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

CHAPTER 1

Hello, my name's Jordan Bloom. I'm the surgical director for adult congenital heart disease here at the Mass General Hospital in Boston, Massachusetts. Thank you for joining me today. Today we have a 61-year-old female who was born with a bicuspid aortic valve. Bicuspid aortic valve is a congenital abnormality that affects approximately 2% of the population. The normal aortic valve has three leaflets. When your aortic valve has two leaflets, it can be commonly associated with aortic valve failure, which can result from either stenosis, or narrowing, or regurgitation, dilating. The other common association in patients with bicuspid aortic valve, which applies to our patient today, is aortopathy, or dilation of the aorta, most commonly the ascending aorta. So in fact, the patient today has bicuspid aortic valve stenosis. Her stenosis is severe, and she's got a very calcified bicuspid valve. So when we look at the valve today, it's going to look very thick and calcified, and it's gonna take me some time to get all of that calcium out of her aorta. Her aorta is also dilated. As I mentioned, she has the associated aortopathy, and we need to replace that at the time of surgery. Now the other interesting thing about this patient is she has a patent foramen ovale. That is a small hole between the left and right atrium in the heart. And that, again, is something that everybody has in utero, but most people's close as soon as they take their first breath or in the first few weeks of life. When we're doing heart surgery for certain patients that have holes inside of their heart, we will close those at the time of surgery, and I'm planning to do that today. So the patient will be brought into the operating theater and placed supine on the table. Anesthesia will be induced, and the patient will be intubated. After that, monitoring lines will be placed, and we will prep her skin sterilely as we prepare to make a midline skin incision followed by a midline sternotomy with an oscillating saw. After we've got the sternum open, we will establish full heparinization, meaning get the blood thin enough for the heart lung machine and proceed to open the pericardium. Once we've opened the pericardium, the heart and the aorta will be exposed, and we will hang the pericardium by tying it to the skin edges, which creates a pericardial well. The next step in this operation is to achieve cannulation. For this patient, I do not want to use circulatory arrest, so I need to cannulate her aorta as far away from me as possible so I can replace a bit of her aorta with a clamp on. So I will use a special cannula that will help facilitate a very distal aortic arch cannulation. And then instead of cannulating her right atrium, I will cannulate bicavally. That means I will separately cannulate both the superior and inferior venae cavae. And that is what is necessary if you want to open the right atrium, which I will be doing to close her PFO. Once we are cannulated, we will establish cardiopulmonary bypass and empty the heart out. At that point, ventilation can be stopped, and I can proceed with a couple of housekeeping steps, which will include placing a vent into the left ventricle and placing snares around both the SVC and IVC cannula. Again, these are all just to facilitate the specific operation that I need to do. When we're finally ready to stop the heart, we will do so by placing a cross clamp on the ascending aorta and giving cardioplegia directly into the aorta to achieve an electromechanical arrest. The next step will be transection of the aorta and inspection of the aortic valve. We will notice a very calcified bicuspid aortic valve that has leaflet fusion, which I will demonstrate in the operating theater. I will then remove the aortic valve using a combination of sharp and blunt dissection, and we will take extreme care to make sure that all those little bits of calcium do not end up in the patient's left ventricle. After that, I will size the annulus and choose the valve for replacement. This patient has decided on a biologic valve. Another alternative would've been a mechanical valve, but again, she's chosen a biologic valve. It's a valve that is made from tissue of a cow. I will then place sutures circumferentially around the annulus of the aorta where the valve lived previously and carry them through the sewing ring of the prosthesis and tie all of the knots. That will conclude the aortic valve replacement. And then I will move on to replacing her ascending aorta. This will be done to approximately two to three millimeters above the sinotubular junction where I will sew an anastomosis using a 4-0 Prolene suture. And I may use external felt support, again, depending on the character of the aorta. The final step in the aortic replacement is to complete the distal anastomosis where I will be sewing that Dacron graft to the aorta with the clamp in place. The final step of this operation is to close the patient's PFO. To do that, I will make a right atriotomy and close the hole in the inner atrial septum, probably with a single stitch. Finally, I will close the right atrium, and after deairing maneuvers, I will remove the cross clamp. Warm blood will perfuse from the heart-lung machine into the coronary arteries, and I would expect the heart to start beating almost immediately. At this point, there'll be a period of reperfusion and rewarming. I will then start ventilating, fill the heart with blood, and complete a series of de-airing maneuvers, and eventually separate from cardiopulmonary bypass. After I've separated from cardiopulmonary bypass, the patient will be partially decannulated in preparation for us to give protamine sulfate, which is the drug used to reverse the heparin and make the blood thick again. After appropriate hemostasis, all cannulation sites will be oversewn, and hemostasis will be achieved. We place chest tubes into the mediastinum, as well as temporary pacing wires on both the right ventricle and the right atrium. And the sternum will be closed using stainless steel wires. After sternal closure, the skin and soft tissues will be irrigated with Betadine, followed by antimicrobial saline and closed in layers. Dry sterile dressings are placed on the chest, and the patient will be transported to the heart center intensive care unit, hopefully in stable condition.

CHAPTER 2

All right, incision. So we're gonna start with a midline skin incision here. It's very important when you're doing heart surgery to dissect right in the middle of the skin and soft tissues and get down to the middle of the sternum. That usually is an amuscular plane. When I think about trying to make reasonably small skin incisions, I, you know, nobody cares how low their skin incision is, but people tend to care about how high it is. So again, I'm dissecting down. I'm opening linea alba above the xiphoid process of the sternum, which is here. Making a small hernia, and then cauterizing down to the fibers - you can relax - to the decussation of the fibers of the fascia, which is this point right here. And that's always in the middle. Trying to find my mysterious vein. Now, today we're trying to make a little bit of a smaller incision for her. So David's gonna help me with the use of this Richardson type clamp, which we call McEnany. Okay, go ahead, and try not to block the camera as you do it. Just, you gotta be a little bit cognizant of that, but you're doing fine. Tent that up so I don't button hole the skin. All right, David, pull better. Now I am just exposing the sternal notch, which is going to be impossible to see with the camera 'cause I can't see it with my eyes. All right, two curved snaps, please. Again, in the dead center.

CHAPTER 3

Perfect. All right, so our line is good. All right, we can stop ventilation. Halting ventilation. So we stop ventilation when we make a sternotomy to decrease the probability of inadvertently entering the pleural space. Okay, you can ventilate. Ventilating. Alright, two loops.

CHAPTER 4

Now I am gonna cauterize the entire posterior table of the sternal edges, and anteriorly, we just cauterize what's bleeding. We do that to improve or decrease the probability of devascularizing the sternum. You can give full dose heparin please. A full dose heparin. We have 25,000 units. Dr. Miranda will now cauterize the sternal edges on the patient's right. We don't cauterize the marrow itself. If the marrow is bleeding a lot, there are agents that can be sculpted into the marrow edges, although I prefer to do that at the end of the operation rather than the beginning. Alright, we'll take two blue or green towels, whatever we have today.

