From prasannasimha at gmail.com  Fri Dec  1 08:10:26 2006
From: prasannasimha at gmail.com (prasannasimha)
Date: Thu Nov 30 21:40:38 2006
Subject: [HSF] RV failure management strategies
Message-ID: <456F961A.3080207@gmail.com>

Can the list members enumerate their management strategies for RV failure.
This is for two reasons. _ one for th3e Wiki and presently
I have  a patient who was in low output  and taken for a semi emergency 
MVR with maze with TV plasty. Patient had RV dysfunction and congestive 
hepatopathy. Had a difficult wean - LV good but RV function was pretty 
poor. Patient is in coagulopathy which seems to have decreased .No 
mechanical problem on epicardial echo.
Patient has an open chest and has adequate CI (PA cath with CCO) has a 
high PVR and low SVR and is requiring multiple inotropes (Dopa = Dobut 
+Adrenaline + Norad +Milrinone and Vasopressin on one hand and multiple 
vasodilators on the other (getting constrictors via the central lumen of 
the IABP and dilators via the PA catheter) . I put the IABP as the 
patient has OK CI but low pressures due to a vasoplegic state and was 
worried that the coronary flow may not be adequate creating a vicious 
spiral 9and is helping in maintaining pressures).
Funny thing is patient has bilateral dilated and fixed pupils but has 
actually woken up once !! (On an infusion of morphine + Ketamine)
Prasanna
From arey at mexico.com  Fri Dec  1 11:53:07 2006
From: arey at mexico.com (Alejandro Rey)
Date: Thu Nov 30 22:53:46 2006
Subject: [HSF] RV failure management strategies
Message-ID: <20061201035307.2D8797AEBC@ws5-10.us4.outblaze.com>

Sir,

One of the most important things in this patient is his age as 
well as renal function. And do you have prostaglandin or 
nitrous oxide to low his high (?) pulmonary artery pressure 
and how is mechanical ventilation, FiO2, Peep, and blood 
gases. Coagulopathy is because long aortic cross clamp time 
or long cardiopulmonary bypass or hepathic dysfunction 
secundary to RV failure.

If your patient is not very old and has good renal function 
could have long ICU stay but good recovery, specially if you 
support him with RVAD but cost is really high. Could you tell 
us more about him. Good luck, you will need it.

Alejandro Rey
University of Mexico








> ----- Original Message -----
> From: prasannasimha <prasannasimha@gmail.com>
> To: "OpenHeart-L@lists.hsforum.com" <OpenHeart-
L@lists.hsforum.com>, ccm <ccm-l@ccm-l.org>
> Subject: [HSF] RV failure management strategies
> Date: Fri, 01 Dec 2006 08:10:26 +0530
> 
> 
> Can the list members enumerate their management 
strategies for RV failure.
> This is for two reasons. _ one for th3e Wiki and presently
> I have  a patient who was in low output  and taken for a 
semi 
> emergency MVR with maze with TV plasty. Patient had RV 
dysfunction 
> and congestive hepatopathy. Had a difficult wean - LV 
good but RV 
> function was pretty poor. Patient is in coagulopathy which 
seems to 
> have decreased .No mechanical problem on epicardial 
echo.
> Patient has an open chest and has adequate CI (PA cath 
with CCO) 
> has a high PVR and low SVR and is requiring multiple 
inotropes 
> (Dopa = Dobut +Adrenaline + Norad +Milrinone and 
Vasopressin on one 
> hand and multiple vasodilators on the other (getting 
constrictors 
> via the central lumen of the IABP and dilators via the PA 
catheter) 
> . I put the IABP as the patient has OK CI but low pressures 
due to 
> a vasoplegic state and was worried that the coronary flow 
may not 
> be adequate creating a vicious spiral 9and is helping in 
> maintaining pressures).
> Funny thing is patient has bilateral dilated and fixed 
pupils but 
> has actually woken up once !! (On an infusion of morphine 
+ 
> Ketamine)
> Prasanna
> _______________________________________________
> OpenHeart-L mailing list
> 
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> OpenHeart-L@lists.hsforum.com
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archives:
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From anianyanwu at hotmail.com  Fri Dec  1 00:00:55 2006
From: anianyanwu at hotmail.com (Ani Anyanwu)
Date: Fri Dec  1 00:01:25 2006
Subject: [HSF] RV failure management strategies
References: <20061201032422.38455.qmail@web81604.mail.mud.yahoo.com>
	<14019B30-FA90-406E-9E50-267DB2CD1752@charter.net>
Message-ID: <BAY131-DAV9240309E8B6FEE8642A0DD2DA0@phx.gbl>

