Pulmonary Valve Replacement with Bentall/Aortic Valve and Root

Report
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
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Chest X-Ray
 Electrocardiogram
 Echocardiogram
 Cardiac Catheterization
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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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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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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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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
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Thrombosis
 Valve malfunction/failure
 Root replacement malfunction/failure
 Infection
 Arrythmia
 Death
Center for Minimally Invasive Surgery

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