CHAPTER 5

So this is a Morris retractor, which is gonna spread open the sternal edges, and we're gonna do a very slow progressive opening. Okay. Forceps, please. And what we can see here is this is the pleural space that contains the left lung and the right lung, and we're gonna dissect right in between those two. We're now exposing the pericardium. PEEP off, please! PEEP off. We are now up here exposing the thymus gland, and under the thymus gland lives the innominate vein, which is a big blue structure that we don't wanna hit up here. Yep. This back there. Okay, good. There are often small venous branches from the thymus draining into this innominate vein that we need to either cauterize or clip. Find the midline here, grab your edge. That looks like midline. I'm not sure if it's midline actually. It should be better than that. Now I'm gonna open the pericardium. Okay, let's just give ourselves another crank or two now that she's had some time to get used to her sternum being open. Okay. I'm now opening the pericardium at the reflection to expose the aorta. And then David, yeah, perfect. And then Dr. Miranda's gonna retract the aorta towards himself and expose another pericardial edge that I will cut. All right, wonderful. Now we'll take some pericardial suspension sutures please. So this is the part where I make the pericardial cradle that we discussed. Okay, take another stitch please. The second stitch goes at the level of the right atrial appendage. Nice. Let's see if you can tuck that little bit of fat with a forcep. Another pericardial backhand please. Okay, so here's the anatomy here. This is the aneurysm. This is the large part of the ascending aorta here. It actually narrows down nicely here. And so next, cautery please. Let's look up there. There's some dark blood up there. David, will you look up there and see if there's like a vein oozing or something? Up here. Alright, so may I have a Schnidt please? Schnidt.

CHAPTER 6

I don't like to do this unless I'm replacing the aorta. Cautery, please. So... Okay, so there's the innominate artery right there. Okay. Oh, artery. Yep. I'm gonna cannulate all the way down there. Now we're gonna examine the aorta, make sure it's soft down there, which it is. Okay. Now I'm gonna put a purse string into the- I'll see if I can show you this 'cause this is hard to see from any other angle. All right. Systolic's 102. Pull down just a little bit. Good. I'm gonna put a partial-thickness purse string in the aortic arch. Okay, relax on the aorta. Let's snare this. Okay, and I'll take another one of these. Alright, David, why don't you pull back down on that aorta for me? We always put a second one just to reinforce that first one. This is the cannula that I'm gonna put inside the ascending aorta at the level of the arch. Okay, I'll take an 11 blade knife please. Blood pressure is 92 over 45, which is good. So... Was there much regurgitation? Patient is 400 and rising. 400? 400 and still rising. The annulus is 23. Okay, could you take the cannula? Forcep please? It's okay. With this one, you don't need a forcep 'cause it's got the introducer in it, so there's plenty of body. Sucker, I have it. David, you just stay still. It does appear to be a bicuspid valve. Thanks. ACP is off 438. Okay, and just back your hand up just a little bit. 438. 438, concentration is 420. Great. Okay, scissor, please. All right, David, slowly release that Schnidt. Let the aorta return to its normal position. I have this. Good. All right, now I'll take the tubing clamp from here. Okay, bucket. Okay, pump the pump. Pumping the pump. Off. Off. Again, this is de-airing, making sure that we have no air bubbles in the aortic cannula. Okay, test the line. Okay, testing the line. And a stitch, please. I'm going to put this off to your side a little bit so it's nice and out of the way. Do you want me to cut your Prolenes or no? No, thank you. Forceps to both of us.

CHAPTER 7

So we're gonna put the SVC cannula through the right atrial appendage today. We just wanna see what the anatomy looks like. So I need, David, if you could take this fat on the heart and just kinda hold it back outta the way. And I'll take a purse string for the right atrial appendage, please. Because again, because of the aneurysm, everything is so shifted. No, yeah, the bigger needle. So yeah, if I cannulate the SVC directly, I use that. Today I'm gonna pass it through the right atrial appendage. Look at that. So that's a good rule that I just violated about where you should grab the appendage, and it should always be inside of your purse string. So let's see here. All right, so take this back. Can we get orange? Okay, relax on what you have. So David, what I'd like you to do is just take this aorta toward you, okay? And let me see down in there. More toward you. Okay, I'll take that stitch again, please. Here take that in your left hand. Should I include it? Hmm? Yeah, I just wanna make sure that there's enough room that if I need to fix that, I can do that without encroaching on a coronary. 'Cause you can get into some trouble marching down on that into that AV groove. We're doing fine. Very friable atrial tissue. Okay, we'll snare this, please. Okay, let's see what we can see there now. Do you have that Satinsky clamp? Yep. David, why don't you grab that fat again. Forceps, please. Good. Okay, and I'll take a scissors, please. And for my SVC cannula, would you please put on a tubing clamp on the end of it, please? I am now amputating the tip of the right atrial appendage. And you're gonna grab... No. Okay, good. I'll take this. 24. Okay. All right, David, grab opposite me with your forceps. Good. Could you take that clamp off for us, please? Not that one. The Satinsky, yep. Just open it. Yep, coming off. Good, now come up on the purse string. Want me to take it off? Yep, you can take it off. Okay, taking it off. Just snug the purse string so we're not bleeding. Okay, now let me guide this into the superior vena cava. Let's see, that's not going. There we go. Okay, and we want that into about 10. So come down on your purse string. Okay, always hold the tip to tip. Don't do that. Yep. Good, snug it up. Yep. All right, give David a tie, please. Just securing our superior vena cava cannula. Yep. Scissors, please. All right, let's get our venous line set up here. Okay. What I normally do is just have you load these connectors onto the cannula themselves, yep. Okay, you can go ahead and start wrapping the venous. Okay, wrapping the Venous now. So I'm gonna take something on a big needle, backhand, double-loaded for the IVC. All right, checklist. Okay, ACT came back at 438. Arterial line is connected. Direction verified, we are patent and pulsatile. Venous line is connected. Direction is verified. Gas flow is on, alarms are activated. Project checklist is complete. I'm ready to go on. Alright, go on bypass. You just have one SVC cannula. Go on with some vacuum. Will not be able to achieve full flow. Okay, going on bypass. Putting some vacuum on. Great. All right, so now I'm gonna put a purse string around the inferior vena cava. Putting my ISO to one. Turning my neo on, David. Tuck. I'm flowing three liters, index of one 1/8 right now. Can you come off or no? No, just... Oh, you only have one. Everybody relax. Give it a second. Okay, snare this please. And VO is on at 100. You got the IVC cannula ready? Okay, 11 blade knife. Okay, come down on the purse string, please. Tie to David. This again is the bicaval cannulation that we mentioned earlier. As low as you can without struggling. Scissors.

CHAPTER 8

All right, you can stop ventilating. Holding ventilation. All right, David, see if you can expose for me the right superior pulmonary vein, Cell Saver in your right hand, that thing in your left hand. This is a 4-0 small needle, back hand. So now way down deep in this hole, guys, is the right superior pulmonary vein. I'm highlighting it with my forceps. And that's how we're gonna get a vent into the left atrium or the left ventricle, wherever it wants to go. So again, I'm putting one of these purse-string stitches into that vein. Is it alright to start cooling? Yeah. Okay... Okay, relax on your exposure, David. Yep. Okay, and regain the exposure. Lemme see the vent please. Okay, leave a little volume in the heart. 11 blade knife. Okay, volume out. Volume's coming out. Tubing clamp. Relax your exposure. Come down on the purse string. And I'll take the yellow vent, please. You want it under everything? Yep. Okay, yellow is an LV vent. Okay. Turn it on. Yellow is on. Okay, no. It is. Okay, we are moving along nicely.