mmm...and the morale of the story????
  ----- Original Message ----- 
  From: Edward Bender<mailto:ebender001@charter.net> 
  To: OpenHeart-L@lists.hsforum.com<mailto:OpenHeart-L@lists.hsforum.com> 
  Sent: Thursday, November 30, 2006 11:11 PM
  Subject: Re: [HSF] RV failure management strategies


  I used the Amed pump for RV failure in a similar situation.  After 8  
  hours of RV support, everything improved, the pump was explanted, the  
  patient was transferred out of the ICU the next day and subsequently  
  went into V-fib and died.

  Ed Bender, MD


  On Nov 30, 2006, at 9:24 PM, Tea Acuff wrote:

  > It seems to me that proper treatment of RV failure likely depends  
  > on its etiology and is largely unrelated to RV effects itself. I am  
  > of the belief that acute ischemic RV failure is a contradiction for  
  > almost any indication of LV revascularization. The treatment is  
  > volume to the LV which is in turn deadly to the ischemic LV. I used  
  > the Amed device, which unfortunately got pushed into the Embolex  
  > venture for economic and ultimately fatal device reasons, for about  
  > 50 OPCABs and was impressed in its small size and 50-60cc internal  
  > volume in supporting CO in the contorted RV even when the LV was  
  > not working. RVs unlike LVs do seem to have the capacity to recover  
  > if LV filling can be maintained in the ischemic/ failing R  
  > ventricle. Fontan physiology seems to suggest the same argument. I  
  > don't know if models of primary RV failure exist as isolated RV and  
  > even RV valvular problems are rare. Almost all surgical treatments  
  > of the LV temporarily worsen the resistance to flow faced by
  >  the RV except if the LV can be markedly improved. In other words I  
  > think the question itself is largely misstated. Kind of like asking  
  > how can one get better pacing when the patients is in  
  > electromechanical dissociation (to use old descriptives.)
  > This kind of BS reasoning is one looking for counter arguments (and  
  > better understanding).
  > Tea
  >
  >
  > ----- Original Message ----
  > From: prasannasimha <prasannasimha@gmail.com<mailto:prasannasimha@gmail.com>>
  > To: "OpenHeart-L@lists.hsforum.com<mailto:OpenHeart-L@lists.hsforum.com>" <OpenHeart- 
  > L@lists.hsforum.com<mailto:L@lists.hsforum.com>>; ccm <ccm-l@ccm-l.org<mailto:ccm-l@ccm-l.org>>
  > Sent: Thursday, November 30, 2006 8:40:26 PM
  > Subject: [HSF] RV failure management strategies
  >
  >
  > Can the list members enumerate their management strategies for RV  
  > failure.
  > This is for two reasons. _ one for th3e Wiki and presently
  > I have  a patient who was in low output  and taken for a semi  
  > emergency
  > MVR with maze with TV plasty. Patient had RV dysfunction and  
  > congestive
  > hepatopathy. Had a difficult wean - LV good but RV function was pretty
  > poor. Patient is in coagulopathy which seems to have decreased .No
  > mechanical problem on epicardial echo.
  > Patient has an open chest and has adequate CI (PA cath with CCO) has a
  > high PVR and low SVR and is requiring multiple inotropes (Dopa = Dobut
  > +Adrenaline + Norad +Milrinone and Vasopressin on one hand and  
  > multiple
  > vasodilators on the other (getting constrictors via the central  
  > lumen of
  > the IABP and dilators via the PA catheter) . I put the IABP as the
  > patient has OK CI but low pressures due to a vasoplegic state and was
  > worried that the coronary flow may not be adequate creating a vicious
  > spiral 9and is helping in maintaining pressures).
  > Funny thing is patient has bilateral dilated and fixed pupils but has
  > actually woken up once !! (On an infusion of morphine + Ketamine)
  > Prasanna
  > _______________________________________________
  > OpenHeart-L mailing list
  >
  > Send postings to:
  > OpenHeart-L@lists.hsforum.com<mailto:OpenHeart-L@lists.hsforum.com>
  >
  > To UNSUBSCRIBE, to CHANGE email address, or to view archives:
  > http://mmp.cjp.com/mailman/listinfo/openheart-l<http://mmp.cjp.com/mailman/listinfo/openheart-l>
  >
  > All messages transmitted by the OpenHeart-L are subject to the  
  > policies and
  > disclaimers posted at:
  > http://www.hsforum.com/listdisclaim<http://www.hsforum.com/listdisclaim>
  > -----------------------------------------
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  >
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  > policies and
  > disclaimers posted at:
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From TSalerno at med.miami.edu  Fri Dec  1 02:05:06 2006
From: TSalerno at med.miami.edu (Salerno, Tomas)
Date: Fri Dec  1 02:09:02 2006
Subject: [HSF] RV failure management strategies
References: <20061201032422.38455.qmail@web81604.mail.mud.yahoo.com>
Message-ID: <E067BF74727CB0479C751AF0E9C9230202C63011@MEDEX03.ad.med.miami.edu>

