Myocardial

Revascularization +
Aortic Valve
Replacement

Anguie Tatiana Herrera Hernandez 01200021060

 Clinical Case

Name: Alberto Einstein

Age: 60 years
Gender: Male
Weight: 89 Kg
Blood group: O+

Alberto Einstein was admitted to the cardiology service with

severe angina pectoris, which had become more frequent in
recent weeks. Additionally, I have experienced episodes of
breathlessness during moderate physical activities.
On physical examination, he had a grade III systolic aortic
murmur, without signs of meningeal irritation.
 Clinical Case
Background
-Pathological: hypothyroidism
-Surgical: Denies
-Pharmacological: stagliptin + metformin, levothyroxine, metoprolol, asa, nifedipine,
dapaglifozin, valsartan, hydrochlorotazide, rosubastatin, spironolactone.
Laboratories:
-Filtration rate:104.09ml/min
-HIV: non-reactive
-Glucometry: 128
-Hepatitis B: non-reactive
-K: 4.75
-AC: 1.24
-HTO: 45
-Platelets: 133,000
 Diagnostic Methods
ANGIOTAC OF THE THORAX, ABDOMEN AND PELVIS:
1. AORTIC VALVULAR CALCIFICATIONS
2. ANGIOTAC OF AORTA AND ILIAC ARTERIES WITHIN NORMAL LIMITS, WITHOUT EVIDENCE OF AREAS OF
SIGNIFICANT STENOSIS
SEVERE AORTIC VALVE STENOSIS OF CALCIFIED ORIGIN PEAK GRADIENT 65MMHG MEAN GRADIENT 44MMHG
AORTIC VALVE AREA 0.9CM2, MODERATE CONCENTRIC HYPERTROPHY OF THE LV PRESERVED GLOBAL
CONTRACTILITY FELV 60% NORMAL SIZE AORTIC ROOT 3.7CM ASCENDING AORTA DILAT ADA 4.0 CM.

COLOR DOPPLER OF LOWER LIMBS: ARTERIAL PERMEABILITY IN

LOWER LIMBS, NORMAL ARTERIAL FLOWS, GOOD DISTAL BEDS,
VENOUS PERMEABILITY, NO VENOUS THROMBOSIS, VALVULAR
INCOMPETENCE OF THE SUPERFICIAL VENOUS SYSTEM THAT
COMPROMISES THE BILATERAL GREATER SAPHENA VEIN, DESCRIBED
VERICES, REFLOW OF PERFORATORS DESCRIBED LEFT LOWER LEMBER,
THE GREATER SAPHENA VEIN IS FOUND WITHOUT INJURIES IN THE WALL
BILATERALLY.

NECK VESSEL DOPPLER: WITHIN NORMAL CHARACTERISTICS

 Diagnostic Methods
ELECTROCARDIOGRAM (ECG): SINUS RHYTHM WITHIN
NORMAL LIMITS

CHEST X-RAY: PROMINENCE OF THE AORTIC

BUTTON WITH CALCIFICATIONS INSIDE WITH
CARDIOVASCULAR RISK FACTOR REST WITHIN
NORMAL PARAMETERS
 Diagnostic Methods

Coronary Angiography (Cardiac

Catheterization): Revealed the presence of
significant stenosis in the main coronary artery. A
severe eccentric lesion occurred in the anterior
descending artery, in the proximal segment, first
diagonal. Additionally, the thoracic aortogram
shows calcification without insufficiency.

Treatment Plan:
Given the diagnosis of multivessel coronary artery disease, it was decided to perform
myocardial revascularization without extracorporeal circulation using the "off-pump"
heart surgery technique or without a cardiopulmonary pump. This approach was
chosen due to the patient's comorbidity, which included diabetes and his advanced age.
ANATOMY OF THE CORONARY ARTERIES
ANATOMY OF AORTIC VALVE
 GRAFTS ANATOMY
Saphenous Vein Mammary Artery
CHECK LIST
 SURGICAL TEAM POSITION PATIENT POSITION

Anesthesiologist

Nurse

Perfusionist
Surgeon

Surgical

Assistant
Instrumentation

Supine Position
MAY TABLE ARRANGEMENT
RESERVATION TABLE ARRANGEMENT
 TÉCNICA QUIRÚRGICA
-May table arrangement and reservation
-Patient's dress
-Count of compresses and gauze
-Fixing pipes and lines with straight kellys
-Dress of the surgeon and assistant

STERNAL OPENING TIME:

-To make an incision, go to the surgeon MB# 7 and HB# 15

-Pass to surgeon dissection and electrocautery for deep tissue incision.
-For sternotomy pass to surgeon reciprocating saw equipment
-For manual separation of the sternum, go to the Farabeuf separator surgeon.
-Pass bone wax, electrocautery in 60 for hemostasis of the sternal periosteum and bone marrow.
-Pass to the surgeon the sternal protectors and the self-retaining retractor for the fixed retraction of the
sternum.
 TÉCNICA QUIRÚRGICA
DISSECTION OF THE MAMMARY ARTERY:

-Pass to the surgeon microvascular dissection and electrocautery in 20 for dissection of the mammary artery.
-For ligation and hemostasis of this, use Ligaclip forceps and the corresponding clip cartridge according to the
caliber of the vessel and Metzembaum scissors.
-Prepare moist gauze with nitroglycerin-impregnated solution for arterial vasodilation of the mammary artery.
-Pass to the surgeon vascular type dissection and electrocautery device in 40 for the opening of the pericardium.
-Pass needle holder with 0 silk suture to repair the pericardium.
VASCULAR TIME:

