DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Mitral valve prolapse, flail posterior leaflet, posterior leaflet cleft.
2. Anomalous origin of the right coronary artery from the left coronary cusp.
POSTOPERATIVE DIAGNOSES:
1. Mitral valve prolapse, flail posterior leaflet, posterior leaflet cleft.
2. Anomalous origin of the right coronary artery from the left coronary cusp.
OPERATION PERFORMED:
1. Median sternotomy, cardiopulmonary bypass.
2. Mitral valve repair with posterior leaflet segmental resection and ring annuloplasty.
3. Repair of cleft.
4. Reverse saphenous vein bypass to right coronary artery with ligation of the right coronary artery proximally.
SURGEON: John Doe, MD
DESCRIPTION OF PROCEDURE: Under general endotracheal anesthesia, the patient was prepped and draped from the chin to the ankles in the usual fashion. We made a primary median sternotomy and opened the pericardium. There was no pericardial effusion. Transesophageal echo confirmed the presence of a flail P2 segment with severe mitral regurgitation. The anomalous origin of the right coronary artery was also seen by echo. We removed a segment of the saphenous vein from the patient’s left thigh. The vein was of excellent quality. The leg incision was closed in layers of Vicryl. Pericardial stay sutures were placed and the aorta was cannulated using 2 pursestring sutures of 4-0 Prolene.
We cannulated the superior and inferior vena cava separately. The patient was heparinized and cardiopulmonary bypass was instituted. We used a retrograde coronary sinus catheter to administer cardioplegia. In addition, we used an antegrade needle for administration of cardioplegia and for post bypass venting of air. Cardiopulmonary bypass was instituted and the aorta was cross clamped. We placed a caval tape around the superior and inferior vena cava. We opened the left atrium posterior to the intra-atrial groove. The mitral valve was exposed using a Cosgrove retractor. There was a flail segment of the P2 segment of the posterior leaflet with ruptured chordae. This was resected sharply.
We placed multiple valve sutures around the annulus. The commissures were sized and an appropriate annuloplasty ring was selected. The posterior leaflet was repaired using a running 5-0 Prolene suture. There was an additional cleft at P1 and this was also repaired using 5-0 Prolene suture. The valve sutures were then passed through the flexible ring and the ring was placed on the annulus and the sutures were tied and cut. We tested the valve and there was no residual leak. We deaired the ventricle and closed the atriotomy using 2 layers of running 4-0 Prolene suture. We placed a vent in the left atrium through the superior pulmonary vein. We then bypassed the right coronary artery in its mid portion using the reversed segment of saphenous vein. The distal anastomosis was performed with running 8-0 Prolene suture. The vein was trimmed and the proximal anastomosis was performed using 6-0 Prolene suture.
The patient was then deaired and the cross-clamp was removed. A spontaneous sinus rhythm resumed. We placed a single ventricular pacing wire on the right ventricle exiting through an inferior stab wound. We placed 2 chest tubes through separate inferior stab wounds. We gave protamine and removed all cannulas from the patient, repairing the cannulation sites with 4-0 and 5-0 Prolene suture as needed. Following the administration of protamine, we achieved hemostasis and then closed the chest using interrupted wire in the sternum, running 0 Vicryl in the fascia, 2-0 Vicryl in the subcutaneous tissue and 3-0 Vicryl in the skin. Sterile dressings were applied and the patient left the operating room in guarded, but stable hemodynamic condition.
