Pre-op

Control BP with GTN and labetolol (50mg bolus with 5% glucose, 2mg/min)

6u blood, FFP, platelets X-match.

Right radial and right femoral arterial lines to monitor pressure.

Bladder temperature probe.

TOE.

Operative procedure

Prepare left femoral for cannulation. Give heparin. Cannulate. Secure at least 3 different locations.

Femoral access – longitudinal incision over the femoral artery from the level of the inguinal ligament. Norfolk-Norwich self-retaining retractor with handle inferiorly. Haemostasis with ligaclips. Mcindoe scissors to develop plane on to the femoral artery. Right-angle to pass sling around the artery with 2 passes. 2 slings above and below the desired cannulation point. Place two vascular clamps above and below with enough space for insertion of the cannula. Make transverse incision across anterior part of the artery. Insert 24Fr arterial cannula with the rim outside the incision, and remove the proximal clamp simultaneously. Snug the proximal sling by pulling the sling tight and clamping with a clip.

Sternotomy.

Pericardiotomy with diathermy/scissors and securing with pericardial stays/?lift up pericardium.

Right atrial cannulation.

(Coronary sinus cannulation + RSPV LV vent cannulation +Sling the aorta – optional. )

Cross-clamp. Cardioplegia. Ice slush. Cool to 18C.

Excise dissected tissue of aortic root/ascending aorta. Examination of valves, coronaries, sinuses – find tear and make sure it is dissected out. If tear extends to sinuses, excise sinus.

Size graft – Gelweave Ante-Flo (with side-arm, 20-34mm diam) – cut in two pieces, one for the proximal and the side-arm for the distal. Proximal graft to be shaped in case of coronary re-implantation or sinus reconstruction.

Pericardial strip sandwiched between layers of aortic wall for proximal suture line with the graft. (AY – bioglue sandwich, with teflon strip around the proximal and distal aorta to provide a strengthened non-haemostatic suture line using 4-0 or 3-0).

Prepare long teflon strip for distal anastomosis.

Prepare graft and have it on the inferior part of the field with a Roberts forceps steadying it.

Drain and remove cross-clamp. Inspect arch vessels and check for entry points/tears, including the clamp site.

Interrupted horizontal mattress sutures circumferentially with Dunhills at their ends. Might not have room for teflon strips to be placed adjacent, and may have to be parachuted down into place.

Continuous over and over stitching to attach the distal end of the graft to the teflon-reinforced distal aorta.

Clamp the proximal end of the graft. De-air the graft through the side-arm. Clamp the side-arm. Transfer the aortic cannula to the side-arm – secure with 2x heavy silk ties. Back to full flow on the pump and rewarm.

Proximal anastomosis of the grafts with 4-0 prolene double-ended. Bioglue.

De-air through newly inserted root vent, or through white needle/large orange cannula.

Remove cross-clamp.

Wait till difference between core and peripheral temperature is 2C.

Wean off bypass.

Femoral closure in layers (fascia – to prevent lymphatic fistula, fat, skin) with interrupted 6-0/de-air.

“Upon opening the chest, the lungs were in a natural state, free from every appearance of inflammation, or tubercle: but upon examining the heart, its pericardium was found distended, with a quantity of coagulated blood, nearly sufficient to fill a pint cup; and, upon removing this blood, a round orifice appeared in the middle of the upper side of the right ventricle of the heart, large enough to admit the extremity of the little finger. Through this orifice, all the blood brought to the right ventricle had been discharged into the cavity of the pericardium; and, by that extravasated blood, confined between the heart and pericardium, the whole heart was very soon necessarily so compressed, as to prevent any blood contained in the veins from being forced into the auricles; which, therefore, with the ventricles, were found absolutely void of blood, either in a fluid or coagulated state. 

As, therefore, no blood could be transmitted through the heart, from the instant that the extravasation was completed, so the heart could deliver none to the brain; and, in consequence, all the animal and vital motions, as they depend on the circulation of the blood through the brain, must necessarily have been stopped, from the same instant; and his Majesty must, therefore, have dropped down, and died instantaneously: And as the heart is insensible of acute and circumscribed pain, his death must have been attended with as little of that distress, which usually accompanies the separation of the soul and body, as was possible, under any circumstances whatsoever.

…

Upon examining the parts, we found the two great arteries, (the aorta and pulmonary artery, as far as they are contained within the pericardium) and the right ventricle of the heart stretched beyond their natural state; and, in the trunk of the aorta, we found a transverse fissure on its inner side, about an inch and half long, through which some blood had recently passed, under its external coat, and formed an elevated echymosis.”