CHAPTER 9

Now, what we need to do is get some snares around the cavae, and dissect between the aorta and the PA. Blood pressure feels very soft. Why is the blood pressure so low? Forceps. I just hit my level and my RPMs ramped down, but they're coming back up. Okay, cautery. Forceps, please. So grab here where we actually grab the PA. Go ahead and pull it towards you. All right, now grab here. We're separating the aorta and the pulmonary artery. Okay, grab it better, more of it, and pull more towards you. Good. Bring the aorta toward you now, please. Good, that's nice. Show me underneath here. All right, so you have that Semb clamp please? Yep. All right, relax, David. Yep. Forceps, please. Okay.

CHAPTER 10

Okay. Expose the SVC for me. Sometimes just by pulling on this, there you go. Now I would just pull on this, David. All right, cautery. So again, our SVC cannula is here, so maybe do it with your fingers 'cause I gotta see just a little better. All right, so directly above the RPA is generally the safest place to do this. Okay. Do you have a right angle clamp? Like a my clamp or something? Yep, I have one now. Yep. This'll be another umbo tape. This is one that we're gonna snare. Okay. You can relax, David. Snare it toward the ceiling. Turn it the other way. There you go. Good, pull. Yep, Kelly, please. Now just doing a little test here, and let me know if you experience any change in your venous return. Okay. I'll let you know. Okay, SVC is snared. Any change? Losing a little bit, yes. Yes, we are losing a lot. I need another tie for the SVC and a forceps. Okay, David, just relax on this... Okay, come back down on it. Now before we tie it, venous return still okay here? Yes. Okay, gonna check something real quick. How about now? Losing some volume. Okay, it's way up there. This is definitely above the azygos, so I don't understand why he's losing volume. Alright. How about that? Still losing volume. Okay, how much volume, Peter? It's probably 100 every 10 seconds. And it's still going down? Yes. I don't understand that. I'm gonna add some volume and see if that helps. Yeah, I'm just doing some snare tests, so when I go to close the PFO, he doesn't have a problem with volume. Okay. And he loses a little volume when I snare down the SVC, which I don't completely understand. So there's that. And we will unsnare this for now. Okay, now we need to snare the IVC. So to do that I need a forceps and scissors, please, get a sucker to David. All right, so we're gonna open the oblique sinus. Yeah, Cell Saver for this. Yep, come on out. So it's that phlegm right there. Okay, so you have the Semb? Yep. So you can see there that that's a pulmonary vein there. Michelle, can I give you some blankets? It's a little bit challenging 'cause she's just so deep. Okay. Okay, umbo tape. David, it's a two-handed move. You let go of the sucker that you're not doing anything with. You grab the end of the umbo tape with your forceps, and then you just, you take the string with your hand and keep it tight. Okay. Grab the end of the umbo tape. Keep it tight and pass point. There we go. Okay. This is a different width umbo tape, which is strange to get two different widths. The other two were wider than this. All right, gonna do a test snare of the IVC. Let me know if you experience a change in venous return please. Okay, I will. Snared. No change. Wonderful.

CHAPTER 11

Okay, we'll take a, you know what we're gonna use, doctor? We're gonna use a 14-gauge angiocath to arrest the heart today, since we're not gonna put a vent in. You could flush the pledge for me. Okay. I'll take the orange needle. I'm gonna place this angiocatheter directly into the ascending aorta. And that's what we're gonna use to give cardioplegia. Okay, off. Off. Trickle. Trickling. And off. Off. Okay. Now, are you happy with bypass? Yes, I'm happy. Okay, let me have my cross clamp please. You can see based on the comment you made on the last case, how this narrows down really nicely. All right, drop the flow. Flow's coming down. Flow is down. All right, clamp is on, back up. Give antegrade. Thank you. Flow is back up, and I'm delivering antegrade. And you're going through a 14-gauge angio. Through a 14 angio. So we're now delivering ice-cold cardioplegia solution into the root, which is gonna profuse the coronaries and make the heart stop. I'm flowing right now at a rate of 400. Pressure is 210. Good, can I have some blue towels please? Given, how much was the rest? 350. Okay, good. So what we're gonna do next is transect the aorta, and then we'll inspect our aortic valve. We will need the headless sucker.

CHAPTER 12

How much is in? 900. Okay, I'll take the Lilies. And Patrick, is it, or? Oh, hey Michelle. Will you just lower the room temp by two degrees. Yeah, I can. Thanks. That's one liter. Okay, and off. Forceps, please. All right, take that. Again, I have now transected the aorta. Now you can appreciate, this is a paper-thin aorta, which is very typical for bicuspid patients. So this is very clear aortopathy. It's okay, David, there's an LV vent, so you probably don't need that right now. It'd be more helpful to me if you just focus on... Okay, Bovie. All right, now just let go of that. Good, yep, that'll just sit there. This goes away.

CHAPTER 13

Cautery. All right, now David, let's hold this up for me. Good, just like the last case, we're gonna take some of this. We're always gonna look in here. Now show me the left main. Right there. Okay, so the left main is there. Okay, so this stuff should be okay. I'll let you take the aorta here. Good. And again, what I don't want to do is get into the PA, which is here. I'm holding it. Good. Okay, relax now. This should come up more, and it does. All right, scissors to me. Okay, so I'll splay this out so I can cut right down. Yeah, let's do this one first 'cause it's easy. All right, silk stitches next. Right, now look how high that coronary is. That coronary is above... Above the - or above the STJ. It's almost above the STJ, which tends to happen in aneurysms, but you obviously want to think about that, the way you expose things 'cause you don't want to have a tear go down into there. With this lady's tissue, I'm not gonna pull very hard on this, all right? Can open a sheet of felt if you have, and I will certainly use felt. Scissors first. Okay. Now splay this out for me so I can see this other commissure here and try to identify the right coronary artery, which is right there, okay? Also high. Yeah, also high. Oh, you can cut the strip, sure. Okay, and I'll take another stitch, please. And I'm always thinking if these stitches tear, am I gonna be okay? Staying away from that coronary. Okay, here's more aorta. And then let's get this cut a little bit, and we will... Okay, I'll take one more silk, please.

CHAPTER 14

All right, so what we can see here is that this is an interesting valve. There's fusion. This is the non-coronary leaflet, okay? And this is what was supposed to be the left and right, which is totally fused, Sievers Type 1. This coronary, which is the left coronary here, is totally effaced and very high. And this valve is obviously heavily calcified.

CHAPTER 15

Okay, so we'll take the sucker with the head off, and I'll take a pair of scissors, please. Sucker. So I'm gonna start by excising the aortic valve. Grab that little piece of calcium right there with, no, with your headless. Don't stick the forceps in there. Just be aggressive with the headless. I don't want anything to go in the coronary. Okay? Okay. All right, let me see that headless, please. Okay. Coronary's there. Want a retractor or anything? Maybe eventually. Right now I just want you to focus on stroke prevention. Okay, I'll take a straight biter, please. So now I use this little pituitary rongeur to just pick all this little calcium out. And you keep aggressive with your sucker. I'll take the scissors, please. You can open small needles, 2-0 Ethibond with pledgets. Nice, David. There is some debris sitting down in there on that papillary muscle. Do you see that right there? Yeah. Can you get that with your sucker and then clean your sucker. You got stuff all over that thing. Oh, that's - scissors. Could I have a scissors again? Biter again. Okay, now this, let's see, is it? Yeah, so this is the anterior leaflet of the mitral valve here that my forceps are on. And so we have to be careful when we're debriding all this calcium that we don't make a hole in the mitral valve. Okay, now maybe wall retractor would be good here. Just gentle with it because it... Wall retractor, that thing. Thanks. Now I, do you see the right coronary? Not well. Okay, so... what I want you to do with that wall retractor. Lemme see it. Is the right coronary is right up under here, okay? So I just, you're basically on it, and you can just hold it like that, okay? All right, let me see the scissors again, please. Okay, go in there aggressively and get all that out. yep, yep, good. You got pieces flying around. So every one of these pieces of calcium is a potential stroke if it falls into the heart. So that's - yep. Good. Forceps, please. All right. Scissor. It's a little bit deep there. I got a little bit too deep. So we'll fix that with a stitch. Okay, so now let me see that sucker for a sec, please. No, no, no - yep. Okay, I think just a little bit more. Here you go, David. Along the left - up biter, suck the blood from the coronary here. What's this patient's BSA? 1.79. Thank you. I'm gonna take a 21-millimeter sizer next. Okay, so come out with your wall retractor. Gentle finger test where just spin your index finger gently in there to make sure that you don't feel any calcium. Or an unreasonable amount of calcium. Yeah, yeah. Ooh, there's a little thing here.

