Saturday, January 17, 2015

Surgical Q & A

Here's an interesting Q & A exchange that I had with my surgeon's assistant.

1. During my surgery, will Dr. Wheatley be performing a "button" Bentall procedure or using some other technique to re-implant the coronary arteries?

A. If the coronaries need to be reimplanted, they are done with the button technique. If your aneurysm does not involve the sinus segment (where the coronaries are located) he’ll be able to replace the aorta above the coronaries – negating the need to reimplant. This final decision is made at the time of surgery.

2. Can you outline the surgical steps during my procedure once my heart is exposed? Since I agree with Dr. Wheatley's recommendation to select a St. Jude Trifecta bio prosthesis, is the valve sized first then sewn into the Dacron ascending aorta graft before being sewn into the aortic annulus all during my time on the pump? Or do these valves come in different sizes already sewn into a conduit?

A. You’ve done some good homework. This is an excellent question. Currently a “biologic composite graft” does not exist. This is a device where the valve is pre-sewn into the aortic conduit. The answer to this question depends upon the extent of the repair. Regardless of the method, the aorta is first transected (cut open) to expose the aortic valve. The damaged aortic valve is removed and then sized at this time. If the aortic root (sinus segment) is enlarged enough necessitating replacement, then this is done with a composite graft. Dr. Wheatley will sew the valve into the Dacron aortic conduit (replacement aorta) and then implant this unit into the aortic root and then reimplant the coronary buttons as in question #1. If the sinus segment is not dilated, then the valve will be sewn in the aortic annulus (into the heart) first, followed by replacement of the ascending aorta. There are three general techniques used to complete this procedure – revolving around the extent of aortic root involvement – Full root (with a composite graft), Wheat procedure, AVR/ascending repair with retention if the native sinus segment.

3. Can you estimate the total time on the pump and total time in the OR for me? I know I asked this of Dr. Wheatley but I'm a bit confused about it.

A. There are various times we record for cardiac procedures such as this – Cross clamp time, bypass time, operative time. as with any “plumbing repair” (and valve surgery is essentially a plumbing job), the water (in this case blood) needs to be turned off. To “turn off the water” we clamp the aorta (ie cross clamp). We then need to stop the heart in an effort to fix it. Once your pump (your heart) stops, we need to substitute in our pump (the heart bypass machine – also known at the heart lung machine or simply “the pump”). The length of time you are on the pump is recorded. I suspect you’ll be on the pump 2-3 hours. I usually quote the total length of surgery as 4-5 hours and total time out of Dan’s sight about 6-8 hours. I always build into this estimate an hour at the beginning to set you up and an hour at the end to dismantle the equipment: (1 hour set up) + (4-5 hours surgery) + (1 hour dismantle) = 6-8 hours.

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