Physician: Mark D. Plunkett, M.D.
Author: Heather Nolan, BA, AS
Center for Minimally Invasive Surgery
For Aortic Root Repair/Replacement
 Aortic root aneurysm
 Aortic dissection affecting both root and valve
 Symptoms: cough, diastolic murmur, dysphasia, dyspnea on
exertion, fatigue, palpitations, and widened pulse pressures
For Aortic Valve Repair/Replacement
 Aortic valve stenosis
 Aortic valve insufficiency
 Aortic regurgitation
 Symptoms: angina, dizziness, fainting, fatigue, shortness of breath,
swelling of ankles and legs, arrhythmia, and palpitations
For Pulmonary Valve Repair/Replacement
 Pulmonary valve stenosis
 Pulmonary valve insufficiency
 Pulmonic regurgitation
 Symptoms: dyspnea, angina, cyanosis, congestive heart failure,
fatigue, fluid retention, cough, cardiomegaly, and syncope
Center for Minimally Invasive Surgery
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Chest X-Ray
 Electrocardiogram
 Echocardiogram
 Cardiac Catheterization
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Echo Techs
Anesthesiologist
Surgeon 2
Scrub Tech 2
Perfusionist
Surgeon 1
Scrub Tech 1
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Anesthesia Workstation
Transesophageal Echocardiograph
Heart-lung Machine
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For more
information:
www.udmercy.edu/crna/a
gm/02.htm
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For more information:
www.med.yale.edu/intmed/cardio/imaging/
techniques/echo_tee/index.html
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For more
information:
www.surgeryencyclopedia.
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Camera Monitors
45° Laparascope
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Hemoclip appliers +
Vascular clamps +
Forceps +
Needle holders +
Handles +
Nerve hooks +
Penfield
Tourniquets
Dilators +
Spring instruments +
Retractors +
Defibrillator paddles
Mosquitos +
Hemostats
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Kellys, Tonsils, Kockers, Allis
Clamps +
Scissors +
Sponge sticks
Tubing clamps
Wire cutter
Malleables +
Weitlanders
Suction tips +
Suction tube
Tube holder
Cross-clamp
Sternal wire (needle included)
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Procedure Steps
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Small hemoclip appliers
Medium hemoclip appliers
Short yellow hemoclip appliers
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Left blue titanium vascular clamp
Right blue titanium vascular clamp
Deborah Castaneda clamp
Castaneda anastomosis clamp
Derra partial occlusion clamp
Cooley derra clamp
Debakey anastamosis clamp
Debakey general purpose clamp
Straight Debakey bulldog clamp
Debakey spoon perivascular clamp
Debakey multipurpose clamp
Debakey acutely curved clamp
Angled Debakey
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Adson tissue forceps with teeth
Gerald forceps
Debakey forceps
Scanlon smooth tip forceps
Scanlon Debakey fine forceps
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Castro round handle locking needle holder
Non-locking castro round handle needle holder
Fine tip Scanlon needle holder
Sarot needle holder
Creelewood needle holder
Small Berry needle holder
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Beaver handle
Knife handle
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Dandy nerve hook
Dull nerve hook
Sharp nerve hook
Mid tip Janetta right angle hook
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1.0 dilator
1.5 dilator
2.0 dilator
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3.0 dilator
Joseph hook single prong
Aortic arch dilator
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Spring Potts scissor flat handle
Spring Potts scissor round handle
Small Dietrich bulldog
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Kirkland retractor
ALM retractor
Finochetto retractor
Morse retractor
Chest retractor
Ragnell retractor
Sharp Senn retractor
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Vein retractor
Army-Navy retractor
Ankenney retractor
Touffier retractor
Dr. Salley retractor
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CVD mosquito
STR mosquito
Jacobson mosquito
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Jacobs clamp
Pennington clamp
Right angle clamp
Small tubing clamp
Medium tubing clamp
Peer towel clamps
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STR Mayo scissors
CVD Mayo scissors
Metz scissors
Curved fine Cooley scissors
Curved heavy Cooley scissors
Demartel scissors
Jamison black handle supercut scissors
Straight Mayo Harrington scissors
Wire scissors
Pump line scissors
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1/4” malleable
5/8” malleable
3/8” malleable
1/2” malleable
3/4” malleable
1” malleable
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Boss pump suction tip
Frazier suction tip
Yankauer suction tip
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Make sternotomy incision (more)
Place heart on cardiopulmonary bypass (more)
Add cardioplegic agent (more)
Expose and remove aortic valve
Size aortic replacement valve (more)
Expose and remove pulmonic valve
Size pulmonic valve replacement (more)
Attach aortic valve and root replacement to heart (more)
Expose left coronary artery
Expose and trim native aortic root
Attach pulmonary homograft (more)
Attach coronary arteries to aortic root replacement (more)
Attach aortic root replacement to ascending aorta (more)
Take heart off cardiopulmonary bypass (more)
Close (more)
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Post-Operative Care
