Complex Valve Surgery TEE CorrelationSurgical Plan: • 3. rd. time REDO sternotomy • Mechanical...
Transcript of Complex Valve Surgery TEE CorrelationSurgical Plan: • 3. rd. time REDO sternotomy • Mechanical...
![Page 1: Complex Valve Surgery TEE CorrelationSurgical Plan: • 3. rd. time REDO sternotomy • Mechanical aortic valve composite aortic graft • Be prepared for difficult anatomy • Mitral](https://reader033.fdocuments.net/reader033/viewer/2022060821/609a1d3f437a9338b17ece06/html5/thumbnails/1.jpg)
Complex Valve Surgery
TEE Correlation
Dr. Joseph E. Bavaria, MD
![Page 2: Complex Valve Surgery TEE CorrelationSurgical Plan: • 3. rd. time REDO sternotomy • Mechanical aortic valve composite aortic graft • Be prepared for difficult anatomy • Mitral](https://reader033.fdocuments.net/reader033/viewer/2022060821/609a1d3f437a9338b17ece06/html5/thumbnails/2.jpg)
Preoperative Data• 36 y/o male; 65”; 69kg; BSA 1.8m2
• [1990; Age 10; Saudi Arabia] Dx: Rheumatic Aortic Valve Disease causing AV Stenosis (or Bicuspid AV?)
• [1998: Age 18; UK] Surgery: Homograft/ AVR Bioprosthetic#23
• [2006: Age 25: USA (PA)] Surgery: REDO Sternotomy / REDO AVR (#21 mm Edwards 3000 pericardial) / Pericardial patch enlargement of aortic root / Tricuspid ring (#28 mm Edwards 4600 ring)
• [May, 2016: Age 36] Dx: CHF NYHA IV, Severe AS, Severe MR, Moderate TR. Deemed inoperable by Cardiac Surgery at OSH. Recommended evaluation for heart transplant.
• Zero additional PMH (LFTs normal despite RV failure and TR)
![Page 3: Complex Valve Surgery TEE CorrelationSurgical Plan: • 3. rd. time REDO sternotomy • Mechanical aortic valve composite aortic graft • Be prepared for difficult anatomy • Mitral](https://reader033.fdocuments.net/reader033/viewer/2022060821/609a1d3f437a9338b17ece06/html5/thumbnails/3.jpg)
Additional Info:
• PAP = 55/30 mmHg• RAP = 22 mmHg• CI at Cath = 1.5
• Class III CHF symptoms
![Page 4: Complex Valve Surgery TEE CorrelationSurgical Plan: • 3. rd. time REDO sternotomy • Mechanical aortic valve composite aortic graft • Be prepared for difficult anatomy • Mitral](https://reader033.fdocuments.net/reader033/viewer/2022060821/609a1d3f437a9338b17ece06/html5/thumbnails/4.jpg)
![Page 5: Complex Valve Surgery TEE CorrelationSurgical Plan: • 3. rd. time REDO sternotomy • Mechanical aortic valve composite aortic graft • Be prepared for difficult anatomy • Mitral](https://reader033.fdocuments.net/reader033/viewer/2022060821/609a1d3f437a9338b17ece06/html5/thumbnails/5.jpg)
![Page 6: Complex Valve Surgery TEE CorrelationSurgical Plan: • 3. rd. time REDO sternotomy • Mechanical aortic valve composite aortic graft • Be prepared for difficult anatomy • Mitral](https://reader033.fdocuments.net/reader033/viewer/2022060821/609a1d3f437a9338b17ece06/html5/thumbnails/6.jpg)
![Page 7: Complex Valve Surgery TEE CorrelationSurgical Plan: • 3. rd. time REDO sternotomy • Mechanical aortic valve composite aortic graft • Be prepared for difficult anatomy • Mitral](https://reader033.fdocuments.net/reader033/viewer/2022060821/609a1d3f437a9338b17ece06/html5/thumbnails/7.jpg)
![Page 8: Complex Valve Surgery TEE CorrelationSurgical Plan: • 3. rd. time REDO sternotomy • Mechanical aortic valve composite aortic graft • Be prepared for difficult anatomy • Mitral](https://reader033.fdocuments.net/reader033/viewer/2022060821/609a1d3f437a9338b17ece06/html5/thumbnails/8.jpg)
![Page 9: Complex Valve Surgery TEE CorrelationSurgical Plan: • 3. rd. time REDO sternotomy • Mechanical aortic valve composite aortic graft • Be prepared for difficult anatomy • Mitral](https://reader033.fdocuments.net/reader033/viewer/2022060821/609a1d3f437a9338b17ece06/html5/thumbnails/9.jpg)
