Dennis

Anesthesia
Has had a GA, states no issues, states no
family members with issues to anesthesia
• Aortic aneurysm
Incidental finding Known to Dr. Cusimano
since 2019 and reviewed in July 2022 but
wishes to proceed with early operation vs.
continued follow-up
• Arrhythmia
• Chronic a-fib 2000
Ablations attempted x4 and did revert to
NSR for about 1 year, and has been in A.Fib
since, was on Amiodarone orally and was
stopped d/t side effects
• Coronary artery disease
• CVA (cerebral vascular 2016
accident)
small parietal infarct with no residual
deficits, had been off his blood thinner for
prostate surgery
• Dental crowns present
All over molars, missing teeth in lower has
been warned of dental damage with recent
cleaning and clearance
• GERD (gastroesophageal
reflux disease)
Takes medication occasionally
• H/O coronary angiogram 15/05/2023
Mid RCA to Dist RCA lesion is 25%
stenosed. • Ost Cx to Prox Cx lesion is 45%
stenosed. • Ost LAD to Prox LAD lesion is
35% stenosed. • Prox RCA lesion is 40%
stenosed.
• History of echocardiogram 03/2023
Normal LV And RV size and function EF-55-
60%, Severe biatrial enlargement
Moderate AI d/t mal-coaptation of leaflets
aortic root 51mm and proximal ascending
aorta measures 38 mm
• Hyperlipidemia
• Hypertension 1992
On medication since for about 25 years,
well controlled and followed by cardiology
• Kidney stone 1993
Passed on own
• Migraine 13/10/2022
• Sleep apnea
Mild and does not use CPAP
Past Medical History Pertinent Negatives:
Diagnosis Date Noted
• Visual impairment 04/10/2023

Past Surgical History:

Procedure Laterality Date
• BCC
Head,chest, back and left cheek Most recently on right arm 3 wks
ago
• CARDIAC CATHETERIZATION N/A 15/05/2023
Procedure: Right And Left Heart Cath; Surgeon: Dzavik, Vladimir,
MD; Location: TG CARDIAC CATH LAB; Service: Cardiac
• CARDIAC CATHETERIZATION N/A 15/05/2023
Procedure: Selective Coronary Angiogram; Surgeon: Dzavik,
Vladimir, MD; Location: TG CARDIAC CATH LAB; Service: Cardiac
• HERNIA REPAIR Left 1994
Inguinal
• TRANSURETHRAL RESECTION
OF PROSTATE

Op notes

Findings: TEE confirmed the large root aneurysm with moderate to severe aortic insufficiency. The
aortic valve was tricuspid but very degenerated, with large fenestrations and retracted cusps. It was not
a repairable valve and we chose to replace the root with a pericardial valved conduit. He weaned off
pump easily and post pump TEE showed preserved biventricular function with no major issues. The
pericardium was closed at the end of the procedure.

-----\]\

David J

Medical History:
Diagnosis Date
• Anesthesia
Pt reports he has ongoing memory and cognitive ability impairment
since previous tonsil cancer surgery. It has not improved since nor
worsened. He is hesitant to undergo GA unless life threatening or
symptomatic. Pt had previous left neck dissection with scarring
evident, central line access preferred to right side. Neck ROM good
despite previous surgery, MP2, TM distance 3fb, good mouth
opening.
• Anesthesia
Pt denies chest pain or palpitations. SOBOE. No dental concerns
• Anxiety and depression
 on meds
• Aortic root dilatation
moderate aortic regurgitation due to dilated aortic root and an
ascending aortic aneurysm.
• Ascending aorta enlargement
• Duodenal ulcer 1993
treated with cimetidine at the time, no further issues
• Dysphagia
experiencing solid dysphagia. This occurs typically 2-3 times per
month where the food gets stuck at the bottom of his esophagus
and he has to mechanically force himself to regurgitate. Scope done
- investigated for eosinophilic esophagitis which was negative.
Deemed silent GERD and started on pantaloc which has improved
the issue
• Elevated TSH
From July 6, 2023 - 4.85. Thyroid normal on CT. Pt reports it
fluctuates
• Gastric ulcer 1993
• H/O coronary angiogram 24/07/2023
coronary arteries are normal.
• H/O exercise stress test 06/2020
Normal stress echo with preserved LV function; LVEF 64%. No
evidence of previous MI or reversible ischemia. Good exercise
tolerance in an asymptomatic pt. Clinically negative, electrically
negative stress test
• H/O magnetic resonance imaging 2023
Cardiac: Mild-moderate LV dilation measuring 127 ml/m2. Stable
normal global systolic function - LVEF 62%. Normal RV size and low
normal global systolic function (RVEF 51%). Tricuspid aortic valve
with stable moderate root dilation with maximum dimension 46
mm. Markedly dilated ascending aorta measuring 54 mm. Mitral
valve prolapse. Moderate-severe LA dilation. Normal RA size.
• Hernia of abdominal wall
Near umbilicus, pt has had previous general surgery consult but
considering previous issues with GA he has elected to not repair
unless urgent
• Hypertension
controlled on meds
• Lymphocytopenia
CD4. Idiopathic T cell lymphopenia with recurrent herpetic
outbreaks
• Mitral valve disease
severe mitral regurgitation due to leaflet prolapse,
• Muscle fasciculation
bilateral lower legs; pt states it is ongoing, not medicated for it.
Idiopathic
• SOBOE (shortness of breath on exertion)
with incline, mowing grass
• Tonsil cancer 14/04/2021
left tonsillar SCC Stage I (cT2N0M0, p16 positive). The patient
 underwent transoral robotic surgery; oropharyngectomy, left neck
dissection, panendoscopy, left buccal fat flap with Dr. De Almeida
followed by adjuvant radiation therapy in June 2021
• TR (tricuspid regurgitation)
moderate tricuspid regurgitation,