Prevention is the key word for the development of RV failure during surgery. All myocardial protective strategies do not afford full protection to the RV (and neither to the LV), which is subjected to warmer temperatures of the environment and poor deliver of cardioplegia. And most surgeons, who rely on cold cardioplegia, do not even measure myocardial temperatures!   Continuous perfusion (beating heart surgery, as I have described) avoids this problem all together.
 
RV failure in the face of AVR should be suspicious of occlusion (for a variety of reasons) of the RCA, and in previous reports, we recommended bypassing that artery should the situation occur for unexplained reasons.
 
Nothing worse that a poorly protected RV in face of pulmonary hypertension. Treatment after the injury has occurred usually results in poor outcome.  

________________________________

From: openheart-l-bounces@lists.hsforum.com on behalf of Tea Acuff
Sent: Thu 11/30/2006 10:24 PM
To: OpenHeart-L@lists.hsforum.com
Subject: Re: [HSF] RV failure management strategies



It seems to me that proper treatment of RV failure likely depends on its etiology and is largely unrelated to RV effects itself. I am of the belief that acute ischemic RV failure is a contradiction for almost any indication of LV revascularization. The treatment is volume to the LV which is in turn deadly to the ischemic LV. I used the Amed device, which unfortunately got pushed into the Embolex venture for economic and ultimately fatal device reasons, for about 50 OPCABs and was impressed in its small size and 50-60cc internal volume in supporting CO in the contorted RV even when the LV was not working. RVs unlike LVs do seem to have the capacity to recover if LV filling can be maintained in the ischemic/ failing R ventricle. Fontan physiology seems to suggest the same argument. I don't know if models of primary RV failure exist as isolated RV and even RV valvular problems are rare. Almost all surgical treatments of the LV temporarily worsen the resistance to flow faced by
 the RV except if the LV can be markedly improved. In other words I think the question itself is largely misstated. Kind of like asking how can one get better pacing when the patients is in electromechanical dissociation (to use old descriptives.) 
This kind of BS reasoning is one looking for counter arguments (and better understanding).
Tea


----- Original Message ----
From: prasannasimha <prasannasimha@gmail.com>
To: "OpenHeart-L@lists.hsforum.com" <OpenHeart-L@lists.hsforum.com>; ccm <ccm-l@ccm-l.org>
Sent: Thursday, November 30, 2006 8:40:26 PM
Subject: [HSF] RV failure management strategies


Can the list members enumerate their management strategies for RV failure.
This is for two reasons. _ one for th3e Wiki and presently
I have  a patient who was in low output  and taken for a semi emergency
MVR with maze with TV plasty. Patient had RV dysfunction and congestive
hepatopathy. Had a difficult wean - LV good but RV function was pretty
poor. Patient is in coagulopathy which seems to have decreased .No
mechanical problem on epicardial echo.
Patient has an open chest and has adequate CI (PA cath with CCO) has a
high PVR and low SVR and is requiring multiple inotropes (Dopa = Dobut
+Adrenaline + Norad +Milrinone and Vasopressin on one hand and multiple
vasodilators on the other (getting constrictors via the central lumen of
the IABP and dilators via the PA catheter) . I put the IABP as the
patient has OK CI but low pressures due to a vasoplegic state and was
worried that the coronary flow may not be adequate creating a vicious
spiral 9and is helping in maintaining pressures).
Funny thing is patient has bilateral dilated and fixed pupils but has
actually woken up once !! (On an infusion of morphine + Ketamine)
Prasanna
_______________________________________________
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OpenHeart-L@lists.hsforum..com