![Page 10: Complex Valve Surgery TEE CorrelationSurgical Plan: • 3. rd. time REDO sternotomy • Mechanical aortic valve composite aortic graft • Be prepared for difficult anatomy • Mitral](https://reader033.fdocuments.net/reader033/viewer/2022060821/609a1d3f437a9338b17ece06/html5/thumbnails/10.jpg)
![Page 11: Complex Valve Surgery TEE CorrelationSurgical Plan: • 3. rd. time REDO sternotomy • Mechanical aortic valve composite aortic graft • Be prepared for difficult anatomy • Mitral](https://reader033.fdocuments.net/reader033/viewer/2022060821/609a1d3f437a9338b17ece06/html5/thumbnails/11.jpg)
![Page 12: Complex Valve Surgery TEE CorrelationSurgical Plan: • 3. rd. time REDO sternotomy • Mechanical aortic valve composite aortic graft • Be prepared for difficult anatomy • Mitral](https://reader033.fdocuments.net/reader033/viewer/2022060821/609a1d3f437a9338b17ece06/html5/thumbnails/12.jpg)
![Page 13: Complex Valve Surgery TEE CorrelationSurgical Plan: • 3. rd. time REDO sternotomy • Mechanical aortic valve composite aortic graft • Be prepared for difficult anatomy • Mitral](https://reader033.fdocuments.net/reader033/viewer/2022060821/609a1d3f437a9338b17ece06/html5/thumbnails/13.jpg)
![Page 14: Complex Valve Surgery TEE CorrelationSurgical Plan: • 3. rd. time REDO sternotomy • Mechanical aortic valve composite aortic graft • Be prepared for difficult anatomy • Mitral](https://reader033.fdocuments.net/reader033/viewer/2022060821/609a1d3f437a9338b17ece06/html5/thumbnails/14.jpg)
![Page 15: Complex Valve Surgery TEE CorrelationSurgical Plan: • 3. rd. time REDO sternotomy • Mechanical aortic valve composite aortic graft • Be prepared for difficult anatomy • Mitral](https://reader033.fdocuments.net/reader033/viewer/2022060821/609a1d3f437a9338b17ece06/html5/thumbnails/15.jpg)
![Page 16: Complex Valve Surgery TEE CorrelationSurgical Plan: • 3. rd. time REDO sternotomy • Mechanical aortic valve composite aortic graft • Be prepared for difficult anatomy • Mitral](https://reader033.fdocuments.net/reader033/viewer/2022060821/609a1d3f437a9338b17ece06/html5/thumbnails/16.jpg)
![Page 17: Complex Valve Surgery TEE CorrelationSurgical Plan: • 3. rd. time REDO sternotomy • Mechanical aortic valve composite aortic graft • Be prepared for difficult anatomy • Mitral](https://reader033.fdocuments.net/reader033/viewer/2022060821/609a1d3f437a9338b17ece06/html5/thumbnails/17.jpg)
Summary:
36 year old third time entryRedo Redo Aortic Valve (Root)Severe AI Severe AS dysfunctionSevere TR (S/P ring)Mod-Severe MR (some called it Severe)Class IV CHF; CI = 1.5Significant RV dysfunction (RAP = 22)Nice guy!!
What to do NOW??
![Page 18: Complex Valve Surgery TEE CorrelationSurgical Plan: • 3. rd. time REDO sternotomy • Mechanical aortic valve composite aortic graft • Be prepared for difficult anatomy • Mitral](https://reader033.fdocuments.net/reader033/viewer/2022060821/609a1d3f437a9338b17ece06/html5/thumbnails/18.jpg)
Surgical Plan:
• 3rd time REDO sternotomy• Mechanical aortic valve composite aortic
graft• Be prepared for difficult anatomy
• Mitral valve repair (Plan B: mechanical mitral valve replacement)
• Evaluate TR on, intraoperative TEE & repair only if regurgitation is severe (TV replacement??)
![Page 19: Complex Valve Surgery TEE CorrelationSurgical Plan: • 3. rd. time REDO sternotomy • Mechanical aortic valve composite aortic graft • Be prepared for difficult anatomy • Mitral](https://reader033.fdocuments.net/reader033/viewer/2022060821/609a1d3f437a9338b17ece06/html5/thumbnails/19.jpg)
Surgical Procedure
• 3rd time REDO sternotomy• Mitral valve ring annuloplasty #32 mm• LCA 6 mm dacron interposition graft• RCA saphenous vein interposition graft• Mechanical aortic valve composite aortic
graft (#21 mm)• Tricuspid valve ring (#30 mm)• CPB and cross clamp …. Long!
