COLOMBIA HEART

INSTITUTE

CLINICAL CASE
PULMONARY VALVE
REPLACEMENT REINTERVENTION
ANA MARIA BOTHIA
01200022011
 DESCRIPTION OF THE
CASE
Names and surnames: Arturo Diaz
Age: 22 years
Weigth : 67 kg
Gender: Male
Place of residence: Cabecera
Marital statu: Single
Blood type: AB+
Surgical history: Pulmonary atresia correction
Pharmacological: No indica
Pathological: Tetralogy of fallot
 DIAGNOSTIC METHODS

ECHOCARDIOGRAM: IS A HEALTHCARE
TECHNOLOGY THAT USES STANDARD
ULTRASOUND TECHNIQUES TO
PRODUCE TWO-DIMENSIONAL SLICE
IMAGES OF THE HEART.

ERGONOMETRIC STRESS TEST:

EVALUATES THE HEART'S RESPONSE
TO PROGRESSIVE PHYSICAL
EXERCISE. DURING THE TEST, THE
PATIENT TELLS HOW THEY FEEL,
THEIR ELECTROCARDIOGRAM IS
CONTINUOUSLY RECORDED, AND
THEIR BLOOD PRESSURE IS TAKEN
PERIODICALLY.
PEDIATRIC TRANSONIC
ECHOCARDIOGRAM
ERGONOMETRIC STRESS TEST
DESCRIPTION

PROTOCOL: BRUCE

1. HIS RESTING ECHO SHOWS SINUS RHYTHM, RBBB, VENTRICULAR

EXTRASYSTOLES IN DUPLETS AND TRIPLETS.

2. THE PATIENT TOLERATED 13.4 METS ACCUMULATING 10 MIN ON THE

BAND WITH A PERCEIVED EXERCISE LEVEL OF 20 (BORG). SYSTOLIC
BLOOD PRESSURE INCREASED 16 MMHG. HE DID NOT PRESENT ANGINA
OR DYSPNEA.

3.THE ECG DURING EXERCISE DID NOT SHOW REPOLARIZATION

CHANGES COMPATIBLE WITH ISCHEMIA, IN STAGE 3 PRESENTS
OCCASIONAL VENTRICULAR EXTRASYSTOLY.

4. THE PATIENT PERFORMED PHYSICAL EFFORT TO TOLERANCE,

REACHING 100% OF THE MAXIMUM HEART RATE EXPECTED FOR HIS AGE
WITHOUT PRESENTING ANGINA OR REPOLARIZATION ALTERATIONS IN
HIS.

5. ECG. NORMAL PHYSICAL CAPACITY AND RECOVERY. LOW POST-TEST

PROBABILITY FOR CORONARY HEART DISEASE. VENTRICULAR
EXTRASYSTOLY IS OBSERVED IN THE RECOVERY PHASE.
 ANATOMY
THE PULMONARY VALVE IS LOCATED SUPERIOR TO THE CONUS
ARTERIOSUS OF THE PULMONARY ARTERY [INFUNDIBULUM], IN A
SUPERIOR, POSTERIOR AND RIGHT DIRECTION, SEPARATING THE RIGHT
VENTRICLE FROM THE PULMONARY ARTERY; IT MEASURES
APPROXIMATELY 2.5 CENTIMETERS IN DIAMETER.

IT HAS THREE SIGMOID OR SEMILUNAR VALVES: ANTERIOR (ATTACHED

TO THE AORTA), RIGHT LATERAL AND LEFT LATERAL (BOTH OPPOSITE TO
THE AORTA).

THE LEAFLETS INSERT INTO THE VENTRICULAR SEPTUM OR THE FREE

WALLS OF THE RIGHT VENTRICLE AND PROJECT INTO THE LUMEN OF THE
PULMONARY TRUNK.
 TETRALOGY OF FALLOT

TETRALOGY OF FALLOT IS
CHARACTERIZED BY 4 ANOMALIES:
LARGE VENTRICULAR SEPTAL
DEFECT, RIGHT VENTRICULAR
OUTFLOW TRACT OBSTRUCTION,
PULMONARY VALVE STENOSIS,
RIGHT VENTRICULAR
HYPERTROPHY, AND AORTIC
OVERHANG.
 IMPORTANT INFORMATION FOR
SURGERY
FORMULAS CANNULAS
ARTERIAL CANNULA: EOPA #20

F.E: 62% VENOUS CANNULATION:

S.C: 1,8 SELECTIVE: SUPERIOR VENA CAVA

(MALLEABLE VENOUS CANNULA
FLUJO: 4,5 #24) INFERIOR VENA CAVA
(VENOUS CANNULA #28).
HEPARIN: 4,7
CARDIOPLEGIA CANNULA:
ANTEROGRADE-AORTIC ROOT.
 CHECK LIST

