Medical Transcription Cardiovascular Operative Sample Reports for Medical Transcriptionists:

OPERATIONS PERFORMED:  Intraoperative transesophageal echocardiogram with interpretation; coronary vascularization x3 using left internal mammary artery to the severely diffuse diseased anterior descending artery, saphenous vein graft from the aorta to the middle obtuse marginal artery and the right coronary artery; aortic valve replacement. 

OPERATION IN DETAIL:  The patient was brought in to the operating room and placed in the supine position. After general endotracheal anesthesia, the patient was prepped and draped in the usual fashion. Median sternotomy was utilized. Simultaneously, the saphenous vein grafts were harvested from the lower extremities. The left internal mammary artery was taken down with cauterization and clips. The patient was heparinized and cannulated in the usual fashion. The patient was placed on cardiopulmonary bypass and the aorta was cross-clamped. Antegrade as well as retrograde cardioplegic arrest was obtained and was also cooled systemically. Attention was directed to the right coronary system. There was a 2.6 mm vessel with some diffuse disease present with posterior plaquing. It was anastomosed, saphenous vein graft, with good flow following anastomosis.  The obtuse marginal was a 2 mm vessel. It was also anastomosed with a saphenous vein graft with good flow. At that point, the anterior descending artery was opened. There was severely diffuse disease. It was anastomosed to the left internal mammary artery with a running 8-0 Prolene suture. At that point, the aorta was opened in tangential fashion. The valve was severely calcified and cut out. Using pituitary rongeuer, we decalcified the annulus. We sewed a 23 mm pericardial valve into place. We used a ThermaFix supraannular valve. The aorta was closed in two layers with running 4-0 Prolene suture.  Once this was completed, proximal anastomosis was performed of the ascending aorta.  This was done with running 5-0 Prolene suture. Clamp was removed. The aorta was de-aired. Satisfactory flow was obtained. The patient was allowed to reperfuse for a brief period of time and was weaned off cardiopulmonary bypass uneventfully. Two ventricular and one right atrial pacing wires were placed. One mediastinal and one left pleural chest tube was placed. The chest was closed in routine fashion and postoperative record revealed good bioprosthetic valve function. The mitral insufficiency was somewhat improved with just mild to moderate insufficiency with just a mild central jet. The rest of the examination was unremarkable. The patient was transported to cardiovascular recovery unit postoperatively in stable condition.

 

PREOPERATIVE DIAGNOSIS:  Ascending aortic aneurysm and aortic insufficiency. 

POSTOPERATIVE DIAGNOSIS:  Ascending aortic aneurysm and aortic insufficiency. 

PROCEDURE PERFORMED:  Aortic valve replacement with a 23 mm Mosaic bioprosthetic valve and replacement of ascending aorta with a 30 mm Hemashield graft. 

SURGEON:  John Doe, MD 

ASSISTANT:  Jane Doe 

ANESTHESIA:  Endotracheal. 

DRAINS:  Two 32 French chest tubes. 

DESCRIPTION OF OPERATION:  The patient was identified and placed on the operative table in the supine position. General endotracheal anesthesia was induced. The chest and lower extremities were prepped and draped in the normal sterile fashion. The patient was given IV antibiotics prior to the start of the case. A standard midline sternotomy incision was made and the sternum was opened in the midline using a sternal saw. Once the sternum was opened, we noted immediately that the patient was more coagulopathic than normal and we did send off the patient to make sure that we had platelets and FFP available at the end of the case. It is unclear as to why the blood was so thin, but the patient bled a tremendous amount from the subcutaneous tissue and from the sternum. We then opened the sternum in the midline using a sternal saw. We opened the pericardium and evaluated the heart. The patient had a normal-appearing heart with no evidence of any left ventricular hypertrophy or wall motion abnormalities. The patient’s ascending aorta was markedly dilated in the mid ascending aorta and was normal at the level of the takeoff of the innominate artery and normal at the level of the sinotubular junction. The patient did have a very thin-walled aorta and we had to be careful as we were placing stitches in the aorta to avoid any injury to the aortic valve. We then heparinized the patient to an ACT of greater than 500. We placed aortic and atrial cannulation stitches as well as aortic and atrial cannulae, connected to the bypass tubing ensuring that there was no evidence of any air within the arterial limb of the bypass tubing. We then placed a retrograde cardioplegia catheter and vent within the coronary sinus. We then went on bypass.

