Aorta valve replacement (대동맥판막 치환술)

 

Aorta Valve Replacement 대동맥판막 치환술 

/aorta stenosis

/aorta regurgitation 

 

 

 

 

 

op table setting 상차림

 

 

 

 

 

 

1.incision 

s-pen 과 black silk로 incision line 확인

no.10 mess 로 skin incision

bovie로 fascia 박리 (med-debakey 와 army 사용)

sternum low part 와 xiphoid process 를 mayo scs로 잘라 분리

 

 

 

 

 

2.sternotomy

sternal saw로 sternum절개

pericardium 보이면 army 2개로 sternum 당겨 bovie와 bone wax로 sternum bone bleeding control

 

 

 

 

 

3.pericardiotomy

sternal ret apply (morse)

pericardium을 debakey 로 잡고 bovie로 incision

아래쪽 xiphoid process 쪽은 Lg kelly를 잡고 'L' 자로 박리 한다.

1/0 black silk 로 stay suture - kelly 로 물어 둔다 : 왼2 / 오3 

 

 

 

 

 

 

 

4.Cannulation 

 

1)Aorta purse-string suture 

2)SVC purse string suture

3)aorta cannulation

4)venous cannulation

5)IVC Purse-string suture

->pump on

6)CPS Perfusion

->cooling

7)Retrograde cardiopledgic perfusion 

8)Vent insertion + blue line

9)SVC & IVC Snaring 

aorta를 Rt-angle (or Kidney clamp) 로 박리 

->SV 를 Rt-angle로 박리 한 후 snairing u tape 걸어 둔다.

 

1)Aorta purse-string suture 

(1)2/0 ethibond F/0

->1st assist에게 torniquet , 2nd assist 에게 mezt scs 후 needle cut 하고 torniquet 하면 mosquito 로 잡아 놓기

(2)2/0 ethibond F/F + Pledget

->1st assist에게 needle holder + counter pledget -> torniquet -> needle cut 하고 나면 mosq로 잡기

 

2)SVC purse string suture

Rt angle로 SV 박리 한 후 Utape sling걸어 놓은 후 + Lg kelly -> Torniquet 잠깐 걸어둔다.

4/0 prolene F/F -> torniquet (1/3+) ->mosquito

 

3)aorta cannulation

*nylon tape - black silk - 1/0 black silk suture 

​

bovie 20

ice pack 준비

 

sharp metz으로 aorta 박리

->no.11 으로 puncture

->aorta cannular 넣는다. (1st assist: tubal clamp)

->1/3 torniquet을 조인후 nylon tape (먼저)

->1/0 black silk 를 함께 tie

->tubal clamp 로 clamping

->air 없는 것을 확인하고 connection 

->tubal clamp를 풀고 1/0 black silk로 skin 을 고정 

->소방 배게 만들어 tower clip 작은 것으로 고정

 

4)venous cannulation

11mess pucture 

->sharp metz으로 opening

->SV Cannulation 넣은 후 torniquet으로 조이고 

->1/0 black silk tie

->cannula에 blood채운 후 tubal clamp 로 잡는다.

->1st assist에게 IV Cannulation 과 clamp 

->Extension Line + 3/8 Line

->Y 자 connector

 

5)IVC Purse-string suture

4/0 prolene FB 

->1st assist : Lg needle holder

->1st assist: lg needle holder

->torniquet 1/3++

->no.11 mess puncture

->sharp metz으로 opening

 

*pump on

 

6)Vent

4/0 prolene F/B suture

->torniqeut nelatone 8Fr

->11mess , sharp metz opening

->vent insertion

->고정: black silk suture ​

->blue line을 vent canular 옆에 준비

 

*청소방 준비, CO2 준비

 

7)root (anterograde perfusion)

4/0 prolene F/0 Suture

->1/3 torniquet

->black silk tie

 

->ice apply 한 후 snaring 조이고, ACC Clamp

 

 

​

7)Retrograde cardiopledgic perfusion 

11mess RA incision

->sharp metz으로 open, vein retraction

->4/0 prolene F/B

->8Fr nelatone torniquet + tie

->retrograde cardiopledgic insertion : coronary sinus

->10cc sry 로 ballooning 하고, cps regurgi하여 확인 + pressure line

->black silk suture

​

 

*Retrograde pefusion

Retrograde cardioplegia is preferred when there is coronary artery disease with high-grade stenoses, aortic valve or aortic root disease, mitral valve disease, or during operations on the ascending aorta.

This method has the advantage of providing uniform perfusion of the myocardium through the completely unobstructed venous system when there is coronary artery disease that may inhibit flow to some segments of the heart.