PULMONARY VALVE
REPLACEMENT
REINTERVENTION
 TABLE SETTINGS
May table
Reservation Table
 POSITION OF THE PATIENT AND
LOCATION OF THE SURGICAL
EQUIPMENT

Location of surgical equipment

Supine Position
 SURGICAL PROCEDURE

SURGICAL PROCEDURE INSTRUMENTAL

1. A double incision is made and hemostasis is performed. 1. Scalpel handle #7 Scalpel blade #15 and Electroscalpel.
2. The entire scar is removed. 2. Electroscalpel and Dissecting forceps with claw.
3. The wire is removed from the sternum. 3. Farabeuf separators.
4. Hemostasis of the sternum is performed. 4. Electroscalpel.
5. The sternum and skin are separated. 5. Rake separator.
6. The cut of the sternum is made. 6. Oscillating saw.
7. Separation of adhesions is carried out. 7. Electroscalpel.
8.The separation of the sternum is performed with self-aesthetic 8. Sternal Separator.
fixation. 9. Polipropileno 5/0 C-T1.
9.The correction of the injury caused by the saw to the heart is 10. Electroscalpel and Metzenbaum scissors.
performed. 11. Silk 0 con SH.
10. Continue separating the adhesions. 12. Poliglactina 910 0 con CT1.
11. Perform pericardium separation. 13. 23,000 units of Heparin.
12. Repair of damage to the heart. 14. Polipropileno 4/0 con pledget RB1and tourniquet.
13. We perform the placement of heparin.
14. We make the arepas for cinnamon are arterial and
tourniquet.
 SURGICAL PROCEDURE INSTRUMENTAL

15. We make the fins of the inferior vena cava. 15. Polipropileno 5/0 con RB1.
16. Tourniquet placement in the inferior vena cava and perform 16. Tourniquet and Venous cannula #28.
annulment of the inferior vena cava. 17. EOPA cannula #20.
17. We perform the placement of the arterial meat. 18. Saline solution.
18. We transfer the pericardial patch to the table and let it rest. 19. Polipropileno 5/0 con RB1.
19. We perform the earrings in the Superior vena cava. 20. Malleable venous cannula #24.
20. We perform the tourniquet in the Superior vena cava and 21. Polipropileno 4/0 con RB1.
cancel it. 22. Cardioplegia cannula.
21. We make the purse for the cardiology cannula. 23. Total arterial clan.
22. We introduce the cardioplegia cannula into the root of the 24. Scalpel handle #7 Scalpel blade #11 and cavity aspirator.
aorta. 25. Polipropileno 5/0 con RB1.
23. We perform total occlusion between the cardioplegia 26. Scalpel handle #7 Scalpel blade #11.
cannula and the arterial cannula. 27. Valve gauge #27.
24. We make the cut in the pulmonary artery and introduce the 28. Biological pulmonary valve Avalus #27.
free cavity aspirator. 29. Biological pulmonary valve Avalus #27.
25. We place two repairs in the pulmonary artery. 30. Polipropileno 4/0 RB1.
26. We expanded the pulmonary artery incision.
27. Introducing the pulmonary valve gauge.
28. We ask the nurse for the Biological pulmonary valve.
29. Placement of the pulmonary biological valve.
30. We fix the valve.
 SURGICAL PROCEDURE INSTRUMENTAL

31. We place the pericardium in the pulmonary artery. 31. Polipropileno 4/0 RB1.
32. We place the pacemaker wire in the epicardium. 32. Pacemaker wire 2/0.
33. We place the Blake drain, one in each pleura and the other 33. Blake drain.
in the mediastinum. 34. Polipropileno 5/0 RB1.
34. We repair injuries to the heart. 35. Scalpel handle #7 Scalpel blade #11.
35. We open a contracture to remove Blake's drains. 36. Polipropileno 4/0 con Rb1.
36. Close up of cardioplegia cannula puncture in the atrium. 37. Venous cannulas and arterial cannula.
37. We remove the venous cannulas and arterial cannulas. 38. Metzenbaum scissors.
38. The separation points in the pericardium are removed. 39. Electrobisturi.
39. Hemostasis of the sternum and revision of the cavity are 40. Surgical wire 6.
performed. 41. Poliglactina 910 0 conct-1.
40. Closure of the sternum is performed. 42. Monocryl 3/0 With needle 3/8.
41. Closure of sternal fascia subcutaneous cellular tissue. 43. Gauze, Tegaderm. Dermabon and leukomed.
42. Leather closure.
43. We perform healing.
 POSTOPERATIVE COMPLICATIONS

BLEEDING.
BLOOD CLOTS.
FAILURE OF A REPLACEMENT
VALVE.
HEART ATTACK.
IRREGULAR HEART RHYTHM
(ARRHYTHMIAS)
INFECTION.
STROKE.
DEATH.
THANK YOU SO
MUCH
BY YOUR ATTENTION