Once we were on bypass, we placed a vent within the main pulmonary artery and we also placed an angiocatheter in the ascending aorta to give cardioplegia. We then cross-clamped the aorta. We gave 500 mL of cold antegrade cardioplegia and topical ice through the antegrade catheter and then gave 800 mL of cold retrograde cardioplegia and topical ice and arrested the heart. We gave 500 mL of cold retrograde cardioplegia every 20 minutes throughout the entire case and kept ice packs on the heart throughout the entire case. We then opened up the aorta at the level of the sinotubular junction and removed the entire aneurysmal portion of the aorta and sent this to pathology for routine evaluation. Once again, we noted that the patient had an exceedingly thin-walled aorta. We had to be very careful with this as we were sewing on it, because of the thin-walled nature and the difficulty with causing tears within the aortic valve secondary to the stitches. Once the aneurysmal segment was gone, we then gave cold antegrade cardioplegia down both of the coronary orifices. We then removed the aortic valve and sized the annulus to a 23 mm. We then placed 14 interrupted horizontal mattress stitches with pledgets that were noneverting around the entire annulus. We then sutured the 23 mm Mosaic valve in place. We then measured the aorta to 30 mm and got a 30 mm Hemashield graft. We then sewed this in place using running pledgeted 3-0 Prolene stitches and buttressed the stitches with felt on the outside of the aorta. We also placed several pledgets on the inside of the aorta to avoid any tearing of the intima due to the thin-walled nature of the aorta.

Once we got everything in place, we sutured the proximal end. We then fashioned the distal end for the aorta and then sewed this in place as well. Once it was sewn in place, using meticulous care to avoid any tearing of the aorta, we used several extra pledgets on both ends to avoid tearing of the aorta. Once the sutures were in place, we then gave a warm hot shot of retrograde cardioplegia. We placed a deairing catheter within the graft itself and then we removed the cross clamp. The patient spontaneously came back into normal sinus rhythm. We spent several minutes deairing the graft. Once we were sure that all air was out on the echo, we then placed atrioventricular pacing wires. We did check our suture lines meticulously to see if there was any leakage from any of the suture lines. When we assured that there was none, we then coated the areas with CoSeal as well as Tisseel. When we assured that there was no significant bleeding from the suture lines, we then began coming off bypass. When we were half way off bypass, we removed our vent from the PA as well as our cardioplegic catheter from the coronary sinus and tied down our cannulation stitches. We then came all the way off bypass and we assured that the valve was working well and there was no evidence of any AI and the valve was working well and no gradient across the valve, we then gave protamine. When we assured there was no air within the heart, we removed the vent from the ascending aorta and oversewed this site with pledgeted Prolene stitch. Then, we proceeded to give all the protamine. Once all the protamine was in, we removed our aortic line and tied down our cannulation stitch as well as the atrial line. We tied down our cannulation stitches. We oversewed the aortic cannula with a 3-0 Prolene pledgeted stitch.

We then checked all our cannulation sites for bleeding and the sutures lines for bleeding. We assured that there was none. We checked the suture lines. We did not note any evidence of any leakage from any of the suture lines or the cannulation sites. We then closed the pericardium loosely over the top of the heart and then we obtained meticulous hemostasis with Bovie cautery all along the sternum. We placed a chest tube along the base of the heart as well as the chest tube within the mediastinum. We then proceeded to close the sternum using several interrupted figure-of-eight #7 sternal wires. When we assured there was no bleeding from the wire holes, we then tightened the wire. We then closed the pectoral and rectus fascia and closed the subcutaneous tissue and skin. The wounds were then cleaned and dried and sterile bandages were placed. All needle, sponge, and instrument counts were correct at the end of the case. The patient tolerated the procedure well.

