Pascotto Sample 1
SURGEON:
Robert D Pascotto, MD
ASSISTANT:
Dan Beitelschies, PA
DATE OF PROCEDURE:
10/14/2004
PREOPERATIVE DIAGNOSIS:
Critical aortic stenosis with associated
bicuspid valve.
POSTOPERATIVE DIAGNOSIS:
Critical aortic stenosis with associated
bicuspid valve.
PROCEDURE PERFORMED:
Aortic valve replacement utilizing a 25-mm
Carbomedics mechanical prosthesis.
ANESTHESIA:
General endotracheal anesthesia.
OPERATIVE FINDINGS:
At the time of operation the patient had a
bicuspid densely calcified aortic valve. Once this was excised, the annulus accepted a
25-mm sizer and a Carbomedics valve as previously discussed with the patient was
implanted. The patient was weaned from cardiopulmonary bypass without difficulty.
PROCEDURE DESCRIPTION:
After satisfactory general endotracheal
anesthesia was accomplished, the patient was prepped and draped in the customary
fashion. A median sternotomy incision was made and the sternum was split and the
pericardium was entered. The patient received heparin intravenously. Aortic cannulation
as well as single two-stage venous cannulae was inserted and cardiopulmonary bypass
was initiated. While the patient was being cooled to 26 degrees centigrade, aortic crossclamp was applied and the patient received 1500 cc of cold blood cardioplegia
retrograde. Throughout the cross-clamp period, the patient received intermittent doses
of cold blood cardioplegia retrograde into the coronary sinus every 15 minutes.
Antegrade cardioplegia was not delivered as the patient did have associated mild aortic
insufficiency.
An oblique incision was made on the proximal aspect of the ascending aorta and the
above-described densely calcified bicuspid valve was appreciated. The valve was
excised with great care taken not to allow any spicules of calcium to fall within the left
ventricular cavity. Once he valve was excised, the annulus was debrided of a significant
amount of calcification. The calcification extended onto the anterior leaflet of the mitral
valve. Once this was accomplished, the annulus accepted a 25-mm sizer and a
Carbomedics mechanical prosthesis as previously discussed with the patient was
selected. Seventeen (17) horizontal mattress sutures of #2-0 Ethibond were then placed
with pledgets through the aortic annulus with the pledgets on the ventricular side.
Subsequently they were placed through the sewing ring of the valve and the valve sat
within the annulus quite satisfactorily. The sutures were secured. The leaflets opened
without difficulty and the coronary ostia, that is, both the right and left coronary ostia
were visualized and were not encumbered by the valve at all.
The aortotomy was then closed in two layers with a running horizontal mattress suture of
#4-0 Prolene followed by an over-and-over suture of #4-0 Prolene. Prior to closure of
the annular aortotomy, the patient was placed in a steep Trendelenburg position and the
de-airing procedure was accomplished in the customary fashion. While retrograde blood
cardioplegia was being delivered, the aortic tack was also utilized. Once this was
accomplished, the aortotomy was closed and the aortic cross clamp was released after
101 minutes. The rewarming process was continued. This took a while as the patient
was overweight.
Once the patient was at 37.5 degrees Centigrade and in normal sinus rhythm, she was
weaned from cardiopulmonary bypass after a 136-minute average flow of 4.0 liters per
minute. Post-bypass transesophageal echocardiogram performed by Dr. Clark from
Anesthesia demonstrated good ventricular function. No significant air on the left side of
the heart. There was no perivalvular leak and the valve leaflets opened and closed
without difficulty.
The patient was then decannulated, the purse string sutures secured and heparin
reversed with protamine sulfate. Right ventricular pacing wires were placed. The
sternum was then approximated with wires after platelet gel was applied. Customary
closure was accomplished and a subcuticular closure for the skin.
Dry sterile dressings were applied and the patient went to the open-heart recovery unit in
satisfactory condition.
Pascotto Sample 2
SURGEON:
Robert D Pascotto, MD
ASSISTANT:
Dan Beitelschies, PA.
DATE OF PROCEDURE:
11/26/2004
PREOPERATIVE DIAGNOSIS:
Unstable angina pectoris secondary to
critical multivessel coronary artery
disease with totally occluded left anterior
descending, status post large anterior
myocardial infarction in the distant past,
moderately severe left ventricular
dysfunction.
