Transcribed by: Dilip Kumar Panigrahi. Date: March 31, 2013.

TITLE OF OPERATION: Aortic and pulmonary valvotomies, Gore-Tex patch enlargement of aortic root , and main pulmonary artery incision median sternotomy ___ 24 French anterior mediastinum. POSTOPRATIVE DIAGNOSIS: Valvular and supravalvular aortic and pulmonary stenosis,? Williams syndrome. BRIEF HISTORY: This 3-year-old black girl has been followed by us from the first year of life with diagnosis of aortic and pulmonary stenosis. _____ developed a severe biventricular hypertrophy and has had poor growth. Because of increasing exercise and tolerance, her ___ was reevaluated and cardiac catheterization had demonstrated a transpulmonary gradient >82 and transaortic gradient exceeding 112. FINDINGS AT OPERATION: There was a marked biventricular hypertrophy. The aorta and pulmonary arteries had marked ___. The aorta was smaller than usual. The pulmonary was larger than usual. The pulmonary valve had 3 casts but was ___ and mildly dysplastic. There was a supra-annular constriction below the height of the commissure which contributed to this stenosis, but the majority of the stenosis was at the valve level. The aortic valve was biscuspid with the commissure is oriented anteroposteriorly, and this valve was severely stenotic and markedly dysplastic. Both leaf were thought of were ___ second and had ____ edges. Before commissurotomy the aortic orifice would accept only a 6 mm Hagar probe. After commissurotomy accepted an 8 mm. There was only a mild amount of supravalvular aortic stenosis. DESCRIPTION OF THE OPERATION: The patient was brought to the operating room placed in the supine position and underwent smooth induction of general anesthesia through an oral endotracheal tube. A central venous mild____ and a radial artery catheter were placed. Foley catheter was inserted in the bladder. The chest was prepped and draped in usual sterile fashion, and a median sternotomy performed. The right hemicolectomy was carried out and the pericardium opened and tightened up on Tycron suture. The aorta was dissected free from the pulmonary artery. It was then encircled with a Silastic loop. Post rings of 4-0 Tycron were placed in the ascending aorta in the right atrium. Heparin 220 units per kilogram was administered in the aortic annula with a ____ cannula. Bicaval

cannulation was carried out with 20 French straight venous cannula to the superior vena cava and a 22 French to inferior vena cava. Cardiopulmonary bypass was began, and the patient cooled to 28 degree centigrade. ___ was placed in the left atrium just inferior to the right superior pulmonary vein. The aorta was cross clamped and a 120 mL of ___ in cardiac ___ solution and administered through the aortic root. The heart arrested properly and was kept cool by a continuous topical ___ with cold saline. The main pulmonary artery was incised longitudinally and the valve inspected. Commissurotomies were performed in each of the 3 commissures all the way back to the annulus. The pulmonary arteriotomy was then carried anteriorly at 3 ___anterior commissure and about 3mm to 4 mm in to the right ventricular outflow tract. This completely relived the pulmonic stenosis. The patch of thin-walled Gore-Tex was then cut to a size and sewn in place with 26-0 Gore-Tex suture. Attention was then directed to the aortic root. A ___ aortotomy was began and carried in to the noncoronary sinus. The aortic valve was inspected and a ____ is noted. Delicate commissurotomies were performed in each of the 2 commissures completely back to the annulus. There was however, nothing else which could be done to modify or improve this markedly dysplastic valve. We thought that the ___ was not ____ to ____ an extended aorta ventriculoplasty with prosthetic valve replacement. However, the patient will not even require this eventually. The aortotomy was carried out to the aortic annulus and a gortex patch cut to enlarge the aortic root. This was also sewn in the place with ___ 6-0 Gore-Tex suture. ___. The patient was placed in ____ position, and ____. The cross clamp was removed and ____ in the ascending aorta. Cardiac action returned promptly and normal sinus rhythm was restored. When heart recovered, the left atrial clamp was removed and repaired with ____ repaired with 6-0 Prolene. The ____ was carried out and in the _____ the ascending aortic __ with 6-0 Prolene. Pressure measurements were not taken in the operating room, but thrill was absent over the pulmonary artery and marked ___ over the aortic. The patient was ___ from a cardiopulmonary bypass without difficulty and the cannulae. Acannulation ___ were resolved with Prolene.