Pathophysiology
Left ventricular reconstruction which can be hereditary or acquired mostly after a heart attack. Some of the hereditary cases that can cause this myocardial infarction and hypertropia cardiomyopathy and arrhythmogenic. Myocardial infarctions occur when a weakened section od the wall of one of the ventricles, expand and bulges like a balloon at the spot where the heart attack occurred. Usually after, scar tissue forms which can calcify and causes complications. Symptoms of a heart attack include shortness of breath, chest pain or heart rhythm disturbance (arrythmias). If these are left untreated, they can lead to heart disease or fatality.
Diagnostic testing
For the testing to diagnosis the patient is a routine series of test. Electrocardiography, echocardiography and cardiac catherization are useful diagnostic procedures for the evaluation of cardiac diseases and may be performed in interventional radiology (Frey, K. B. 2018). AP and lateral X-rays of the chest can give the surgeon better overall view of the heart and great vessel. CT and MRI scans are used for evaluation of the pericardial and intracardiac and extracardiac masses. CT are especially useful in for the detection of thoracic aorta dissection. MRI better help us detect abnormal positioning. We also did test to look for cancer (i.e. pap smear, mammogram, colonoscopy). Resting electrocardiography. Stress test electrocardiography. Echocardiography. Thoracic aorta arteriograms if the patient is to have ventricular aneurysm repair. Also, it’s possible the patient will need a cardiac catheter.
Surgical intervention
Cardiovascular cases are usually done in the biggest OR suite due to accommodate for the number of personal and equipment. Make sure the cardiopulmonary bypass machine is in the room as well. The patient will be brought in on a gurney, the team will ask the patient to move over to the surgical table if they are awake and alert. If the patient is sedated or unable to move, we will assist the patient in transferring over. Once the patient is on the surgical table, we will pad the boney areas as the anesthesiologist is getting the patient put under. For this specific procedure we are going to put the patient under General anesthesia.
Surgical steps
The surgeon makes a medial sternotomy. Anesthesia will give the patient heparin depending on the weight and age of the patient. From there the surgeon will cannulate the ascending aorta and the right atrium with the start of CPB, including administration of cardioplegia. The aorta will then be cross clamped. The reason for cardioplegia and the cross clamping is so the mural thrombus will not shift when the aneurysm is dissected from the pericardial sac.
Next, the left ventricle is vented by putting in a vent through the spot where the portion of the right superior pulmonary vein and the left atrium. The paracardial adhesions will then be blunt and sharp dissected which will free the aneurysm from the pericardial sac (Frey, K. B. 2018).
The surgeon inspects the left ventricle and confirms the location of the aneurysm. Using a #15 blade and Potts-Smith scissors, a ventriculostomy is made on the anterior aneurysm wall 3-4cm from the left anterior descending (LAD) coronary artery. The heart will then be slightly elevated from the pericardial sac and the center of the incised wall of the aneurysm is identified.
With the left ventricle open, the mural thrombus is carefully dissected from the ventricle. The margins of the viable myocardium are identified, and the scar tissue is excised. Loose thrombi are removed. Care is taken to preserve the papillary muscle from injury. A wet lap sponge may be placed inside the ventricle to cover the aortic and mitral valve to prevent debris from entering the aorta or left atrium.
Remaining portion of the aneurysm is excised, but a 2-3cm rim of scar tissue is left in place for the placement of the sutures when the Dacron patch is placed rather than placing the sutures through viable myocardium. The ventricle is inspected and irrigated with warm saline to remove any small remaining pieces of thrombus.
Inferior and posterior located aneurysms require repair with a circular Dacron patch, but anteriorly located aneurysms can also be repaired with the patch. The following are the steps of the repair:
1. The Dacron patch is cutting the circular fashion approximately 2cm larger in diameter than the ventricular opening.
2. Polypropylene suture with felt pledgets is placed in purse-string fashion through the scar tissue rim and tightened to reduce the size of the ventricular opening.
3. The 2-0 or the 3-0 pledgeted polypropylene sutures are placed in interrupted horizontal mattress fashion though the aneurysm fibrous scar tissue located on the ventriculotomy rim and then through the patch. The pledgets are located on the exterior ventricle.
4. The sutures are tied bringing the patch into place and covering the ventricular opening.
Air is removed by venting the ascending aorta and the left ventricle while allowing the heart to fill and ventilating the lungs. Additionally, the patient is rewarmed. Temporary pacing wires are placed on the right atrium and ventricle. CPB is discontinued and heparinization reversed. The surgical site and median sternotomy are closed in routine fashion. Patient is then cleaned, and wounds are dressed. Patient is transported to CCU via gurney (Frey, K. B. 2018).
Positioning
The patient will be positioned supine with legs externally rotated for proper circulation. All boney prominences will be padded properly so we don’t damage any nerves. Always make sure the bed strap is on over the patient’s blanket. Arms are properly positioned at 45⸰ angle. The patient is usually awake during this time so ask them if they are comfortable. The only time the patient will be asleep is when we need them to be prone and we move them when they are under anesthesia.