CHAPTER 16

Okay, so this is a 21. Okay, how about a 23? Alright, so... Oh, aorta tore. That's okay. I was sort of expecting that. 23 will sit fine. Alright, 23 Inspiris. You can open it. I'll take that biter again. I'm gonna do just a tiny little bit more debridement. Now, may I have some irrigation please? Can you turn your LV vent off? LV vent is off. Take another one please. So turn the LV vent off, it floods the ventricle of the blood. Go down, blast, but don't shoot air. All right, vent back on. Vent is back on. All right, here you go. Just to confirm, 23 Inspiris. Yep, right. Yeah, guess it's just a thick ventricle. Okay, so we've completely debrided the aortic valve now, and we're gonna put stitches in. Okay, so let's get another set of towels up to cover this stuff for the valve snaps. First stitch is gonna be a green stitch that's loaded backhand. Maybe one more towel in front of David there. And a forcep, please. Wall retractor, please.

CHAPTER 17

So, if I follow that native annulus, the first stitch, probably that is a commissure. It's gonna go here. Okay, you take this. You don't need a headless sucker in your hand anymore. It's an AVR now. Yeah, but how do you want me to get stuff outta the coronaries? Well, I don't usually need anything outta the coronaries for the AVR. This gets a shod, please. Shod, okay. Okay, David, so it's... So I'm putting stitches from the ventricle to the aorta around the aortic annulus. And I'm just following what I think is the surgical annulus of the valve, which can be a little bit tricky with a bicuspid. Okay? And here I'm gonna repair that little defect that I made. Okay, so that's three stitches. We are gonna do the left sinus now, David. And your vent is on, right? Your... Vent is on. Okay. Getting a lot back. Oh, good. You can load the other half of this forehand please. The last one has a little tear in it, so we just wanna be really careful how hard we pull on these. It's not your fault. It's the patient's fault. It's just crappy tissue. Okay. All right. The next one is green, and we'll get a shod. Okay. So we've got, come to... We've come to the commissure between the left and non. Good. Can I have a shod please? Yep. That's good, that's plenty of pulling. Good. The next stitch is the last stitch. Number 12. 12? Yeah. Perfect. You can move the other side of that backhand. And get the other side. It's okay. You're fine. Okay. All right, so I've now placed stitches circumferentially around the crown-shaped bicuspid annulus. We have 12 stitches. So we have a commissure, one, two, three, four. Commissure, one, two, three. And commissure, one, two. Okay, so what we're gonna do is show me where the left main is. Left main is very high today. So we're gonna shift this. So grab that snap off there and put it on here. Yep. So it's commissure, one, two, three. Commissure, one, one, two, three, four. Commissure, one, two. So we're gonna switch this. This is all just about symmetry. Doesn't really matter. Okay, perfect. All right, so hand David the valve, please. So here's the valve. Again, it's made from bovine pericardium. You're gonna hold it just like that. Take this. I'm gonna start at this commissure, which is just throwing me off because it's normally green. That's okay. And we'll double load forehand. Okay, and let's see if we cannot mess with the, get in the way of the camera. I'm gonna sew this toward myself. So that's a commissure. Now I have three stitches to the next commissure. There you go. Now Dave, this is gonna sit down like this, okay? So I'm going toward myself. Okay? So... One. And just keep rotating it for me. Good, and I'll take a snap please. Okay. Now this is the next commissure. Again, think about where I'm trying to put the stitches. Be the world's greatest assistant. That's always your goal when you're assisting. Now give David and I both needle holders. We're gonna ask you to hold the valve for us. So suspend that over there. Let go, David. If you would hold the valve just like this. So we have three stitches to get to the next commissure. We're gonna start here. David, you're gonna take that one. You're the... You're gonna go right at the white. Don't, yep, you're right there. This is perfect. This is the left coronary. It's right under the nadir of the sinus, which is exactly what you want. Okay, now I'm gonna ask you to take those two strings. Don't hold the instruments, just the strings. Yep, pull the strings up. Good. Now with an aorta this fragile, I wanna be very careful here. So relax. Forceps to me, please. Okay. Okay, now 15 blade knife. 15 blade. Forceps. Forceps please. Okay, so we're gonna look through the valve. Second forcep to me, please. That is our pledgets. So it's not all the way down. So we're gonna seed the sinuses first, which I don't always do, but we're gonna do today because this thing doesn't wanna go all the way down perfectly. Let's see here. David, take those for one second. Okay, now take those. Yep, I want to get that white one. Great. Okay, take that and hold it in your hand. Orange. Do you have the short killer Metz? The sharp ones. Okay. So take these in your other hand, these in that hand, squirt my gloves. I have to tie all the knots, but I have to take extreme caution to make sure that the valve is all the way down. I'm gonna tie this one next, just 'cause you're holding it. All right, you're gonna put a snap on those. Here you go. That aorta is so thin. It's impressive. Okay, these are dull today. Get me the long ones that you gave me first, please. Let's put a snap on the ones you're holding onto. I'm gonna come around towards myself now. As I've said, we gather data at all times. When there's blood pooling in the sinuses like that, it makes you think that there's not likely some massive paravalvular leak. It's certainly not diagnostic of that, but it's something that I notice. Rule of thumb, David, you never, ever, ever cut one of these stitches unless you see the knot with your own eyes, no matter who you are or what level you are, okay? It's just your final confirmatory step that that stitch is tied. I don't care if you watched me tie it. You wanna see that knot. And you hold yourself to that same standard, and you'll never have an untied knot on an AVR. Here you go. See how it's looking so far? Pretty good. Okay, let's keep going around this circle. There you go. Okay, good. Right coronary's fine. All right, two more to tie. You have the felt ready? Take this. Yes. Scissors, please. Cautery to me please. Yep, drop is on white. David, grab this fat here. Cautery to you and forceps.

