Pricing
Sign Up
Video preload image for Aortic Hemiarch and Valve Replacement for Severe Aortic Stenosis with Ascending Aortic Ectasia
jkl keys enabled
Keyboard Shortcuts:
J - Slow down playback
K / Space - Play / Pause
L - Accelerate playback
  • Title
  • 1. Introduction
  • 2. Midline Incision and Sternotomy
  • 3. Pericardiotomy and Pericardial Well
  • 4. Heparinization and Aortic Dissection
  • 5. Distal Aortic Arch Cannulation
  • 6. Venous Return Cannulation into Right Atrial Appendage and Right Atrium and IVC
  • 7. Retrograde Cardioplegia Cannulation into the Coronary Sinus
  • 8. Commencing Cardiopulmonary Bypass
  • 9. Left Ventricle Vent
  • 10. Antegrade Cardioplegia Cannulation into the Ascending Aorta
  • 11. Clamping the Ascending Aorta
  • 12. Cooling the Heart with Cardioplegia and Topical Cooling with Ice
  • 13. Resection of Ascending Aorta
  • 14. Aortic Valve Replacement
  • 15. Ascending Aorta Replacement
  • 16. Reversing CPB, Decannulation, and Restarting and Rewarming the Heart
  • 17. Hemostasis, Drain Placement, and Closure
  • 18. Post-op Remarks

Aortic Hemiarch and Valve Replacement for Severe Aortic Stenosis with Ascending Aortic Ectasia

3495 views

Adeel Ahmad, MD; Peter A. Collings, MD; Kirill Zakharov, DO
University of Michigan Health-Sparrow

