Mitral valve repair

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

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OR SETUP. While the anesthesia care provider places the monitoring lines, the circulating nurse and scrub person prepare the sterile field. Standard cardiac trays are used along with a valve tray, mitral valve retractor, and the appropriate valve sizers. The scrub person prepares the aortic cannula, bicaval cannulae, left ventricular catheter for ventricular decompression, and antegrade cardioplegia needle. The circulating nurse and scrub person perform the sponge, needle, and instrument counts. The circulating nurse confirms that all sizes of required implants (eg, mitral annular bands and rings) as well as necessary suture for valve repair are available.

PREPARING THE PATIENT. After the anesthesia care provider has secured the monitoring lines, all perioperative team members including the surgeon and anesthesia care provider actively participate in the surgical time out. The anesthesia care provider then induces the patient under general anesthesia, after which the circulating nurse inserts an indwelling urinary catheter with a temperature-sensing probe. The circulating nurse ensures that the patient is in an anatomically correct, supine position and pads and tucks the patient's elbows at the patient's sides. The circulating nurse then places the electrosurgical unit (ESU) dispersive pad on the patient's buttock.

The direction of the regurgitant jet helps determine the mechanism of regurgitation because the jet flows in the opposite direction of the flailing or prolapsing leaflet. (1) The anesthesia care provider ensures that preload, afterload, and blood pressure are controlled during the TEE examination so that the degree of mitral regurgitation is not distorted. The anesthesia care provider inserts the TEE probe, and performs a preoperative assessment of valve function. Ideally, the anesthesia care provider and the cardiologist should perform the TEE together because TEE interpretation may vary between observers. (1)

When the TEE is complete, the circulating nurse preps the patient's surgical site from chin to knees and lateral to the nipple line. The surgeon and scrub person then place the surgical drapes on the patient and the suction and ESU pencil on the sterile field.

PLACING THE PATIENT ON CPB. The surgeon makes a median sternotomy incision from the sternal notch to the xiphoid process and opens the sternal bone using a reciprocating saw. The surgeon uses electrosurgery and bone wax to obtain sternal-edge hemostasis and then secures a Morse sternal retractor in place to expose the patient's heart. He or she then opens the pericardium using Debakey forceps and Metzenbaum scissors and uses silk suture for pericardial stay stitches. After the pericardium is open, the surgeon dissects the aorta, superior vena cava (SVC), and inferior vena cava (IVC) and starts dissecting posteriorly to the interatrial groove.

The anesthesia care provider administers heparin and checks the patient's activated dotting time (ACT) after three minutes. The ACT test is used to monitor the effectiveness of high-dose heparin therapy administered during CPB surgery. High-dose heparin anticoagulation during CPB is necessary to reduce the risk of microthrombi that result from the extracorporeal manipulation of blood. The ACT test is used to demonstrate the inability of the patient's blood to coagulate rather than quantifying the ability to clot.