CHAPTER 18

Grab the fat that I'm holding. Okay, so I wanna develop just a little of this so I can use this to buttress our anastomosis. Can you change this please? Yep, want me to change the tip? No. Okay. Okay, white on. White is on. All right, yeah, this one's good. Okay, forceps. Take another forcep, please. This is an anastomosis that has to be just shown absolutely perfectly because of how thin it is. It's a really bad aorta. Okay, I haven't sized it yet. Jordan. That was a 23 graft. Can I see, that was a 23 valve rather. 23, yeah. All right, I'll take a 28 graft please. 28 straight, no side branch. Lemme see if I can give plege. All right, let me have a handheld cardioplegia cannula, please. Start with a 45. 45. And where's the plegia? Right there. Alright, flush the plege. Okay. And I'm flushing the plege. Okay, off. Off. All right, go ahead and give to the left main. Okay. Okay, come out. Giving down the left main. Still coming up. Lowering, 250 right now. Pressure is 120. Coming up. And that's 200. Okay, and off. Come off. All right, we're gonna give cardioplegia as soon as I get this thing sewn again, okay? Wow. These don't need to even be half this length. Hey, let me see a 23 sizer please and a pen. Okay. Right there, David. Okay, 4-0 small needle backhand shod on the end. Okay, now I need to see this really well. Okay. Michelle, may I have another blood gas, please? I don't want to nerve hook this anastomosis. It's too thin. So we're just gonna have to put about two or three in and then bring it down. Can I have a pericardial stitch please? I'm inside. There's the left coronary. Okay, so I need most of this length. I'll take the graft. Let go of the graft. Okay, let me see a nerve hook please. Good. All right, now snap that to the drape on tension. Okay, you're gonna follow with your right hand, and you're gonna switch to your left hand. Alright, so we are outside in the graft. Peter, gimme about five minutes, we'll give another dose of pledge on both coronaries, okay? Okay. Just be careful how much you york on that. You're not doing it too much, but I just want you to think about it. The sucker in there with the metal tip would be helpful. Okay, now let's get this positioned a little better. That isn't as... Hm? Inside as it could be. Yeah. I'm not sure how useful that's gonna be today. Okay, I'm gonna take this bite, and I'm gonna come out. Okay, now let's change the shods for now. That's fine, I'll just take that shod. Okay. Okay. And that, keeping that fat back would be really helpful. Yep. Right coronary certainly. Okay, yep. What? Graft's a little small small... Yeah, I mean... Yeah, lemme see a scissors. So you can just do this a little bit if necessary. I don't generally like to do this 'cause I don't find that's usually necessary. I mean, this aorta is so paper thin. Yeah. If you were doing a valve spring root or some sort of valve-conserving operation, that would matter a lot more. How would it matter more? Well, 'cause if you distort the valve by cinching down the sinuses, you may end up causing some AR. That's not gonna be one of the many things that could go wrong with this operation. Go look inside there, make sure I didn't... Lets see. Relax. Okay, I need to see that last bite a little better. There we go. Okay. Forceps. Okay. Okay, could you squirt my gloves please? What did you say? Hmm? Garbled speech. Oh, okay. Okay. Now, yeah, cut that felt please. Okay, now here, cut this a lot shorter. All right, we'll take the plege. Do you want the two Kellys? Yeah. Yep. All right, LV vent off. LV vent is off. And we're gonna give some plege down the graft. Okay? Okay. Saline to me please. Running plege. Yep, run it. Forceps please. Help me out, David. See how it came out? Kelly. All right, go ahead, and you have it set up so you can grab. Yep. That's a little low. Your forcep... Okay, now move that. Okay, and relax. How much would you like? Let go. Please let go. Give me 400 here please. What's your back pressure right now? Back pressure is 150. I'm flowing 520. Good. How much did you say you wanted? 400 please. 400. You can start. Let's see, do I want you to start warming? Yeah, you can start warming. Okay. Okay, could you...? Now, let me get this next anastomosis set up, and then I'll probably move the camera to make it a little better, okay? Okay, so first thing is, do we have as much of the aorta as we can have? And the answer is usually no. Let me have a DeBakey cross clamp please. Okay, could you drop the flow please? Flow is coming down. Flow is down. Regular suction. Okay, back up. Cell Saver. Your back pressure okay? Back pressure is okay. Okay, I got you a little close to the clamp. All right, forceps and scissors. Yep. Okay. Okay, you can relax on everything just so we can see how everything's gonna lie here in this place. Your vent back on? Vent is back on. Was it off. Orange. It was off. Okay, good. I only say good 'cause the heart was full. I forgot to ask you to turn it back on. Okay, let's let go, David. That's still too long. I am now reverse beveling the aortic graft, so it maintains some of the normal contour. Still feels a little bit too long. Okay, 4-0. Let's see the felt. This is 4-0 small needle backhand. This is a little too thick. Okay, so it's gonna be 4-0, small needle backhand. Now let's get this position. Second forcep please. So unlike the last operation that I sewed without a clamp, because we're not circ arresting, I have to sew this with a clamp, which is much more difficult. All right, I think the black will go there today. Can I get the suction? There was a drop sucker. It's right here. Yeah, I'd rather just leave this in there if we can. Okay. Forceps, please. Actually you know what, I don't really need it. It's mostly the coronary blood flow. Oh, I was gonna try to position the camera better. You know what FRED stands for? Fog reducing something. Yeah, fog reduction and elimination device. Elimination device. Reduction and elimination, so redundant. Well, not really. To reduce is not to eliminate. Yeah. I'm trying to put these stitches in like butter 'cause that's what the tissue feels like to me. It's quite hard to sew around that scope. Another forceps, please. What's the issue? We'll have to like lay this in. Yeah, we're going to. We're gonna use a nerve hook to do it. Lemme just get the back wall sewn. Okay, an I have a nerve hook, please? Alright, David, pull up on yours just to keep it snug please. Can I have a Cell Saver, please? Okay, are you snug? Yes, I am. Okay. I can go more, but... Yeah, well don't break it, but keep it tight. Okay, put that back on tension, please. Okay. Okay, a couple more real painful bites. So I need to see all the way down there. Come out. That's nice. Don't miss the felt. Okay. Okay. Relax. Still deep to it, but yeah. Yep. That's annoying. You take the Cell Saver. Could you rotate the table a little bit more towards me, please? Rotating towards you. Sorry, banged the camera. More? That's okay. Could you turn the LV vent off? LV vent is off. Relax for just a second. You have some saline? Okay. Vent is still off? Vent is still off. Okay, you can turn it back on. Back on. All right, let's see about this PFO now.

CHAPTER 19

All right, I'm gonna snare the SVC. Okay. Forceps, please. Yeah, you can change the tip on that. Snaring IVC. Thank you. Okay, forceps to me, please. Just be gentle with that heart, okay? 15 blade knife. So I'm gonna open the right atrium now, which like every other part of this patient's heart is very thin. Okay, just relax there. Okay, now may I see... Take that out. May I see a loop please? David, when you lift up on this, you gotta do it gently, okay? So I just want you right there. Okay, and I'll take a 4-0 Proline. Yep. Thank you. Yeah, sure. Can you see it? Oh, I see something. All right, take these needles. This is a retraction stitch. I'll take a snap please. Let me see that Cell Saver. Okay, so... (suction suctioning) You can see the vent right there. So let's see if we can show this to the camera 'cause this will be cool. So inside the right atrium here, guys, is, this is the PFO right here. See if I can show it a little better. SVC's there, nope. So my suction is in the PFO. Okay? That's a hole in the interatrial septum. All right, 4-0 big needle backhand. And I can see everything I need to, can see, if you can just film the closure here. All right, so I'm gonna actually stick my forcep in the PFO. Get a big bite of this septum here. Oh, let go of that. Okay. And it locked. What is that caught on? Okay, good. All right. Yeah, it's okay. I will need another 4-0 big needle. Okay, let's see that. Bring the scope out. Okay, suction to me. All right. That's this... Okay, all right. I wanna make sure that this vent didn't get tied in, and it didn't. Okay. Okay. PFO is closed. Needle goes back. Yeah? Oh, okay. All right, stitch for the right atrium. Big needle? Yep, now the easiest thing for you, nope, no, no, no. You just... Forceps please. Forceps to you. Yeah, you don't need that anymore. Just hold this up for me so I can see. Yep. What's that? Yeah. Orange please. It's okay, David. This isn't gonna take very long to close. Just... Just follow? Yep. You need to learn to release your follow a split second earlier. You always, not always, but often have just a tiny little bit of tension. It's hard because you gotta anticipate what I'm doing, but I think it's the hardest thing about following is if you release it too soon, I get stuck in your knot. You're doing a good job. It's just one minor thing. So I'm now closing the right atrium. See, that's what happens if you release it too soon. That was too late. Yeah. So you know I reload in the field. So basically as soon as I click, you know I'm gonna pull. Okay, so follow that way. I'm gonna sew back down now. Okay, IVC is unsnared. Thank you. SVC is also open. Don't push it over that much. All right, could you give me a 4-0 Prolene, small needle pledgeted next? That's gonna be for the vent. Okay.