POSTOPERATIVE DIAGNOSIS:
Unstable angina pectoris secondary to
critical multivessel coronary artery
disease with totally occluded left anterior
descending, status post large anterior
myocardial infarction in the distant past,
moderately severe left ventricular
dysfunction.
PROCEDURE PERFORMED:
Four vessel coronary artery bypass graft
surgery (SVG-distal RCA, left radial-
obtuse marginal, SVG-diagonal, LIMALAD).
ANESTHESIA:
General endotracheal anesthesia.
OPERATIVE FINDINGS:
At the time of operation, the patient's heart
had a fibrous scarring around it. As noted above, he had a totally occluded left anterior
descending with critical multivessel coronary artery disease. The patient had an
intraoperative transesophageal echocardiogram performed by Dr. Ralph Gregg and
demonstrated trivial mitral regurgitation that was trivial to mild immediately after
termination of cardiopulmonary bypass. The patient went to the open heart recovery unit
in satisfactory condition.
PROCEDURE DESCRIPTION:
After satisfactory general endotracheal
anesthesia was accomplished the patient was prepped and draped in the customary
fashion. A concomitant incision was made overlying the chest and the left leg. The left
saphenous vein was dissected out endoscopically for its full length. The vein was
removed from its bed, prepared in the customary fashion, and a layered closure was
accomplished in the two small incisions of the leg. The left radial artery was harvested
in the customary fashion and incision was made from the wrist to the elbow crease. A
pulse oximeter was placed on the index finger of the left hand. It had an excellent wave
form as well as 100% saturation prior, during and after the radial artery was harvested.
A layered closure was accomplished.
A median sternotomy incision was made and the sternum was split. The left internal
mammary was dissected out and after heparin was administered, dissected distally, flow
was checked and noted to be satisfactory.
The pericardium was entered. Aortic cannulation as well as a single, two-stage venous
cannula was then inserted and cardiopulmonary bypass was initiated. While the patient
was being cooled to 28 degrees centigrade aortic cross-clamp was applied and the
patient received 1000 cc of cold blood cardioplegia antegrade. Throughout the crossclamp the patient received intermittent doses of cold blood cardioplegia both antegrade
into the aortic root as well as antegrade through the grafts.
The distal anastomosis was performed in the following fashion: A reverse segment of the
saphenous vein was sutured end-to-side to the distal right coronary artery. The left
radial was placed to the obtuse marginal, a second segment of vein to the diagonal and
lastly, the left internal mammary artery to the left anterior descending. #7-0 Prolene was
used for the construction of the four distal anastomoses. The aortic cross-clamp was
released a partial occluding clamp was placed on the ascending aorta and a three
proximal anastomoses were performed with #5-0 Prolene. The proximal anastomotic
sites were marked with washers.
All the areas were checked and with the heart being placed right ventricularly, the patient
was weaned from cardiopulmonary bypass without difficulty and with satisfactory
hemodynamics. All areas were checked. Hemostasis being achieved, the patient was
decannulated, pursestring sutures secured and heparin reversed with protamine sulfate.
A left pleural tube, which was a $19 French Blake drain was placed. Two anterior
mediastinal tubes were placed.
The sternum was approximated with wires. Customary closure was accomplished in a
subcuticular closure for the skin. Dry sterile dressings were applied and the patient went
to the open-heart recovery unit in satisfactory condition.
Pascotto Sample 3
SURGEON:
Robert D Pascotto, MD
ASSISTANT:
Dan Beitelschies, PA
DATE OF PROCEDURE:
11/21/2004
PREOPERATIVE DIAGNOSIS:
1. Cardiogenic shock secondary to acute
anterior wall myocardial infarction with
severe left ventricular dysfunction,
pulmonary edema and congestive heart
failure with:
2. Severe left main disease.
3. Severe triple-vessel disease.
4. History of hypertension.
5. History of hyperlipidemia.
6. Possible history of diabetes mellitus.
POSTOPERATIVE DIAGNOSIS:
1. Cardiogenic shock secondary to acute
anterior wall myocardial infarction with
severe left ventricular dysfunction,
pulmonary edema and congestive heart
failure with:
2. Severe left main disease.
3. Severe triple-vessel disease.
4. History of hypertension.
5. History of hyperlipidemia.
6. Possible history of diabetes mellitus.
PROCEDURE PERFORMED:
1. Five-vessel coronary artery bypass graft
surgery (saphenous vein graft-diagonalleft anterior descending sequential graft,
saphenous vein graft-first obtuse
marginal-second obtuse marginal
sequential graft sequential graft,
saphenous vein graft-posterior
descending artery) - salvage procedure.
