Complex Valve Surgery
TEE Correlation
Dr. Joseph E. Bavaria, MD
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)
Additional Info:
• PAP = 55/30 mmHg• RAP = 22 mmHg• CI at Cath = 1.5
• Class III CHF symptoms
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??
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??)
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!
Post op TEE
Post op TEE
After Chest Closed