PREOPERATIVE DIAGNOSIS: Rheumatic heart disease, status post previous aortic valve replacement, residual aortic stenosis (AS)

and aortic insufficiency (AI), mitral stenosis (MS) and mitral regurgitation (MR). POSTOPERATIVE DIAGNOSIS: Rheumatic heart disease, status post previous aortic valve replacement, residual aortic stenosis (AS) and aortic insufficiency (AI), mitral stenosis (MS) and mitral regurgitation (MR). OPERATION: Repeat aortic valve replacement, mitral valve replacement, tricuspid valve anuloplasty, excision of left atrial appendage. ANESTHESIA: General oral endotracheal. OPERATIVE PROCEDURE: The patient was brought to the operating room and monitoring lines were placed. Following induction of anesthesia, the chest was prepared and draped in sterile fashion. Sternotomy incision was made vertically and the old scar was cut and removed. The old wire sutures were removed, and the sternum split through the anterior table with a Stryker saw, and the posterior table with scissors. Adhesions were taken down underneath the sternum using the electrocautery. Gradually, the right atrium and aorta were freed up and a good part of the right ventricle and anterior left ventricle. Cannulation was then performed with 2 #28-French catheters in the vena cava to the right atrium, and the #20-Bardic catheter in the ascending aorta. Cardiopulmonary bypass was instituted, a vent placed in the pulmonary artery, and the remainder of adhesions were taken down around the left ventricle. At the apex of the left ventricle, where previous vent and plegetts had been placed, we did not separate it from the pericardium. Next, the aorta was crossed-clamped, an oblique aortotomy made from on top down into the non-coronary sinus, and the left coronary artery was visualized, and 500 mL of cool cardioplegic solution were instilled into the orifice. We could not find the takeoff of the right coronary artery and it was not separately perfused. Topical cold saline was used to induce myocardial hypothermia, and a drip of cold saline was used to maintain it. Next, the old aortic prosthesis was removed by cutting the sutures and gentle teasing away the sewing ring from the annulus. It was obvious that this was a rather small aortic root, although coming off superiorly, and to the left lateral side, was the annular disruption and aneurysm formation. This was all calcified and healed, and the old patch that had been placed across it, covered only about half the orifice. After the valve was excised and the old patch and all the material removed, we irrigated the heart and aorta with copious amounts of cold saline. Only a 19 mm prosthesis seemed to fit through the annulus, and a 21-mm valve would sit on top of it. We elected to use a 21 mm St. Jude prosthesis, and planned to patch over the orifice of the aneurysm. Next, we opened the left atrium in the usual place, exposed the valve, excised it, and found that it would accept a 29 mm prosthesis. Next, the annulus of the mitral valve was rimmed with sutures of 2-0 Ti-Cron on Teflon felt bolsters. These were passed through the sewing ring of a 29 mm St. Jude prosthesis, which was lowered in place and the sutures tied and cut. The left atrium was closed with 3-0 Prolene. We had removed several lumps of thrombotic material from the left atrium, which had come from the left atrial appendage. At this point, we retracted the heart to the right, dissected free the left atrial appendage, and excised it at its base. There were several additional pieces of thrombotic material up in the atrial appendage. The left atrium was again sucked out and irrigated with saline. The cut edge of the atrium was burned with the electrocautery, and the opening closed with 3-0 Prolene in 2 running layers. Next we returned to

the aortic root. Sutures were passed from below up through the annulus using 2-0 Ti-Cron on Teflon felt bolsters. Additional sutures were placed in an interrupted fashion around the opening of the aneurysm cavity. There were common sutures in the annulus and the base of the aneurysm cavity, approximately 5 of them. A 2 cm in diameter Dacron savage patch was cut to the appropriate size, and then these sutures were passed through it, and it was lowered in place and the sutures tied and cut. This effectively closed the aneurysm. Next, the sutures were all passed through a 21 mm St. Jude valve sewing ring, the valve lowered in place, and the sutures tied and cut. I was concerned about the tissue underneath the valve and some possible restriction of leaflet motion, but I thought that when the heart filled and dilated, this area would open up and the leaflets could move adequately. Accordingly, the aortotomy was closed with 4-0 Prolene in 2 running layers. Air was aspirated from the heart and the aortic cross-clamp removed. It was obvious right away that there was a fair amount of aortic insufficiency and we had to continually decompress the heart manually in order to get it to start beating again. It was able to resuscitate adequately and resume an effective contraction. We then made several attempts to come off of cardiopulmonary bypass. The heart showed right ventricular distention and hypocontractility, but the left ventricle appeared to be working adequately. We decided to measure left ventricular pressure, and placed a long spinal needle through the anterior right ventricle, septum, and into the left ventricle. In measuring pressure, we found a 50 mm gradient between the left ventricle and the aorta, with a left ventricle (LV) pressure of 110 systolic and a systemic arterial pressure of 60. Therefore, we decided to go back on cardiopulmonary bypass, and look again at the aortic valve. Accordingly, the aorta was cross-clamped, the aortotomy reopened, and 500 mL of cold cardioplegic solution instilled into the left main coronary artery. A drip of cold saline was started for topical hypothermia. The St. Jude prosthesis was still impinged in its motion, and we removed it. Again I looked very closely to try and find the orifice of the right coronary artery, and it was clear that it was not coming off anywhere outside of the aneurysm. We, therefore, removed the patch over the aneurysmal opening and, although I could not see it, I suspected it was coming off fairly close to the anterior and right lateral edge of this abscessed cavity. We then chose a #21 CarpentierEdwards porcine valve because of its central flow and opening characteristics, which could allow it to sit on top of the annulus and still function adequately. We rimmed the aortic annulus with sutures of 2-0 Ti-Cron on Teflon felt bolsters, passed them through the sewing ring of the prosthesis, and lowered it into place. The sutures were tied and cut, and we left the aneurysm cavity open, in order to protect the right coronary artery. Next the aortotomy was again in 2 running layers, the aortic cross-clamp removed, and all air aspirated from the heart. The heart returned again to a regular rhythm, and eventually, surprisingly, into a normal sinus rhythm. At this point, we re-measured aortic and left ventricular pressure and there was a 10 mm gradient between LV and aorta, and also gratifying, the right ventricle showed much better contractility. After starting a low dose drip of Dobutamine and epinephrine, bypass was discontinued without difficulty. Cardiac index was measured and 2.2, pulmonary artery pressures were 30 systolic, and we were much pleased with the function of the heart at that time. Decannulation was performed routinely, hemostasis was good right away, and temporary pacing wires were applied to the atrium and ventricle. Chest tubes were placed in the mediastinum and the left pleural space, and the sternum was approximated with interrupted wire suture. Fascia, subcutaneous tissue closed with Dexon, and the skin with staples. Sterile dressings were applied and the patient returned to the surgical intensive care unit in satisfactory condition. The total time on cardiopulmonary bypass added up to 4 hours and 35 minutes, she had aortic cross-clamp time of approximately 2 hours and

20 minutes initially, and an additional 70 minutes thereafter for the second aortic valve replacement.