of the mitral valve anterior leaflet postrepair by transesophageal
echocardiogram
20. Inadequate control of hemostasis prior to sternal closure/bleeding from cannulation sites
21. Improper closure of sternotomy
Template Dictation
Preoperative Diagnosis:
1. Severe mitral valve regurgitation
2. NYHA class II
3. Prolapse of the middle scallop of the posterior leaflet
4. Prolapse of the middle segment of the anterior leaflet
Postoperative Diagnosis: Same
Procedure(s) Performed:
1. Mitral valve repair with triangular excision of the unsupported lateral half of the middle scallop of the posterior
leaflet
2. Placement of two artificial Gore-Tex chordae to the middle segment of the anterior leaflet
3. Insertion of C-shaped posterior annuloplasty band (63 mm)
4. Establishment of temporary extracorporeal circulation using the FX15 membrane oxygenator with 3000-ml reservoir
with 3/8 loop to 37 degrees
5. Cardioplegic arrest (blood) 4:1
6. Intraoperative transesophageal echocardiography
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Drainage: 2 No. 32 Argyle chest tubes
Indication(s) for Procedure: [AG E] year old [GENDER] with [DURATION] history of [CO MPLAINT –e.g. increasingly
shortness of breath]. Preoperative transthoracic echocardiography reveals [FINDINGS - e.g. severe mitral valve regurgitation
secondary to bileaflet prolapse, rupture chord of the middle scallop of the posterior leaflet with estimated ejection fraction of
50-55%], and preoperative coronary angiography revealed non-significant coronary artery disease.
Description of the Procedure: After satisfactory general endotracheal anesthesia was induced, a right internal jugular central
venous line, pulmonary artery catheter and radial arterial line were inserted. Preincision transesophageal echocardiogram was
then performed to evaluate the mitral valve and cardiac function. The patient was prepped and draped from chin to knees while
in the supine position. A standard median sternotomy was performed and Morse sternal retractor was placed. We opened the
pericardium in an inverted T-shape fashion and pericardial stay sutures were placed on the right side. Heparin was given
systemically and a 20-French DLP cannula was inserted through two pursestring sutures in the distal ascending aorta, secured
and de-aired. A two-stage cannula was placed in the right atrium for venous return and was secured. An aortic root
cardioplegia/vent was then inserted. After confirming ACT of more than 400 seconds, cardiopulmonary bypass was
commenced at 2.4 L/min per m2 for 41 minutes. We maintained normothermia during perfusion. The aorta was cross clamped
and 1 L of antegrade cold blood cardioplegia was administered. Waterston’s groove was dissected and an incision was then
made posterior to the interatrial groove to expose the mitral valve. There was redundancy of the valve, and the appearance
was typical for a myxomatous mitral valve disease. The prolapsing portion of the posterior leaflet was the lateral half of the
middle scallop and the medial half of the lateral scallop. We excised this area in a triangular fashion and sewed the middle
scallop to the lateral scallop in two layers with 4-0 Prolene. The middle segment of the anterior leaflet was noted to prolapse
as well, and we placed two 2/0 Gore-Tex sutures to this prolapsed segment passing each limb of the suture twice through the
free edge of the leaflet. One mattress suture was anchored to the anterolateral papillary muscle and one was anchored to the
posteromedial papillary muscle. The valve was tested with saline infusion to facilitate adjustment of the Gore-Tex suture
length, and the sutures were tied with multiple knots. Next, seven interrupted mattress sutures of 2-0 Ethibond were placed
along the posterior circumference of the valve beginning at the right and ending at the left fibrous trigones. These sutures were
passed through a 25 Medtronic annuloplasty band (63 mm in length) and tied securely. We tested the valve, and there was no
leakage. The left atrial incision was closed with 3-0 Prolene. Air was evacuated from the heart and the aortic cross-clamp
was released after 30 minutes. Sinus rhythm was restored with a single countershock. We de-aired the heart thoroughly and
discontinued bypass easily. No inotropic agents were required. Postprocedure transesophageal echocardiography confirmed
absence of mitral regurgitation, good ventricular function and absence of SAM.
The right atrium was decannulated and confirmation of adequate de-airing of the heart, the aortic root vent was removed.
Protamine was administered followed by removal of the aortic cannula. All cannulation sites were reinforced with 3-0 and 4-0
Prolene sutures. Two atrial pacing wires were attached to the heart. Two No. 32 Argyle chest tubes were led into the
mediastinum through stab wounds inferior to the incision. After adequate hemostasis was obtained, we closed the chest using
interrupted stainless steel wire for the sternum and Vicryl for the subcutaneous and subcuticular layers.
All instrument, sponge and needle counts were confirmed to be correct x 2 at the end of the operation. The patient tolerated the
procedure well and was transferred to the intensive care unit in a stable hemodynamic condition.
Intraoperative autotransfusion was present.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of this procedure.
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