 

A purse-string stitch is placed in the right atrium opposite the acute margin of the heart near the atrioventricular groove.

An incision is made within the purse string, and a retrograde perfusion catheter is introduced into the right atrium and directed into the coronary sinus. The catheter can also be guided into the coronary sinus by placing the fingers of the right hand medial to the inferior vena cava near the posterior atrioventricular groove to monitor the catheter’s position.

 

As the catheter enters the coronary sinus anterior to the venous uptake cannula, it is directed more cephalad to follow the course of the coronary sinus along the atrioventricular groove. The tip of the catheter is positioned at about the midpoint of the coronary sinus. Catheters with manual or self-inflating balloons are available. The pressure port is attached to an appropriate pressure monitoring device, and retrograde cardioplegia is delivered with the coronary sinus pressure about 50 mm Hg.

​

8)SVC & IVC Snaring 

RA가 열린 경우 SVC, IVC Snaring torniquet

 

 

 

 

 

 

 

 

5.Aorta Valve Replavement

 

 

1)incision

marker로 aorta의 open 할 부분 marking

->11mess incision 후 sharp metz으로 oeen

sucker tip : andrew 제거

 

 

*direct CPS 줄 경우 Aorta 열리고 난 후

 

*짧은 쪽에 extension 연결해서 기계 
 

 

 

 

2)Aorta tenting suture

4/0 Proelene + 딱딱한 pleget : FF / FF / BB / BB

 

3)Aorta valvectomy

tamponade gauze

valve fcp, metz blunt, sharp kelly, yanker 뚜껑 빼고, rongeur, nerve hook blunt

valve kit 내의 cvd metz

->valve biopsy : RCC/LCC Marking 후에 사진

 

 

4)Valve sizing

tissue : trifecta (SJM set)

mechanical : ON-X (black sizing 부속)

 

<aortal valve stenosis 일 경우>

2/0 ethibond + pleget : B1055 Suture 사용 하기도 함.

stenosis 일 경우 RA 안 열고 Retrograde plegia 안 함

->SVC, IVC snaring 안함

1)녹색 소공포 (root suture 한 후 준비) -> suture guide -> t.c 큰거 3ea로 고정

 

2)Valve marking suture : 2/0 ticron + 4mm spagetti 3ea

3)Suture : white 3/3/4 , Green 3/3/4 -> 부속 set 내의 needle holder

valve suture : set 내 needle holder

한쪽면 suture 다 한 후 needle cut - sry 로 물 많이

debakey 로 suture 한 부위 tighten 하게

​

4)valve insertion

v

5)alve test : valve tester 로 check, spoid + valve tester로 irrigation

->irrigation 할 때 vent stop

 

Aorta close

4/0 prolene + pledget 딱딱한 것 FF/BB

닫을 것 준비

 

 

 

 

 

 

6.Pump weaning

 

1)aorta close: FF/BB

 

2)Root cannular : sharp mosquito로 root suture 부위 확인 후 다시 cannular 넣고 3-way 마개로 막기

->빨간색 line 연결

 

3)RA Close

Retrograde pledgia cannualr out : 11mess로 tie 제거 먼저

warm n/s 사용

RA 다 닫고 마지막 tie 시점에 IVC Snaring 한 t.c 제거

 

4)Venous close

체온 올리고, air 제거 확인 된 후 venous line 정리

tubal clmap 3ea

IVC, SVC, Venous line 각 한 군데 tubal clamp 집고 난 후 물 빼는 line 연결

11mess -> SVC off -> tie -> reinfoce suture

 

5)pace maker pacing

brdycardia 시 주로 RV (FB) -> 1/0 Black silk tagging or RA(FF) 1ea 더 함.

 

 

 

 

 

 

 

 

7. close

1)drain

10 mess incision -> bovie 30 -> 1/0 black silk

Operator: F-Tie-B-mosquito

asisst: F-Tie-F-mosquito

hemostate -> c-tube

 

pericardium : 32 cvd

medi : 32 fr

 

2)pericardium closure: 4/0 prolene

3)sternum closure : steel wire 7ea

anti saline spray

4)skin closure

fascia: 1/0 vicryl 2ea

subcu: 3/0 vicryl 2ea

skin: steri-strip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cardiac Surgery: Operative Technique

Second Edition

Copyright © 2012 by Saunders, an imprint of Elsevier Inc.

 

저작권 등 다른 사람의 권리를 침해하거나 명예를 훼손하는 게시물은 이용약관 및

관련법률에 의해 제재를 받을 수 있습니다.