Well, it’s now 29 days to my surgery. I just called the U of W to get my Angiogram scheduled. I literally just got a call back and now I am going to get it scheduled with DR. McCabe.

Here are my notes from Dr. Gabe and LORD WILLING, it all goes well and I TRULY BELIEVE that I could NOT be in better hands with Dr. Gabe and Dr. Christopher Burke.

OUTPATIENT FOLLOW-UP CONSULTATION

This is a follow-up consultation on Mr. Brian Scott Tinsley, U2347635.

The patient is well known to us. He underwent a replacement of ascending aorta on an emergency basis in 2003 for a type A dissection. He now presents with progression of aortic insufficiency to severe, and a moderate drop in his ejection fraction. The aortic root is dilated. The aortic valve is most probably bicuspid.

I had a very lengthy discussion with the patient, his wife, and his parents. We have reviewed the previous scope of the surgery. It appears that the patient had an ascending aortic interposition graft placed. The graft itself appears to be calcified. The aortic root is dilated to approximately 50 mm. Severe aortic insufficiency is associated with this root aneurysm. The left main coronary artery is large and takes off at a normal location. The right coronary artery also appears to be anatomically appropriately oriented, but is quite diminutive. There is some scattered calcification in the coronary arteries that does not seem to be critical in nature.

As far as preoperative testing, we will obtain a coronary angiogram to assess coronary anatomy and particularly define whether or not the right coronary artery is dominant or nondominant and r/o significant CAD (not likely but important to define).

In addition, I focused my discussion to point out to the patient and family that all the arch vessels are chronically dissected. There are chronic dissections in the innominate, left carotid and left subclavian arteries. The axillary artery is uninvolved, and there is a good lumen that would feed the carotid.

The patient’s physical examination is unchanged from prior exam. Sternotomy is well healed. There is a femoral cannulation incision. Chest is clear to auscultation. Heart is in regular rhythm, but there is a loud systolic murmur that is appreciated with a diastolic component. Neurological exam is nonfocal.

ASSESSMENT AND PLAN:
In my discussions with the family, I have emphasized the need of intervention now. The immediate proximal goal of the surgery is a completion Bentall procedure to replace the insufficient valve. I do not believe the bicuspid valve, particularly in the presence of aortic insufficiency and massive root dilatation, is salvageable. The root is going to be replaced as well, and the coronary arteries will be reimplanted. The major decision that will also be made is whether or not to extend the surgery to at least involve the hemiarch under deep hypothermic circulatory arrest, and I believe that consideration for this should be given.

We have discussed the benefit of axillary versus femoral retrograde perfusion cannulation in this situation. If cerebral oximetry or pressures are at all involved, we can augment this with central cannulation to enhance body and cerebral perfusion. While undergoing deep hypothermic circulatory arrest, we will dissect the heavily calcified graft from the adjacent pulmonary artery and superior vena cava, and at least initiate the Bentall. Despite my discussions with the patient and his very young age (57), the patient is leaning toward a bioprosthetic valve with an Edwards INSPIRIS Resilia prosthesis. Again, we reviewed that regardless of newer anticalcification therapies, it is not clear what the durability of this valve will be in a young patient such as he, and the likelihood that he will need a re-intervention (catheter based or open) in the future. My personal bias was to consider a mechanical valve conduit as a definitive surgery with the least chance of future re-intervention, but the patient is leaning toward a bioprosthetic valve. He understands that he will need future re-interventions, including TAVRs and possibly open surgery in the future.

Again, from a technical planning point of view, the plan is to place femoral artery and vein cannulas (5 Fr. percutaneous catheters), dissect the axillary artery, redo the sternotomy, initiate venous central cannulation, cardiopulmonary bypass and venting. During the cooling period and with venting of the right superior pulmonary vein, the ascending aorta will be clamped, retrograde and direct ostial cardioplegia coronary artery will be administered, and the root will be prepared for the Bentall procedure. When reaching deep hypothermic circulatory arrest conditions, the hemiarch will be completed, and central perfusion through the side Y-graft of the hemiarch neo-ascending aorta will be reinitiated, and warming will be initiated. Completion Bentall would then be completed.

I have discussed the risks for this procedure in detail with the patient and family. I have quoted them a 20% risk of morbidity, including myocardial dysfunction, stroke, respiratory, renal, bleeding, infectious, healing, and arrhythmic complications requiring a permanent pacemaker. The very calcified nature of his ascending aorta is concerning, and I anticipate significant adhesions to the adjacent pulmonary artery and to the superior vena cava. Despite young age, the patient is at higher risk for a stroke given that all 3 cerebral vessels are involved in a dissection (particualrly with retrograde femoral cannulation which we hope to avoid), and I have discussed this in detail with the patient and his family.

The patient will meet us again 1 week prior to surgery to make a final decision on the type of prosthesis that he wants as part of the Bentall procedure.

I have answered all of the patient’s questions fully.

TIME-BASED EVALUATION:
Duration of evaluation is 1 hour. Forty-five minutes were used in counseling. Please see the above notes for specifics of counseling.

Gabriel S Aldea, MD at 11/12/2019 4:00 PM