CHAPTER 20

Yep. And pull that fat back as always. Forceps please. Right here. We're now gonna put a vent in our ascending aortic graft. Get ready to take our cross clamp off and reanimate the heart. Okay. Snare. Snare. 11 blade knife. Dave, the heat, sorry, the glucose just came back 179. Ooh, really flying right under there. Yeah. Think we can finally invest in... Alright, could you, you have a vented Y? Could you put some volume in the heart? Yeah. Could you do up and down the lungs? Up and down on the lungs. Get the white ready for me, David. So this is deairing. It's up top. Yeah, just find it. We'll use something else. LV vent? No, yellow should be LV vent. Yep. Let me take this off. LV vent off. LV vent is off. No, no. I'm watching. You're gonna put it on a minute. I'd like to see this air come out. Okay, good, volume out. Volume's coming out. Stop ventilation. Stopping ventilation. Drop the flow. Flow's coming down. Flow is down. Cross clamp is off. Back up, all vents on. Flow's coming back up. All vents are on. Okay, scissors. Let's just relax there. This is a time where less is more. Watch the heart, learn from it. You'll know if there's a lot of bleeding 'cause it will fill up. So if you wanna just park this down here, you can, but... What we wanna see is that the heart starts beating without any need for electrical defibrillation. And the heart is beating. So we'll just, we'll leave it alone here for a minute. Let's clean this up just a little bit. I can go towards you. CO2 off. CO2 is coming off. CO2 is off. You mean the tip is angled? Yep. You don't have to do that. I don't have to do that? No, that's fine, I'll start. Okay. Yeah, I was gonna let the... All, so... See if the pressure... I'll take a V-wire please. So I'm now gonna put a bipolar ventricular epicardial pacing wire on the inferior surface of the right ventricle. You can give David the cables to pass off please. All right, I'm still at 75. I'll start coming down. Yeah, that's fine. We'll take care of it. Once the clamps off, Pete, and we have access to the coronaries, we're gonna start giving, you know, vivo and stuff. Yeah, okay. The clamp is off, my friend. No, no, I know, that's what I'm saying. Just not like in general. Oh, okay. Do you have any more slack there? Is that it? You got tons. Yeah, you can keep pulling. Okay, cut this please. Okay. So we're now gonna tunnel this pacing wire through the anterior abdominal wall. Alright, my video's off now. Thank you. Dr. Miranda's Gonna hook it up to the cables. You can start us pacing at a rate of 40. Starting pacing at a rate of 40. What are your MAs set at? 10. Go to 20 please Going up. What you're seeing on the ECG is electrical activity of the atrium. Something is not right with the pacer, I promise. There we go. That would be a user error. Yeah, that was my assumption. Okay. So right, right, right. Yeah, you need a little more exercise is what you need. Okay. Yeah, don't worry about that. All right, so we're not in any plural space. We're gonna make incisions here for chest tubes, which will be an angled and a straight. Two silks, please. You know, we're a little bit worried about that right atrial appendage. It's kind of junky tissue. So since I have this IVC cannula in, what we'll end up doing is taking the SVC cannula out first, reconstructing that, making sure that we're happy before we take the IVC cannula out. Does that make sense? Now... What's the alternative? Well, most people would take the IVC cannula out first 'cause it's easier to repair down there. Oh. Alright. So you guys can, we can appreciate in comparison to an aortic replacement where you do it without a cross clamp. The graft is much shorter.

CHAPTER 21

It looks like she's competing with you, David. So if you wanna just put her on a VVI backup for now, that would be perfect. Yeah, she's a 40 VVI. Oh, okay, wonderful. And how long was the cross clamp time? Cross clamp time was 92 minutes. Okay. I'm gonna reperfuse for 10 minutes. You wanna take a short break, or are you okay? All right, why don't you put a little volume in the heart. Just let us eject a bit. Let us push some of the air out of those coronaries. The STs are already starting to get a little bit better. Bring it up slowly, just... Coming up slowly. So now we're going to put some volume in the heart, which will allow the heart to start ejecting some blood, which will move blood through the coronary arteries and move air around, which we always wanna look for. It's interesting, David, I don't know if you've noticed this. There's, there'll be like, oh, I think they're PVCs. Yeah, intermittently. Yeah. Are you guys looking at it bigeminy or something? Yeah, exactly. Turn the LV vent down. Yeah, sounds good. Yeah, that's a nice amount of volume there. Okay, holding there. So David Convissar, you have volume in the heart if you wanna have a initial gander at the aortic valve. QRS is totally normal now. I mean, it's wide, but there's no STs. And we're looking for big glaring things right now. So at this point we wanna look at the aortic valve. We wanna make sure the leaflets are opening and closing. We wanna make sure that there's no leakage of blood around the sewing ring, which could be a technical error. Maybe a little more volume? Yep, a little more volume. It's tough 'cause you got that air in the atrium, and you got the vent. Why don't you clamp the LV vent for now. Okay, LV vent's off. David, did you see, you said you saw some atrial bleeding, right? Yeah, outside of the... Where was that 'cause there's a fair amount of blood in here that I wouldn't expect. Oh, right there. That wasn't even it, but it's almost gone to the center, but it might have been, I can't remember if it was in this cannula or that cannula. Okay. Are you ventilating? Oh, I am. Oh, no, no. All right, go ahead and start. And Angela, would you give a couple of big breaths there please? First look, I'm not seeing anything egregious. Good. All right, so we're moving some air around. There's just no room in here for anything. All right, so let's take the volume back. Okay, taking the volume. Empty out. We're gonna get the LV vent out, okay? Okay. It's currently off right now. You can turn it back on. Just emptying, just in case there's any air there. We still on breath? You can keep ventilating, but no more big breaths. I do think I'm gonna want a second drop sucker today. You do? Yeah. Those still things that there's a shortage of or? We're back in business, those things. Nice, I'm gonna stop feeling badly asking for 'em then. Suck that blood with a blood sucker. One of these things. Let's put the other drop sucker on the yellow vent line, please. All right, David, would you hold that for me, please? You will want that Cell Saver in your other hand. And I'll take a 4-0 small needle backhand plain. And you're gonna expose that for me so I can repair it. Suck all the blood behind the root. Yep. All right, where's that other vent line? Okay, turn the yellow back on. Yellow's back on.

