complex valve surgery tee correlationsurgical plan: • 3. rd. time redo sternotomy • mechanical...

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Complex Valve Surgery TEE Correlation Dr. Joseph E. Bavaria, MD

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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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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