Mitral valve repair

AORN Journal,  Jan, 2007  by Margo Winters,  Pam Obriot

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TRANSESOPHAGEAL ECHOCARDIOGRAM (TEE). A preoperative TEE allows anatomy to be defined, assesses the degree of mitral regurgitation, and measures left ventricular function. The direction of the mitral regurgitation jet seen on a TEE can identify which leaflet is flailing or prolapsing. An anteriorly directed jet indicates a posterior leaflet prolapse or flail; whereas a posteriorly directed jet indicates an anterior leaflet prolapse or flail. (1) A centrally directed jet may indicate annular dilation.

Intraoperatively, the TEE is a useful tool to more accurately

* determine valve anatomy,

* assess the degree of the mitral valve disease,

* assess the degree of regurgitation,

* evaluate left ventricular function,

* assess annular size and degree of enlargement, and

* assess for a regurgitant jet.

With the patient under anesthesia, a TEE probe is placed in the patient's esophagus so that the probe lies behind the heart. The probe will remain in place throughout surgery. After the surgical repair has been performed, the surgeon will clamp the cardiopulmonary bypass (CPB) cannulas, fill the heart, and check the repair using a TEE. Based on this examination, the surgeon will decide if the repair is adequate. If the surgeon decides that additional repairs are needed, CPB will be reinitiated.

PREOPERATIVE PHASE OF SURGERY

In the preoperative holding room, the circulating nurse assesses the patient and verifies the patient's identity. Before any narcotics are administered, the nurse confirms the proposed procedure with the patient and his or her family members, cross checking the procedure with the surgical consent and OR schedule, and resolving any discrepancies with the surgeon before the patient is taken to the OR. The nurse performs an examination to assess the patient's physical health status, emphasizing identification of cardiovascular risk factors, such as height, weight, presence of hypertension or diabetes, and use of alcohol or illicit drugs. He or she further identifies the patient's relevant medical history (eg, chronic illnesses, injuries, surgeries), and obtains the patient's medication history, including medication allergies, and any use of

* aspirin or other anticoagulants and the date of discontinuation of those medications,

* prescribed medications,

* over-the-counter medications, and

* herbal therapies.

The circulating nurse notes the results of pertinent laboratory studies, such as chest x-rays and complete blood count (CBC). He or she ensures that the patient has undergone blood typing and cross-matching and that two units of packed red blood cells are available. After completing the history and physical examination and reviewing the medical record, the nurse develops a nursing care plan specific to this patient and the proposed surgical procedure (Table 2).

INTRAOPERATIVE PHASE

The circulating nurse and anesthesia care provider transport the patient to the OR. To maintain the patient's temperature during the preparatory phase of the procedure, the circulating nurse places a temperature-regulating blanket on the patient after helping make the patient comfortable on the OR bed and securing the safety strap and arm boards. The anesthesia care provider places a radial arterial line in the patient's nondominant wrist and a central line with a pulmonary artery thermodilution catheter in the patient's right internal jugular.