-Pass vascular dissection, T. Mayo and 2/0 polyester suture for the surgeon to make the tobacco pouches in:
oAscending Aorta
oright atrium
-Prepare 4/0 polypropylene for the surgeon to make the tobacco pouches in:
o Right Upper Pulmonary Vein (Vent Aspirator)
-Prepare pass threads (tourniquet) and Kelly to refer the tobacco bags made by the surgeon.
-Prepare the appropriate cannula for the patient's infusion as appropriate.
-Go to the surgeon MB# 7 HB# 11 to perform the arteriotomy to perform the corresponding cannulation.
-Prepare pre-cut silk 1 for fixing the placed cannulas by passing them through the surgeon's hand.
-Prepare tube clamp and gauze for purging the arterial cannula.
-Go to surgeon MB#7 HB#11 to make the incision in the right atrium.
Pass the long Metzembaum scissors to the surgeon to widen the incision and perform the corresponding
cannulation.
-Prepare pre-cut silk 1 for fixing the placed cannulas by passing them through the surgeon's hand.
-Prepare suitable connectors for the connection of the cannula to the extracorporeal circuit.
-Go to surgeon MB#7 HB#11 to make the incision in the right upper pulmonary vein.
-Go to the surgeon P. Kelly Adson to widen the incision and perform the corresponding cannulation.
-Prepare total occlusion vascular clamp for the surgeon to perform aortic clamping.
(AORTIC VALVE REPLACEMENT)

-Pass to the surgeon MB#3 HB# 11), and vascular dissection to incise the aorta, then pass long tissue scissors.
-Pass the suction cannula of the machine, to collect the blood.
-Pass coronary perfusion cannula, for direct antegrade cardioplegia in coronary ostium.
-Silk pass 4-0 to repair the walls of the aorta.
Pass vascular grasping forceps and scissors for dissection and removal of the aortic valve.
-Keep in mind that when the valve is calcified, the surgeon removes the valve using allix forceps, scissors and
vascular grasping forceps.
-It is washed with saline solution, remember to place an extension to the aseptosyringe
-The valve is measured with the gauge approved by the surgeon and confirmed.
-The nursing assistant is asked for the valve device to be implanted, confirmed aloud.
-If the valve to be implanted is biological, wash it according to the valve device washing protocol.
-Pass the valve to the assistant surgeon.
-Support the surgeon in the passage of the sutures in the valve annulus.
-The surgeon is passed a 2-0 vascular polyester suture in each of the posts and the respective repair, then the
following sutures are passed, taking special care not to repeat the color of the thread.
-After implantation of the medical device, pass a closing suture (prolene 4-0 16mm round needle with pledget).
-Ready root suction.
-4/0 polypropylene pass for aortic root purse string
(MYOCARDIAL REVASCULARIZATION)

-Give the surgeon compresses and gauze to improve exposure.

-Give the surgeon a scalpel with a 15 blade, and vascular apprehension, to
dissect the epicardial fat and locate the coronary artery to be revascularized.
-Pass the cardiac retractor to the surgeon to improve the surgical area
-Pass to the surgeon with umlaut instruments, microvascular elastic
apprehension to perform the coronary arteriotomy (scalpel handle blade 15)
and to extend the incision pass antegrade and/or retrograde Potts type
microvascular scissors depending on the cut.
-Pass the coronary shunts (1.0,1.5,2.0,2.5) to the surgeon using a fine elastic
grasping forceps in order to maintain coronary flow
-Prepare the 7/0 and/or 8/0 polypropylene synthesis and suturing
instruments for the surgeon to perform the distal anastomoses.
-For better exposure of the surgical field at the anastomosis site, use
continuous CO2 aeration with a suction line and cannula.
-If it is necessary to reinforce the suture, prepare microvascular synthesis
instruments, microvascular dissection forceps and suture.
-Hemostasis check.
CLOSING TIME:

-Prepare warm saline solution, to speed up patient warming.

-Prepare for aortic unclamping and removal of the patient from extracorporeal circulation.
-Pass Mayo scissors, vascular dissection and assist the surgeon at the time of removal of
the cardiovascular cannulas, anticipating partial occlusion clamp and reinforcing sutures
with and without supportfrom pledget.
-Pass pacemaker wire so that the surgeon can position them ashe sees fit in the atrium
and ventricle.
-Pass HS#3 SB#15, vascular dissection, suture and Long Metzenbaum Scissors and
chest tubes so that the surgeon can position them as he sees fit in the pleurae and mediastinum respectively.
-Nelaton 14 probe is inserted for chest tube aspiration
-Assist the surgeon in general hemostasis with electrocautery of the surgical area, providing suture material,
gauze, compresses and hemostasis elements.
-Verification of counts
-Prepare number 5 surgical wire, Rochester, needle holder, and wire cutters for the surgeon to face the sternum.
-Prepare 2/0 or 3/0 polypropylene to face the muscles and subcutaneous tissue with needle holder, claw
dissection, and Mayo scissors.
-Prepare poliglecaprone to face the skin with needle puller, adson dissection with claw and mayo scissors.
-Make the patient heal by cleaning and covering the wound with dressings and/or adhesive tapes.
 BIBLIOGRAPHY
https://cardiovascularpractice2023.weebly.com/