![Page 20: Complex Valve Surgery TEE CorrelationSurgical Plan: • 3. rd. time REDO sternotomy • Mechanical aortic valve composite aortic graft • Be prepared for difficult anatomy • Mitral](https://reader033.fdocuments.net/reader033/viewer/2022060821/609a1d3f437a9338b17ece06/html5/thumbnails/20.jpg)
Post op TEE
![Page 21: Complex Valve Surgery TEE CorrelationSurgical Plan: • 3. rd. time REDO sternotomy • Mechanical aortic valve composite aortic graft • Be prepared for difficult anatomy • Mitral](https://reader033.fdocuments.net/reader033/viewer/2022060821/609a1d3f437a9338b17ece06/html5/thumbnails/21.jpg)
![Page 22: Complex Valve Surgery TEE CorrelationSurgical Plan: • 3. rd. time REDO sternotomy • Mechanical aortic valve composite aortic graft • Be prepared for difficult anatomy • Mitral](https://reader033.fdocuments.net/reader033/viewer/2022060821/609a1d3f437a9338b17ece06/html5/thumbnails/22.jpg)
![Page 23: Complex Valve Surgery TEE CorrelationSurgical Plan: • 3. rd. time REDO sternotomy • Mechanical aortic valve composite aortic graft • Be prepared for difficult anatomy • Mitral](https://reader033.fdocuments.net/reader033/viewer/2022060821/609a1d3f437a9338b17ece06/html5/thumbnails/23.jpg)
![Page 24: Complex Valve Surgery TEE CorrelationSurgical Plan: • 3. rd. time REDO sternotomy • Mechanical aortic valve composite aortic graft • Be prepared for difficult anatomy • Mitral](https://reader033.fdocuments.net/reader033/viewer/2022060821/609a1d3f437a9338b17ece06/html5/thumbnails/24.jpg)
![Page 25: Complex Valve Surgery TEE CorrelationSurgical Plan: • 3. rd. time REDO sternotomy • Mechanical aortic valve composite aortic graft • Be prepared for difficult anatomy • Mitral](https://reader033.fdocuments.net/reader033/viewer/2022060821/609a1d3f437a9338b17ece06/html5/thumbnails/25.jpg)
![Page 26: Complex Valve Surgery TEE CorrelationSurgical Plan: • 3. rd. time REDO sternotomy • Mechanical aortic valve composite aortic graft • Be prepared for difficult anatomy • Mitral](https://reader033.fdocuments.net/reader033/viewer/2022060821/609a1d3f437a9338b17ece06/html5/thumbnails/26.jpg)
![Page 27: Complex Valve Surgery TEE CorrelationSurgical Plan: • 3. rd. time REDO sternotomy • Mechanical aortic valve composite aortic graft • Be prepared for difficult anatomy • Mitral](https://reader033.fdocuments.net/reader033/viewer/2022060821/609a1d3f437a9338b17ece06/html5/thumbnails/27.jpg)
![Page 28: Complex Valve Surgery TEE CorrelationSurgical Plan: • 3. rd. time REDO sternotomy • Mechanical aortic valve composite aortic graft • Be prepared for difficult anatomy • Mitral](https://reader033.fdocuments.net/reader033/viewer/2022060821/609a1d3f437a9338b17ece06/html5/thumbnails/28.jpg)
Post op TEE
After Chest Closed
![Page 29: Complex Valve Surgery TEE CorrelationSurgical Plan: • 3. rd. time REDO sternotomy • Mechanical aortic valve composite aortic graft • Be prepared for difficult anatomy • Mitral](https://reader033.fdocuments.net/reader033/viewer/2022060821/609a1d3f437a9338b17ece06/html5/thumbnails/29.jpg)
![Page 30: Complex Valve Surgery TEE CorrelationSurgical Plan: • 3. rd. time REDO sternotomy • Mechanical aortic valve composite aortic graft • Be prepared for difficult anatomy • Mitral](https://reader033.fdocuments.net/reader033/viewer/2022060821/609a1d3f437a9338b17ece06/html5/thumbnails/30.jpg)
![Page 31: Complex Valve Surgery TEE CorrelationSurgical Plan: • 3. rd. time REDO sternotomy • Mechanical aortic valve composite aortic graft • Be prepared for difficult anatomy • Mitral](https://reader033.fdocuments.net/reader033/viewer/2022060821/609a1d3f437a9338b17ece06/html5/thumbnails/31.jpg)