Prep solution
We need to check the preference card to see what that patient is allergic to just to make sure we don’t put something on them that could potentially harm them in any way. Like an allergic reaction to the type of skin prep used. Either betadine or cloraprep will be used in these cases.
Supplies
We will need the routine supplies for this aneurysm repair and mind you, cardiac cases are the most complex and in-depth cases there can be besides neurology. As follows Cardiac back table pack. Double basin set. Knife blades #10×4, #11×2 #15×4. Beaver knife handles x2. Beaver blades #64 and #69. For this procedure we will get some heparinized saline for intra-arterial irrigation and for the soaking of the saphenous vein before anatomosis. We are also going to need to have the circulator grab some topical papaverine for the prevention of vasospasm, involving the mammary artery.
As in every case in the OR we should have the antibiotic solution of the surgeon’s choice (saline and bacitracin). In the room we will also need internal defibrillator paddles and cord. Venous and arterial cannulas. Cardioplegia needle and administration set. Cell saver suction tubing. Asepto syringe x2. Alligator pacing cables. IV tubing and needles for intrachamber pressure readings. Bone wax. Gelfoam. Surgicel. ESU x3 (one for saphenous vein and 2 for the chest). Hemoclips or various sizes. Teflon felt pledges. Left ventricular sump catheter. Coronary artery direct perfusion cannula. Pacemaker wires. Teflon/Dacron patch material. Red rubber catheters for tourniquets and rubber shods. Vessel loops. Y-connectors for chest tube. Fogarty inserts for aortic cross clamp. Saphenous vein cannula. Various sizes of syringes and needles (Frey, K. B. 2018).
Draping
Cardiac procedures don’t require any crazy drapes like in urology, but we will need three-quarter sheets x5. Plastic adhesive incise drape. Split sheet. Also, any other drapes the surgeon request which should be stated on his preference card. Always have extra drapes on the back table in case the surgeon asks for more.
Incision
Incisions sites for cardiac procedures are very basic. Have the marking pen ready. Most surgeons use a median sternotomy on cardiac procedures, but this will vary from cases to case. It all depends on what the surgeon is going in to do on the patient. Some surgeons will do whatever incision they want that will benefit the patient.
Equipment
For these types of cases there will be quite a bit of items on hold because something very bad can go wrong very quick. We will need to have the following CPB machine, Hypothermia/hyperthermia unit, Hypothermia mattress. Cell saver. External pacemaker. Defibrillator unit. ESU machine. Suction system. Ice slush machine. Endoscopic equipment for saphenous vein removal (if needed).
Suture
Suture is a whole other world to me. I always as for surgeon’s preference but for most cardiac cases we will need 5-0 and 6-0 polypropylene. 0, 2-0, 3-0, 4-0 silk for the pericardial stays. For the chest tube to kept in place will use a 0 silk. Silk and Vicryl ties 0, 2-0 and 3-0. Stainless steel sternal wires. Absorbable suture for wound closure. The circulator will always grab more for you when needed or have multiples on hold it doesn’t hurt if they aren’t opened yet.
Instrument
For most cardiac procedures these instruments will be used, A sternal saw. Sternal retractors. IMA retractors. Valve retractors. As far as the instruments go, we will need a cardiac and a Dietrich tray which has over 100 instruments easily. Have fun counting those bad boys! Not every instrument that is in the tray will be used. Some of the trays I get out in the field will have 77 instrument and the surgeon will only use 2-5 instruments from that one tray, it’s preference of the instruments.
Counts
For all cases you should at least be counting your softs and sharps which are Laps, Reytecs, Peanuts and cottonoids. The sharps are going to be blades, bovie, suture and hypo needles. Now there are certain things that will need to be added to the board as a countable which includes the drain, the vessel loops, the catheter that is being used as tourniquet, also any suture or instruments your circulator grabs extra needs to be placed up there too.
Specimen
The aneurysm will be sent off to pathology in formalin to determine if the aneurysm will continue to come back. Of if the surgeon wants a frozen section done, we need to notify pathology right away. Unless the surgeon has stated otherwise these are how the specimens will be going to pathology.
Drains and dressings
Now not every case in the Operating room will use a drain but for this case we are going too. Most cases will defiantly use dressings. Again, for the drain I will ask what the surgeon prefers before we open an item we didn’t need. As for this Aneurysm repair, I’m going to get some chest tubes of various sizes to keep my options open. The drain that is most commonly used is closed seal drainage. We suture the drain in place using a 0 silk. Dressing on cardiac surgeries are 4×4 sponges, ABD and tape.
Special considerations
Complications
The complications from a ventricular aneurysm repair could range from several things. Left ventricular failure which the most common hospital mortality. Low cardiac output, ventricular arrythmias and respiratory failure.
Postoperative care
The short- and long-term results of LVA have significantly improved over the last 10 to 15 years due to improvements in surgical technique, instrumentation, equipment and preoperative diagnostic testing. The patient is expected to make a full recovery with a few limitations in activity. The patient is expected to stay at the hospital 14 to 21 days after the procedure.