Past Surgical History:

Procedure Laterality Date
• CARDIAC CATHETERIZATION N/A 24/07/2023
Procedure: Selective Coronary Angiogram; Surgeon: Barolet, Alan
W., MD; Location: TG CARDIAC CATH LAB; Service: Cardiac
• CARDIAC CATHETERIZATION N/A 24/07/2023
Procedure: Left heart cath; Surgeon: Barolet, Alan W., MD;
Location: TG CARDIAC CATH LAB; Service: Cardiac
• GASTROSCOPY 19/07/2023
no esophageal malignancy. There are signs of eosinophilic
esophagitis most prominent in the distal esophagus.
• SELECTIVE NECK DISSECTION 13/04/2021
Direct laryngoscopy. Transoral robotic pharyngectomy on the left
side. Left-sided neck dissection. Left buccal fat axial pattern pedicle
flap to cover transoral robotic defect. Left sternocleidomastoid flap
for closure of cervical communication. Left-sided pharyngoplasty.

Procedure Details:
The patient was seen in the preoperative area. The risks, benefits, complications, treatment options,
non-operative alternatives, expected recovery and outcomes were discussed with the patient. The
possibilities of reaction to medication, pulmonary aspiration, injury to surrounding structures, bleeding,
recurrent infection, the need for additional procedures, failure to diagnose a condition, and creating a
complication requiring transfusion or operation were discussed with the patient. The patient concurred
with the proposed plan, giving informed consent. The site of surgery was properly noted/marked if
necessary per policy. The patient has been actively warmed in preoperative area. Preoperative
antibiotics have been ordered and given within 1 hours of incision. Venous thrombosis prophylaxis have
been ordered including chemical prophylaxis

Findings:

000

Brian M

Operative Procedure(s): October 11, 2023

* REPLACEMENT VALVE AORTIC (#25 mm Magna Ease tissue valve)
* REPAIR AORTA ASCENDING (#30 mm Dacron graft)
* ECHO TRANS ESOPHAGEAL
* BYPASS CARDIOPULMONARY
Surgeon(s): * Ouzounian, Maral - Primary
 * Souto Alvarez, Juglans - Assisting

Allergies:
No Known Drug, Environmental, or Food Allergies

Past medical history

Past Medical History:
Diagnosis Date
• Abnormal hemoglobin
Hgb 167 June 2023
• Aortic stenosis
Bicuspid AV; severe AS. Mild ascending aortopathy.
• CAD (coronary artery disease) 02/2023
• Exercise therapy 26/09/2023
His job is very physical, however since his MI, he has not
gone back to work and has put on 20 lbs. Unable to climb
stairs d/t c/o leg weakness. He has mild shortness of breath
on exertion NYHA class II.
• H/O coronary angiogram 02/2023
The left main is patent. The proximal circumflex has mild
disease. The distal circumflex has mild disease. The
proximal LAD has mild disease. The mid LAD has mild
disease. The distal LAD has mild disease. The RCA is a
large dominant vessel. The proximal RCA is 100% occluded
and thrombotic.
• H/O echocardiogram 02/2023
This shows normal LV size and function. He has severe
concentric LVH. He has severe aortic stenosis with peak and
mean gradients of 92/61 mmHg. His aortic root is not dilated
but his ascending aorta is enlarged at 4.4 cm. His LVOT
diameter by echo is somewhat small at 21 mm.
• Hypertension 2021
amlodipine and peridopril/indapamide
• OA (osteoarthritis)
knees, back
• PAD (peripheral artery disease) 2023
Mild PAD as per recent doppler, however pt describes c/o
claudication
• Peripheral edema
minimal bilateral peripheral edema
• Prediabetes
Hgb A1C 6.2 Aug 8/23, mild neuropathy, no nephropathy
• Snores
States he might have signs of OSA, however he was never
tested.
• STEMI (ST elevation myocardial infarction) 02/2023
Brian presented with an inferior STEMI and underwent urgent
PCI to his RCA

Indications: Brian MacKenzie Parnell is an 61 y.o. male who is having surgery for severe symptomatic
aortic stenosis in the setting of a bicuspid aortic valve. He had no obstructive coronary artery disease
and a 45 mm ascending aortic aneurysm. His heart function was preserved and he had no other major
valvulopathies. Risks and benefits were discussed and he was taken to the operating room for an
elective AVR and replacement of his ascending aorta.

Findings: We found a heavily calcified bicsupid valve with fusion of the left and right cusps. He had an
ascending aortic aneurysm that tapered before the arch and did not need circulatory arrest to repair. He
had up to moderate central MR with no clear structural problem that was repairable with the mitral
valve, so we left the mitral valve alone. He weaned off pump easily with minimal support. Post pump
TEE showed a well seated bioprosthetic valve with a low gradient an no paravalvular leak. The entire
pericardium was closed at the end of the procedure.