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Make incision along sternal midline using scalpel
Cauterize any bleeding vessels
Use sternal saw to cut sternum
Apply bone paste to cut edge of sternum
Place sterile towels on cut edge of sternum
Use retractors to access surgical area
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Procedure Steps
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Put purse string suture into superior vena cava
Thread suture through tourniquet and secure with hemostat
Cut vein wall
Insert bypass cannula into vein
Cinch tourniquet and secure with hemostat
Repeat above to inferior vena cava
Repeat for aorta
Attach retrograde cardioplegia
Cross-clamp aorta
Connect cannulae to bypass tubing
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Procedure Steps
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Uncinch tourniquet of superior vena cava
Remove cannula while simultaneously tightening purse string
sutures
Add 6 knots to purse string suture
Repeat for inferior vena cava
Repeat for aorta
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Procedure Steps
For Antegrade Cardioplegia
 Once aortic valve is removed, administer cardioplegic agent
at the aortic root
 Repeat approximately every 20-30 minutes
For Retrograde Cardioplegia
 use purse string sutures to place retrograde cannula in
coronary sinus
 Cardioplegic agent is administered continuously
 Remove cannula, close purse strings, tie off suture
Antegrade versus Retrograde Considerations
 Size of anatomy
 Length of procedure
 Access to coronary sinus and aortic root
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Procedure Steps
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Replacement valve sizes range from 16-33 mm
These sizes are measured as the external diameter of the
prosthetic valve with the sewing ring compressed
Use a valve sizing tool (pictured) to get optimal size
Match the replacement size to the native valve
Error on the large side to get the largest possible diameter
for maximal blood flow
Check valve function prior to placement
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Procedure Steps
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Replacement includes valve and root
When removing native aorta/aortic root detach the coronary ostia
(opening) from the aorta leaving a small rim of aortic tissue
(Note: this is deemed the “button”)
Size aortic replacement device (valve and root combination)
Suture the device to the aortic annulus (fibrous tissue ring
surrounding the opening to the aorta) (more)
Cut two holes in the root replacement for the coronary ostia using a
thermal cutter or blade
Suture the coronary ostia to the root replacement (more)
Trim the root replacement to size
Suture root replacement to native ascending aorta
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Procedure Steps
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Use pledgetted sutures
Run end one of suture through the annulus starting from under the
annulus
(animation)
Run end one of suture through device’s sewing ring starting from
under the device
Repeat with end two so that pledgett is up against underside of
annulus
Alternate suture colors to allow for easier manipulation and tying of
the device to the annulus
Push device into the annulus using previously placed suture to
guide the device into place
Needle
Tie sutures in place
Pledgett
Annulus
Suture
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Bentall Steps
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Use a teflon strip for reinforcement
Place ostia within pre-cut opening in an end-to-side manner
Use a running stitch to secure ostia to device
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Bentall Steps
Replacement valves can be biological or mechanical
Biological Replacement Valves
 A homograft, or allograft, comes from a human donor (pictured-in forceps)
 A xenograft comes from animal tissue
 Another option for aortic valve replacement is a pulmonary autograft in
which the aortic valve is replaced with the patient’s native pulmonary
valve
Mechanical Replacement Valves
 Are manmade and come in a variety of designs and materials
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Biological Versus Mechanical Considerations
 Biologic valves reduce the risk of associated clots but are not
as durable
 Mechanical valves theoretically will last forever; however, there
is an increased risk of clotting on the prostheses which can lead
to stroke
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Procedure Steps
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Place external pacemaker leads
Check pacemaker leads and pacing
Place chest tube drainage cannulae
Prepare exposed sternal bone for closure using bone paste and
electrocautery
Use sternal wires with the attached needle to close the sternum
Twist sternal wires together (twist number varies but 3-4 is
recommended for optimal strength)
Bend exposed metal ends of sternal wire toward sternum
Close fascia
Close skin
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Procedure Steps
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Connect patient to ventilator
 Monitor ECG, oxygen saturation, blood
pressures, and blood gases
 Check urinary output and chest tube output
 Prior to discharge: wean off ventilator, train
patient on incentive spirometer,
anticoagulation therapy, diet as tolerated,
and ambulation
Center for Minimally Invasive Surgery
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Thrombosis
 Valve malfunction/failure
 Root replacement malfunction/failure
 Infection
 Arrythmia
 Death
Center for Minimally Invasive Surgery