OPERATION PERFORMED:  Dual chamber pacemaker placement with lead fluoroscopy and right upper extremity venogram and hand injection and synchronous direct-current cardioversion.

OPERATION IN DETAIL:  After informed consent, the patient was brought to the operating room in a fasting unsedated state. Continuous electrocardiograph monitoring, noninvasive blood pressure monitoring, pulse oximetry and standby pacing and defibrillator pads were provided. In addition, the patient was evaluated by the anesthesiologist who provided for sedation and airway management. The right prepectoral area was prepped and draped in a sterile manner and anesthetized with 2% Xylocaine. A 2 cm incision was made two fingerbreadths inferior to the clavicle near the deltopectoral groove. Using blunt dissection and electrocautery, a pocket was made for the pacemaker at the level of the pectoralis fascia. Using a blunt dissection in deltopectoral groove, the left cephalic vein was located and dissected free. The distal portion of the vein was tied with 0 Ethibond tie and the proximal portion was looped with an 0 Ethibond loop. The vein was incised and an attempt was made to insert a vein pick and cannulate the vein. However, this cephalic vein was not of sufficient quality structurally and the cephalic approach was therefore stopped. The proximal tie was tied. Next, with the patient in Trendelenburg position, a right upper extremity venogram was performed using 10 mL of nonionic low-molecular weight contrast to visualize the course of the right subclavian vein. Using this venogram as well as anatomic and fluoroscopic landmarks of the guide, the extrathoracic portion of the right subclavian vein near the transition to the axillary vein was cannulated via modified Seldinger technique and 0.035 guidewires were placed x2 and advanced under fluoroscopic guidance to the cavoatrial junction. The patient was taken out of Trendelenburg position, and first, the guidewire was used to place a #7-French peelable introducer, which was used in turn to advance the ventricular lead under fluoroscopic guidance to the septal portion of the right ventricular apex. The active fixation screw was advanced and parameters were measured as below. High output pacing did not stimulate the diaphragm. The ventricular lead was sutured in place using the suture sleeve and 0 Ethibond sutures x2 into the pectoralis fascia. Next, the remaining guidewire was used to place a second 7-French peelable introducer, which was used in turn to advance the atrial lead under fluoroscopic guidance. The atrial lead was placed in the high right atrium area and the active fixation screw was advanced. Stable position and impedance in atrial fibrillation and good atrial fibrillation electrogram were obtained. Next, using 100 joule biphasic waveform, anteroposterior atrial fibrillation was terminated and sinus rhythm ensued with temporary pacing provided by the pacing system's analyzer connected to the atrial lead and the ventricular lead. The patient remained out of atrial fibrillation and did not convert back into atrial fibrillation during the procedure. The atrial lead was sutured in place using a suture sleeve and 0 Ethibond sutures x2 into the pectoralis fascia. Careful attention was paid to hemostasis in the pocket. The pocket was then irrigated with antibiotic solution. The pacemaker leads were attached to the pacemaker generator and proper operation was confirmed. The leads and generator were placed in the pocket. A fluoroscopic survey was made of the pocket as well as the leads, and there was also no evidence of right-sided pneumothorax on fluoroscopy. The sponge and needle counts were correct. Deep portion of the pocket was lined with FloSeal thrombin paste. The pocket was closed with two layers of 3-0 Vicryl running suture as well as subcuticular layer of 4-0 Vicryl running suture and Dermabond adhesive on the skin surface. The patient tolerated the procedure well and was discharged from the operating room in good condition without any immediate postprocedure complications. A chest x-ray was ordered to exclude pneumothorax.

 

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