[[100 Welcome to Outlines of Technique in Cardiac Surgery]] # Technical Outline of Aortic Valve Replacement ## Positioning - [[Positioning for Cardiac Case]] ## Preparation and Draping - [[Preparation and Draping]] - [[Analysis of BSA and Preliminary Aortic Valve Prosthetic Sizing]] - Time-out Checklist ## Sternotomy - [[Determine and Mark Midline on Skin]] - [[Sternotomy Skin Incision]] - [[Sternotomy with Bone Saw]] - Administer Heparin [^a] ## Cannulation - [[Pericardiotomy]] and [[Creation of the Pericardial Well#Aortic Valve Pericardial Well]], [^b] - [[Aortic Cannulation Pursestring]] - [[Double-Stage Venous Cannulation Pursetring]] - [[Aortic Cannulation]] - [[Venous Cannulation]] - LV Vent Cannulation - Retrograde Pursetring and Insertion of Retrograde Cannula - Antegrade Pursetring and Insertion of Antegrade Cannula - Carbon Dioxide Instillation ## Cardiopulmonary Bypass and Cardiac Arrest - Initiate Cardiopulmonary Bypass - Stop ventilation - Cross Clamp - Cardiac Arrest and Myocardial Protection - LV Vent Insertion ## Aortic Valve Replacement - [[Aortotomy for Aortic Valve Replacement]] - [[Excision of Aortic Valve and Annular Debridement]] - [[Aortic Annular Sutures]] - [[Aortic Valve Prosthetic Sizing]] - Placement of Annular Sutures through Aortic Valve Prosthetic Ring - Slide Aortic Valve Prosthetic down Annular Sutures - Secure Aortic Valve Prosthetic Annular Sutures - Aortotomy Closure after Aortic Valve Replacement - Preliminary De-Airing after Aortic Valve Replacement - Maintenance of Cardioplegia during Aortic Valve Replacement ## Reperfusion of the Heart and Termination of Cardiac Arrest - Placement of Epicardial Pacing Wires - Reperfuse Heart with Warm Blood - Defibrillation - Restoration of Stable Rhythm - Check Aortotomy for Hemostasis - Secure Epicardial Pacing WIres to Skin ## Weaning Cardiopulmonary Bypass - Trial Wean/De-Airing Wean/Diagnostic Wean - Add Chemical Support - Remove Cardioplegia Catheters - Final Wean - Protamine Administration ## Decannulation - Venous Decannulation - Aortic Decannulation ## Hemostasis Ritual - Preparation for Hemostasis Ritual - Hemostasis Ritual ## Sternotomy Closure - Chest Tube Placement - Xyphoid Fascial Figure-of-Eight - Sternal Closure - Periosteal Layer - Five Minute Rules - Dermal Layer - Subcuticular Layer - Dressings - Chest Dressing - Leg Dressing [^a]: See [[Philosophies in the Timing of Heparin Administration]] [^b]:See [[Creation of the Pericardial Well#Philosophy of Pericardial Well Creation]]