ANESTHESIA:
General anesthesia.
OPERATIVE FINDINGS:
After the induction of anesthesia, the patient
became more hypotensive and required more pressors. Therefore, cardiopulmonary
bypass was instituted without taking down the left internal mammary artery. Upon
entering the pericardium, the patient had an infarcted anterior wall with some thinning of
the area and collaterals over the left anterior descending, compatible with a previously
occluded left anterior descending. All vessels were satisfactory targets for grafting
except for the left anterior descending, which was a diffusely diseased vessel and which
accepted only the 1-mm probe. The patient came off of cardiopulmonary bypass with
the use of the previously placed intraaortic balloon that was placed by Dr. Lee in the
catheterization laboratory as well as multiple pressors. He was then taken to the
intensive care unit in critical condition.
PROCEDURE DESCRIPTION:
After satisfactory general endotracheal
anesthesia was accomplished, in actuality, the patient had been intubated in the
catheterization laboratory because of severe pulmonary edema. In actually, we opened
both hemithoraces and he had 1450 cc of pleural fluid in the right hemithorax and 1100
cc of pleural fluid in the left hemithorax, compatible with congestive heart failure.
The patient was rapidly prepped and draped in the customary fashion. After the
induction of anesthesia, the patient became more hypotensive and required more
pressors. Therefore, cardiopulmonary bypass was rapidly instituted without taking down
the left internal mammary artery. The pericardium was entered and aortic cannulation
as well as a single two-stage venous cannula were inserted and cardiopulmonary
bypass was initiated. While the patient was being cooled to 26 degrees centigrade, the
coronary arteries were dissected out. A left ventricular vent was inserted through the
right superior pulmonary vein as the left heart was dilated from his ischemic
cardiomyopathy. A cannula was placed in the coronary sinus for delivery of retrograde
blood cardioplegia. The aortic cross-clamp was applied and the patient received 800 cc
of cold blood cardioplegia antegrade and another 200 cc of cold blood cardioplegia
retrograde into the coronary sinus. Throughout the cross-clamp period, the patient
received intermittent doses of cold blood cardioplegia both retrograde into the coronary
sinus as well as antegrade in the aortic root as well as antegrade through the grafts.
The distal anastomosis was performed in the following fashion: A reverse segment of the
saphenous vein was sutured end-to-side to the posterior descending artery. A second
segment of reverse vein was sutured end-to-side to the second obtuse marginal and
then transversely side-to-side to the first obtuse marginal. A third segment was placed
longitudinally side-to-side to the diagonal and end-to-side to the left anterior descending.
#7-0 Prolene was used for the construction of the five distal anastomoses. The aortic
cross-clamp was released after 68 minutes and then a partial occluding clamp was
placed on the ascending aorta and the three proximal anastomoses were performed
during the rewarming process. #5-0 Prolene was used for the construction over the
proximal anastomotic sites. The sites were marked with washers.
Temporary atrial and ventricular pacing wires were placed and with the patient at 38
degrees Centigrade, he had been cooled to 26 degrees, the patient was weaned from
cardiopulmonary bypass, AV sequentially paced with the utilization of intraaortic balloon
as well as Inocor, epinephrine and Levophed. After a period of observation after the
completion of the cardiopulmonary bypass, the patient was decannulated. A purse
string suture was secured. It should be appreciated that retrograde warm blood had
been delivered right after the institution of cardiopulmonary bypass as well as after the
cross-clamp was applied to more adequately perfuse the myocardium while the proximal
anastomoses were being constructed. Also, cardioplegia was being given antegrade
utilizing an Octopus cardioplegia delivery system into the grafts.
Cardiopulmonary bypass was initiated as noted after 132 minutes. All areas were
checked. Hemostasis being achieved, the patient was decannulated, a purse string
suture secured and heparin reversed with protamine sulfate. A pleural tube was placed
into each hemithorax and two anterior mediastinal tubes. The sternum was
approximated with wires. Customary closure was accomplished and a subcuticular
closure for the skin.
It should be appreciated that the left saphenous vein was dissected out for its full length
and that was also closed in layers and staples for the skin. Dry sterile dressings were
applied and the patient went to the open-heart recovery unit in critical condition.