Cardiac Surgery

Procedure Outline

Table of Contents

  1. 1. Introduction
    1. 2. Exposure and Cardiopulmonary Bypass Initiation
      1. 3. Left Atrial Appendage Ligation
        1. 4. Aortic Resection and Valve Excision
          1. 5. Aortic Valve Replacement
            1. 6. Ascending Aorta and Hemiarch Replacement
              1. 7. Distal Hemiarch Anastomosis
                1. 8. De-airing and Rewarming
                  1. 9. Weaning from Cardiopulmonary Bypass and Hemostasis
                    1. 10. Chest Tube Placement and Wound Closure
                      1. 11. Post-op Remarks
                        1. 12. Discharge Plan
                          1. Anesthesia: The patient was brought to the operating room and placed in the supine position. General endotracheal anesthesia was induced following placement of standard monitoring lines including invasive (arterial line, central venous catheter, Foley catheter) and noninvasive modalities (pulse oximetry, temperature probe). The chest, abdomen, and lower extremities were prepped and draped in sterile fashion. Cardiopulmonary bypass lines were primed and positioned.
                          2. Anticoagulation and Monitoring: Systemic anticoagulation was achieved with intravenous heparin, and an activated clotting time (ACT) greater than 460 seconds was confirmed prior to bypass initiation. Intraoperative transesophageal echocardiography (TEE) was used to confirm proper cannulation and assess aortic anatomy.
                          3. Patient Positioning: The patient remained supine with arms tucked. External defibrillator pads were placed for potential intraoperative pacing or defibrillation. Standard cardiac surgery exposure including bilateral groins and lower extremities was included in the surgical field preparation.
                          1. Median Sternotomy and Pericardial Exposure: A median sternotomy was performed. The pericardium was incised and retracted to form a pericardial well using stay sutures. Cardiopulmonary bypass (CPB) was initiated after appropriate cannulation.
                          2. Cannulation and Bypass
                            1. Arterial Cannulation: A distal aortic arch cannulation site was selected, secured with purse-string sutures, and accessed for arterial inflow. Placement and flow were confirmed with TEE.
                            2. Venous Cannulation: A dual-stage venous cannula was inserted via the right atrial appendage.
                            3. Cardioplegia and Venting: A retrograde cardioplegia catheter was inserted. Antegrade cardioplegia was connected. A left ventricular (LV) vent was placed via the right superior pulmonary vein.
                          3. Bypass Initiation: Retrograde autologous priming was completed, and full CPB was initiated with systemic cooling to 30°C.
                          4. Myocardial Protection: The ascending aorta was cross-clamped in an area free of disease. Myocardial arrest was achieved with antegrade and retrograde cold blood cardioplegia, reinforced every 20 minutes. Topical ice was applied for additional myocardial protection.
                          1. The left atrial appendage was ligated using a size 35 AtriClip device.
                          1. Ascending Aorta Resection: The aorta was transected at its midportion and dissected retrograde toward the cross-clamp until healthy aortic tissue was visualized. The proximal aorta was removed to the sinotubular junction. Specimens were sent for pathology.
                          2. Aortic Valve Resection: The native aortic valve was inspected and found to be bicuspid, heavily calcified, and sclerotic. Valve leaflets were sharply excised, and the annulus was thoroughly debrided. The LV cavity was irrigated to remove debris.
                          1. Suture Placement and Valve Implantation
                            1. A size 23 ON-X mechanical valve was selected after annular sizing.
                            2. 2-0 pledgeted Ethibond sutures were placed in a non-everting fashion around the annulus.
                            3. Sutures were passed through the sewing ring of the prosthetic valve and the valve was seated and tied securely.
                            4. The LV and ascending aorta were copiously irrigated before and after placement.
                          1. Proximal Anastomosis
                            1. A 28-mm Gelweave graft was trimmed and used to reconstruct the ascending aorta.
                            2. A felt sandwich technique was applied at the sinotubular junction.
                            3. The proximal anastomosis was sewn in a running fashion using 3-0 Prolene suture.
                            4. Cardioplegia tack vent was placed into the graft to allow de-airing.
                          1. A cross-clamp was placed on the aortic arch distal to the innominate artery but proximal to the left common carotid artery to allow for unilateral cerebral perfusion and complete lower body perfusion.
                          2. The hemiarch was anastomosed to the 28-mm Gelweave graft using standard technique.
                            1. Pledgeted sutures were used to reinforce the underside of the aorta as needed.
                            2. The graft was de-aired and clamped distally to re-establish bypass flow.
                          1. With the heart still arrested, de-airing was performed, followed by removal of the aortic cross-clamp. The heart resumed sinus rhythm with bradycardia, and systemic rewarming was initiated.
                          1. Weaning from Bypass: 
                            1. The patient was gradually rewarmed to 37°C. 
                            2. Spontaneous circulation resumed with dual chamber pacing wires placed. 
                            3. Intra-aortic balloon pump (IABP) support was resumed.
                          2. Decannulation: 
                            1. After hemodynamic stability was confirmed, bypass was discontinued. 
                            2. Protamine was administered to reverse heparin. 
                            3. Cannulas were removed uneventfully.
                          3. Hemostasis: Coagulopathic bleeding was managed with blood products (PRBCs, platelets, cryoprecipitate, and FFP) until hemostasis was obtained at all operative sites.
                          1. Two 24-Fr chest tubes were placed in the mediastinum (anterior and posterior to the heart).
                          2.  Additional chest tubes were inserted in the left and right pleural spaces.
                          3. The sternum was reapproximated with cables and reinforced with sternal plating.
                          4. The wound was irrigated, fascia and subcutaneous tissue were closed in layers, and skin was approximated with running absorbable suture. A Prevena wound vacuum-assisted closure (VAC) device was applied.
                          1. Immediate Post-op Recovery
                            1. The patient tolerated the procedure well and was transferred to the cardiothoracic intensive care unit in stable but critical condition. 
                            2. He was extubated the evening of surgery and did not require pressor support beyond the first postoperative day.
                          2. Postoperative Course
                            1. Diuresis: Managed with a step-down diuretic regimen (Lasix, Metolazone, Diamox) for fluid balance.
                            2. Hyponatremia: Treated with oral salt tabs.
                            3. Cardiac Rhythm: The patient remained in sinus rhythm. Amiodarone was given prophylactically.
                            4. Mobility: Early ambulation was initiated on postoperative day 1.
                          1. Our patient was discharged home on postoperative day 6.
                          2. Anticoagulation: Lovenox bridge to Warfarin with INR goal 2.0–3.0 for 3 months, then 1.5–2.0. Follow-up was scheduled with the anticoagulation clinic the following day.
                          3. Additional Discharge Medications:
                            1. Metoprolol 12.5 mg BID
                            2. Amiodarone 200 mg BID for 7 days
                            3. Atorvastatin 40 mg daily
                            4. Furosemide 20 mg daily × 3 days

                          Share this Article

                          Authors

                          Filmed At:

                          University of Michigan Health-Sparrow

                          Article Information

                          Publication Date
                          Article ID494
                          Production ID0494
                          Volume2025
                          Issue494
                          DOI
                          https://doi.org/10.24296/jomi/494