Combined Replacement of Aortic Valve and Ascending Aorta with Patent Foramen Ovale (PFO) Closure

1. Introduction

2. Midline Incision

3. Midline Sternotomy with an Oscillating Saw

4. Hemostasis and Heparinization

5. Sternal Retraction and Pericardiotomy to Expose the Heart and Aorta

1. Stitch the Pericardium to the Skin Edges Creating a Pericardial Well

6. Distal Aortic Arch Cannulation

7. Bicaval Cannulation (for Later PFO Closure)

1. SVC Cannulation Through the Right Atrial Appendage
2. Establish Cardiopulmonary Bypass
3. IVC Cannulation

8. Stop Ventilation and Place a Vent into the Left Ventricle Using the Right Superior Pulmonary Vein

9. Separate Aorta from Pulmonary Artery

10. Test Snares of the SVC and IVC

11. Electromechanical Arrest via a Cross Clamp on the Ascending Aorta and Cardioplegia Directly into the Aorta

12. Aortic Transection

13. Excision of Dilated Ascending Aorta Above the Coronary Arteries

14. Aortic Valve Inspection

15. Aortic Valve Excision and Debridement with Extreme Care to Prevent Calcifications from Entering the Heart

16. Sizing Annulus and Choosing Replacement Valve

17. Aortic Valve Replacement

1. Place Sutures Circumferentially Around Annulus Where the Valve was Previously
2. Carry Sutures Through the Sewing Ring of the Valve
3. Position the Valve and Tie all the Knots

18. Ascending Aorta Replacement

1. Prepare for Graft
2. Give Additional Cardioplegia
3. Proximal Anastomosis 2-3 mm Above the Sinotubular Junction with External Felt Support
4. Give Additional Cardioplegia
5. Excise Dilated Ascending Aorta
6. Cut Graft to Appropriate Size
7. Distal Anastomosis with External Felt Support

19. PFO Closure

1. Snare the SVC and IVC
2. Right Atriotomy
3. Expose and Inspect PFO
4. Close PFO
5. Close Right Atrium and Release Snares

20. De-airing Maneuvers and Reanimating the Heart

1. Bipolar Ventricular Epicardial Pacing Wire Placement on the Inferior Surface of the Right Ventricle

21. Reperfusion and Rewarming

1. Inspect Aortic Valve with Ultrasound and Start Ventilation
2. Remove LV Vent

22. Decannulation and Separation from Cardiopulmonary Bypass

1. Decannulate SVC
2. Repair Right Atrium
3. Decannulate IVC
4. Reverse Heparin with Protamine Sulfate and Decannulate Aorta
5. Repair IVC

23. Hemostasis

1. Place Chest Tubes

24. Closure

25. Post-op Remarks