CHAPTER 22

Okay, tubing clamp. I'm gonna clamp the SVC. I'd like to just know what that does to your venous return. Okay? Okay. Losing a little bit, not too much. Okay, knife. We're gonna get that out, Peter. Okay. I'm able to flow 4.5 liters. Good, you can do your checklist. Okay, pulling up the checklist. All right, go ahead and take that out. Yep. Good. Patient is warm. Now. Yeah, you can do that. 36.6, remainder at 36.1. Okay. Oh, I'm gonna leave this. Is reading 8.6. Her last potassium is 3.6. Turn it. My shunts are now closed. Okay, now let's look at that atrium. See, what do I need to repair there. Could you hold that fat back please? Come off bypass. I'm currently flowing 4.5 liters. Okay, hold on for just a sec here. Okay, so let go what you have. So I think that you had that. Go ahead and hold that, and then hold that. And then show me. Is there something bleeding there? I thought there was. Not seeing it now? Not at the moment, no. All right, okay, relax. All right, sorry, what's your flow? Four liters. All right, come down to three, please. Coming at three. So we're now gonna separate from cardiopulmonary bypass. Coming down. Good. And two. At three, coming to two. I'm at two liters here. Yeah, the lateral side. That thing right there? Yep. All right, down to one. Prepare a pledgeted 4-0 backhand big needle. And I'm at one liter. Okay, just sit at one liter for a moment please. Yep, holding here. It's okay, I like you grabbing that fat. Just don't grab that atrium 'cause this all started by me grabbing it. Okay, here you go. I'll take that repair suture please. And hold the fat back with the other hand. Perfect. Right, now where is that? Right there? Okay. Okay, grab your end right here. Yeah, you usually cut those. I gotta have you on my service someday. Yeah, you can come off. Okay, coming off bypass. And I'm off bypass, just keeping up with the roof now. Okay, sounds good. Giving volume? I don't have any volume. Oh, you're - okay. Oh, okay. Well, he'll have volume when I take the pipe out. I just wanna... He can drop a little crys- drop a little crystalloid, prove that she's volume responsive please. Okay, dropping. Is there any air in the left side of the heart? Did you say no? No... Okay, cut. Okay, and a Cell Saver, please. And that's 200 of crystalloid that I just dropped. No air. There's still something bleeding there, yeah. Right there. Oh yeah. All right, another 4-0, on a small needle pledgeted. No air you said. Correct. Okay, forehand. I do have a little bit of bubbles coming through. Yeah, but nothing major. Yeah, nothing major. Okay, so hold that back. This is a very friable atrium. It's a very friable heart. So everywhere we're grabbing with our forceps is bleeding. So I'm just putting some pledgeted repair stitches. Take that. David? Okay, how's the heart function? Normal. And how's the aortic valve? No PBL. Okay, so let's give 'em the IVC cannula now. Now, if I were to emergently need bypass, I don't think I would use this again, but let's just still snare just in case. All right, knife. Grab that silk. Okay, let's, gimme a tag please, and then you can deal with that. All right, good, time to reduce some complexity. Alright, what's the protamine dose? Protamine dose is 70. Okay. Seven zero? Yes. And I can take the venous. Yep. Okay. All right, now David, to decannulate this thing, I'm gonna need you to hold that fat back again. Have 300 now from the venous. Alright, just keep the blood pressure where it is for a second please. All right. Leaving where it is. Get that thing off with your forceps. Grab the pledget. Forceps please. You have a pledget. Oh yeah, you need to hold the fat back, I'm sorry. That's painful. Yep. Good. Now move that pledget back so I can see. No, no, move the pledget up the strings and unstring it. Yep, good. All right, now you're gonna take this in one of your free hands. Got it? Okay. Okay. All right, pull it out. All right, ready for protamine. Okay, test dose is going in. Alright, my suckers are off. Quarter, quarter, quarter, quarter, please. We need a heavy scissor, please. Hold for a second. Let us try and see where we stabilize at. All right, forceps, please. Forceps. Something changed with the QRS. Is the heart function okay? Yes. Okay, sponges. Going to 50%. I start, I started that... Okay, talk to Angela and Dr. Convissar, and... How's the heart look? It looks good. Okay. It looks empty to me is how it looks. Yeah, so put some volume in the heart. Coming, putting volume. Try to V pace. V pacing. Make sure we don't hurt the blood pressure with V pacing 'cause she's actually very stable right now. Just prettier. Okay, good. All right, now I want you to put the head back up a bit. Head coming back up. How much volume do you have left to give? I've got 600... Okay, do you want to back off your pressors? Where we at, three? Three. - Three. Would you like me to start the... Gimme one sec. So what I like about these suction like this is if there's an audible feedback here. You hear it sounds like a slurpee? That means that there's blood in there. And where are we at with the protamine? Almost half. So I don't really need to look to see that they're still bleeding. With these tissues, I cannot do anything else. So bleeding just has to stop. Okay, I need a knife please. And I'm gonna take a pledgeted 4-0 big needle to fix this aorta, okay? How much volume do you have left? That's all the volume. All right, David, would you support that cannula as I get this ready for us? Okay. Okay. Okay, I'll take the cannula. I have the cannula. Get yours ready to tie, please. So we're now gonna remove the cannula from the aorta. Let's try to get the blood pressure down a little bit, David, maybe stop the pacing, see what that does or a little more RT. Okay, alright. Okay, ready? One, two, three. All right, the red line is out. Your finger just stays right on the hole. Okay, that's all it does. Let me know when I can come back up. Yep. And I'd like to get my finger down there if I can. All right, you can remove your finger. Now you just tie. All right, you can do whatever you want with the blood pressure now. Coming back up. And you're still at half on protamine. Yep, I need to just look at the aorta before I ask you to finish it. Making sure you knew. It's very hard to see anything in this patient. Pledgeted stitch please. Forceps. Okay, you can cut what you've got there. Scissors please. Okay, you can finish the protamine. Finishing the protamine. All right, I'm gonna most likely need a 4-0 big needle backhand pledgeted to fix the IVC. That will hopefully be the last repair stitch. Now how's the blood pressure? It's fine. I'm gonna have to look at this IVC, which might hurt the blood pressure a little bit. So for purposes of this, could you give David the discard suction, please? Gently show that to me. Remember this heart. Okay, so that looks pretty reasonable. All right, scissor to me please. Could you give David a sponge please? Yep. All right, now I want you to get in there with your sponge in your right hand, suction in the left hand, and expose that really well for me, even if it lowers the blood pressure. Can I have this for second? Yep. Okay, you gotta go lower. Huh? Yep. We're gonna push on the heart a bit. Nice and easy, David. You don't wanna put your fingers into this heart, okay? Yep, good. Pull back a little more. I gotta be able to fix this hole. Okay, relax. Don't take your hand out. Let her recover. Okay, expose again. Okay, relax. Take this and load it on a free pledget. You are not gonna do that again right now. Are you done with that? Well, I gotta tie it, but... Yeah, yeah, you're good. You can go. All right, just a little bit, David. Less than you did last time, just so I can at least see that the pledget goes down and with a suction in there. Okay, I need a dry sponge. Don't change the exposure. Scissors. Sponge. All right, come on out. Great.

