PATIENT NAME: KO, KANGWEI
DATE OF OPERATION: 11/06/2014
MEDICAL RECORD #: 40498087
ENCOUNTER #: 500007724577
SURGEON: ALAN HARTMAN
OPERATIVE REPORT
DOB: 10/24/1976
CO-SURGEON: LAWRENCE GLASSMAN, MD (057166)
FIRST ASSISTANT: Sanya PA
REFERRING PHYSICIANS: DR. SHUE AND DR. WARSCHAUER
CARDIAC ANESTHESIOLOGIST: IRENE STADNYK, MD (101758)
PREOPERATIVE DIAGNOSES:
1. Severe aortic insufficiency.
2. Obesity, status post morbid obesity surgery with complications including
ventral hernia and wound infection and ultimately a tracheal stenosis, which
was identified preoperatively.
3. Atrial fibrillation.
POSTOPERATIVE DIAGNOSIS: Atrial fibrillation
NATURE OF OPERATION: Procedure done today was an aortic valve replacement utilizing 25 bovine pericardial valve, Edwards Lifesciences, serial number 4093078. Bicuspid aortic valve was removed. Also, additional procedure was a bronchoscopy, examination of tracheal stenosis, and tube exchange. The surgeon was Dr. Hartman on the valve and Dr. Glassman on the bronchoscopy. Partial radiofrequency maze procedure.
SPECIMEN: Bicuspid aortic valve.
OPERATIVE INDICATIONS: The patient is a 38-year-old gentleman who has been in heart failure, severe aortic insufficiency, wide-open aortic insufficiency, and evidence of bicuspid aortic valve, who has had a difficult recovery from morbid obesity surgery. At the time that we examined him preoperatively, he clearly has evidence of tracheal stenosis for which this was worked up and found not to be stenotic significantly, but enough so that we felt that it needed to be examined through bronchoscopy during this procedure.
OPERATIVE PROCEDURE: He was placed on the OR table in supine fashion. After placement of arterial monitoring line, he was induced under general anesthesia. Swan-Ganz catheter placed. He was prepped and draped in usual sterile fashion. Midline sternotomy incision was made. Sternum divided with reciprocating saw. The pericardium was opened, tacked to soft tissue. Mediastinal pleura was opened into the right pleural space and a 32 channel drain was left in the right pleural space. Cannulation sutures placed in ascending aorta as well as right atrium. Heparin 30,000 units had been administered to achieve an activated clotting time of over 5000 seconds. The cannulation achieved. Cardiopulmonary bypass commenced, cooling to 28 degrees. Retrograde cardioplegia line was placed only; no antegrade because of the severe aortic insufficiency; vent line through the right superior pulmonary vein. Aorta was cross-clamped. Retrograde was given. The topical ice was used to augment myocardial cooling, kept below 10 degrees centigrade. A transverse aortotomy incision was made. Actually, it should also be noted that preoperatively, the patient had atrial fibrillation and the patient also had a partial radiogrequency maze procedure. An intraoperative partial maze procedure done with radiofrequency energy source. After cardiopulmonary bypass had been commenced and the patient was cooled down to 28 degrees and good cooling of the heart was achieved, the pulmonary veins on the right side were encircled and the cardioablation was done of the pulmonary veins on the right side. Once that was done, the ablation was done on the left pulmonary veins and this was done as well as bipolar coagulator. With that completed, attention was then placed toward the aortotomy. The aortic valve was excised. Annulus was debrided. A total of 19 sutures were placed circumferentially around the aortic annulus and through a 25 bovine pericardial valve. The valve was seated. Sutured were tied. Cardioplegia re-administered every 10 to 15 minutes. With good seating of the aortic valve, aortotomy was closed with two layers of 4-0 Prolene suture in running mattress fashion. Deairing maneuvers done. Once that was completed, rewarming commenced. The ablation was then done of the right atrium. Three lesion sets were placed in the right atrium including the atrial appendage, superior vena cava and inferior vena cava bipolar lesion sets. With that completed, deairing maneuvers were done further as AV sequential pacing ensured and drains were left, two mediastinal drains and also Blake drain. At 37 degrees, with good AV sequential pacing, the patient was weaned from cardiopulmonary bypass with excellent hemodynamics. The echocardiogram looked good. The protamine was administered. Two mediastinal chest tubes were left as mentioned. The sternum was closed with Robicsek technique, leaving wire on the right hemisternum and then double monofilament wire from both sternal halves.
. The bone was then irrigated with polymyxin. Soft tissue brought together with 0 Vicryl suture followed by 2-0 Vicryl suture. Skin closed with Biosyn. Actually, it should be noted that bacitracin was not used in the antibiotic solution, only polymyxin, because of his allergy. The soft tissue brought together with 0 Vicryl suture followed by 2-0 Vicryl suture. The skin was closed with Biosyn. Once that was completed, Dr. Lawrence Glassman arrived in the room and did a fiberoptic bronchoscopy. The trachea was examined. The circumferential narrowing was noted of the trachea and this area was examined, but not felt to be overly stenotic. The tube was changed from 7 to 7.5 and then the patient returned to the cardiothoracic intensive care unit in stable condition.
------------------------------------
DICT: ALAN R HARTMAN, MD (088237) 11/06/2014 04:17 PM
TRANS: V_JDVIJ_I/ 11/06/2014 19:45
JOB: 2081045
Electronically Signed by: ALAN R. HARTMAN 11/07/2014 04:12:16 PM