CHAPTER 23

All right, we're off the heart. What? Aortic cannula. Yeah, pass the aortic cannula around. Okay. All the protamine is in, right? Yes, sir. Okay. You need this for the... I'll take the discard suction, please. Could you make me, get a SurgiFlo, please, and some Surgicels available? Okay, let's just inspect this. Did I miss one? Yeah. Okay, give David two loops please. Okay. And I'll take the cautery pleases. Loops for you. Can you gimme a little slack on the cautery so you're not pulling on it? Thank you. Yeah, I know, there's just a lot. ACT 109... Awesome, thank you. All right, let's see the top. Okay. Suction, please. You can make us some vanco paste please. Yeah, we're certainly oozy. Can I have a sleeve for my right hand? Thank you. Right arm, please? Did you hear me, Michelle? What's that? Could I have a sleeve? That felt good. Okay, we will take a small spreader now, please. Okay, she has your sleeve, David. I'll take another round of sponges, please. Can you get a squirt, David, and see if the graft is bleeding right there? Yeah, it is. All right, I need a 4-0 pledgeted backhand. I wanna fix this one first, okay. Huh? You wanna pause the breathing or you wanna retract it? No, just make sure you look in there because you're the light. Okay, free pledget. David, can you put the pledgets, the needles wider in the pledget so the pledget, no, has more surface area. There you go. This is the problem with an aorta like this, man. Every repair stitch you put in is a source of potential bleeding. I would rather not put that repair stitch in the proximal at all, but... Cut the stitch, please. Nice thing is that the blood is certainly clotting, so can't blame coagulopathy. Once we get that stopped, we'll do a flow seal. All right, so it's gonna be another 4-0 big needle pledgeted. My fault. Okay. Okay, free pledget this, please. Okay, scissors to me, please. FloSeal and a sponge to David. Okay, let's get a sponge. All right. I found something and fixed it, so hopefully that'll be it. But we shall see. Could you gimme a loop, please, or give David a loop? All looks pretty good, agree? Yeah. Okay. You have some Surgicel? I think I need one more of those stitches. Okay. I know you know this, but these stitches are safe because it's the non-coronary sinus. Yeah. I mean it's safe, not safe in that they can't do harm, but safe in that the aortic valve and the coronaries are not close to there. Okay, can you just, scissors to me? It looks better, doesn't it? All right, I'm gonna take that SurgiFlo and a full length Surgicel. Not perfect, but I don't suck this stuff out. Okay, and that Surgicel. And then a sponge next. Hemodynamic's been okay, guys? Yep. Just about finished. Alright. Whatever you were pushing on before dropped or jumped our CBP, but there's no pressure change with it. Yeah, no, I'm pushing on, pushing hard right now. Where do you think it is, or what are you looking at? It's the proximal anastomosis. There's a little... Oh, but it's on the aorta. It's not on the... It's not anywhere near the coronaries, but it's just in a place that's a little tricky to fix 'cause her tissue is so thin. Every repair stitches I put in just runs the risk of causing a big problem. I mean, it's the kind of situation where I would have a very low threshold to just leave her open and packed if I had to because I don't wanna to put any more repair stitches down there. Oh, that's stitch is in the aortic anastomosis or in like a closure somewhere of the venous cannula? No, no, no, the aortic. Okay. This is oozing a little too. Do you have a little more SurgiFlo? David squirt a little SurgiFlow right on that thing. Any coags or platelets back yet? Go ahead, blast it. Okay. Can you get me some fibrillar, please? Just need clotting to occur. All right, let's put some chest tubes in, and take the straight one first please. Still here. Okay, one piece of that fibrillar, please. Yep. Forceps. Okay, I'm off. All right, so I am going to take one sponge. I'm gonna put it in the chest. I'm gonna give it back to you before I tighten the wires. It's just gonna give us a few more minutes of security. Alright, we'll take a lap pad please. And I'd like an ET tube sucker to go in that tube down the middle, please. All right, we're gonna close. Cool. And with these things you gotta cover this hole.

CHAPTER 24

Alright, David and I will change our gloves. We'll take two blue towels. All right, so that was a little bit of prolonged hemostasis. I knew based on this patient's tissue quality that I wasn't gonna be able to put a lot of stitches in. So a lot of times we just pack, wait for the blood to clot, and the patient to kind of cure their own little holes and stuff. And fortunately so far it seems like we're okay. So important thing will be to not let her get real hypertensive. So no higher than this please. And one in front of David if you don't mind. And now we're gonna use stainless steel wires to close the sternum. I think you might want a McEnany to start with 'cause we made a pretty low incision here, and it's just gonna be challenging. Something happened to the tip of that. You can add a little PEEP now if you'd like. Needles, there's one working. Two is in my hand. Three. Four. Five. Seven. Eight... That's how you get pneumos. Probably jumped the gun on asking for PEEP. Tightener please. What I'm doing, this is the figure of eight that crosses the bones just so you know. One, two, three, four, five... Yeah. Can I expose the previous wire or just - okay. Yeah, that's it. Okay, I can take that wire that I messed up earlier if you'd like. Or whatever. I'm only gonna use six. The other tightener, please. Can I have one? So let's keep her blood pressure like under 110 tonight, okay, up in the ICU. Okay, could I have a number one Vicryl next, please. And a Bonnie. Alright, so I'm gonna start my fascial closure before we tighten the wires, which I normally do. Okay, so we're gonna gather data. We're gonna look in there. Good, so that all looks pretty dry down there. Now let me have a DeBakey, please. All right, let's take a look at the sternal edges. Okay, check this area real well 'cause... Yeah. Just coming from the top or? Yeah, seems to be coming from the top and it's intermittent. Between this one right here. Oh is it, can you see it? Is it bleeding underneath there? Like right now it's not bleeding at all. Okay, how about if I relax? No. All right, do you have a discard sucker just for a sec? Well see, all this blood here is just, I guess this running down. It should stop when we tighten 'em. Yeah. All right, let's close the sternum. I have one, two right here. Three. Four, five. You saw I returned that sponge, right? Yes, got it. All right, wire cutter please. Okay, and a chubby please. You can start doing the Betadine while I'm doing this. Okay, maybe get a goiter now or something. Goiter, please. Okay, turn down, please. And then the antibiotics, please. And the antibiotic irrigation please, yep. Number one Vicryl to David, please. We're gonna close the soft tissues in layers starting with the fascia of the chest wall, and I'll take a Bonnie. So am I allowed to proceed with my closure in here after this? I think so. The sooner we can get these chest tubes hooked up to a bleed Watts, the better. Oh, yeah, I just wanted to suck that one out. Yeah, you're good. Okay. All right, is there Kelly on your side, Dr. Bloom. A Kelly? Yes there is. Okay. It's right here. So one on this side and one on... Hey. David, do you mind closing the skin? No, not at all. Thank you, man. Scissors, please. Thank you, buddy. Thank you very, very much. Nice job. Nice working with you.

CHAPTER 25

Okay, so now we've concluded the operation. You know, I think the key steps of the operation were as we described them before. You know, to abbreviate a little bit, we opened the chest, we went on bypass, we used the aorto-bicaval cannulation. We opened the aorta. We found that heavily calcified bicuspid aortic valve. It had right-left fusion. And we took that out. We decalcified the annulus. We sized it. We put the 23-millimeter Edwards Inspirus Resilia valve, bioprosthetic valve into position, and then we replaced the aorta. You know, one of the things about these patients, we had discussed her having bicuspid aortopathy, but it's very difficult to predict what somebody's tissue quality or tissue character will be like. This patient had a really, a paper thin aorta, severe aortopathy, and it, you know, it's really amazing that these aortas can hold the amount of pressure that they do. That made it a little bit of a technical challenge. I used felt support to buttress the anastomosis. But even with that, there was some bleeding from that proximal anastomosis that required some packing and some time to really stop. And that's really unsurprising given how thin that aortic tissue is. Other than that, I think the case went very well. You know, she's closed, and dry, and very stable in the intensive care unit and will hopefully have a very good outcome.