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-----------------------------------------
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 OpenHeart-L@lists.hsforum.com

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From prasannasimha at gmail.com  Fri Dec  1 17:22:12 2006
From: prasannasimha at gmail.com (prasannasimha)
Date: Fri Dec  1 06:52:26 2006
Subject: [HSF] RV failure management strategies
In-Reply-To: <C442AC3B-010F-1000-A6AD-D15F6F4759C1-Webmail-10023@mac.com>
References: <456F961A.3080207@gmail.com>
	<C442AC3B-010F-1000-A6AD-D15F6F4759C1-Webmail-10023@mac.com>
Message-ID: <4570176C.2090107@gmail.com>

I used NO but it did not make much of a difference so I switched to 
inhaled sodium nitroprusside which had similar effects.
Prasanna
Giuseppe Rescigno wrote:
> Is the NO available in your hospital? Sometimes it is an effective ajunct to what your are already doing. 
>
> Giuseppe
>
> Giuseppe Rescigno M.D.
> Cardiothoracic Surgeon
>
> Lancisi Hospital
> Torrette - Ancona
> Italy
>
>
>  
> On Friday, December 01, 2006, at 03:40AM, "prasannasimha" <prasannasimha@gmail.com> wrote:
>   
>> Can the list members enumerate their management strategies for RV failure.
>> This is for two reasons. _ one for th3e Wiki and presently
>> I have  a patient who was in low output  and taken for a semi emergency 
>> MVR with maze with TV plasty. Patient had RV dysfunction and congestive 
>> hepatopathy. Had a difficult wean - LV good but RV function was pretty 
>> poor. Patient is in coagulopathy which seems to have decreased .No 
>> mechanical problem on epicardial echo.
>> Patient has an open chest and has adequate CI (PA cath with CCO) has a 
>> high PVR and low SVR and is requiring multiple inotropes (Dopa = Dobut 
>> +Adrenaline + Norad +Milrinone and Vasopressin on one hand and multiple 
>> vasodilators on the other (getting constrictors via the central lumen of 
>> the IABP and dilators via the PA catheter) . I put the IABP as the 
>> patient has OK CI but low pressures due to a vasoplegic state and was 
>> worried that the coronary flow may not be adequate creating a vicious 
>> spiral 9and is helping in maintaining pressures).
>> Funny thing is patient has bilateral dilated and fixed pupils but has 
>> actually woken up once !! (On an infusion of morphine + Ketamine)
>> Prasanna
>> _______________________________________________
>> OpenHeart-L mailing list
>>
>> Send postings to:
>> OpenHeart-L@lists.hsforum.com
>>
>> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
>> http://mmp.cjp.com/mailman/listinfo/openheart-l
>>
>> All messages transmitted by the OpenHeart-L are subject to the policies and 
>> disclaimers posted at:
>> http://www.hsforum.com/listdisclaim
>> -----------------------------------------
>>
>>
>>     
> _______________________________________________
> OpenHeart-L mailing list
>
> Send postings to:
>  OpenHeart-L@lists.hsforum.com
>
> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
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>
> All messages transmitted by the OpenHeart-L are subject to the policies and 
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>
>   

From prasannasimha at gmail.com  Fri Dec  1 17:29:39 2006
From: prasannasimha at gmail.com (prasannasimha)
Date: Fri Dec  1 07:06:26 2006
Subject: [HSF] RV failure management strategies
In-Reply-To: <E067BF74727CB0479C751AF0E9C9230202C63011@MEDEX03.ad.med.miami.edu>
References: <20061201032422.38455.qmail@web81604.mail.mud.yahoo.com>
	<E067BF74727CB0479C751AF0E9C9230202C63011@MEDEX03.ad.med.miami.edu>
Message-ID: <4570192B.2000209@gmail.com>

Dr Salerno,
In fact this patient was done under virtually continuous perfusion 
(antegrade and retrograde) though I did have a period of hypothermic 
arrest for around 12 minutes by which time she was getting continuous 
perfusion (antegrade and retrograde). The Tricuspid valve + right half 
of the emaze  procedure was done on beating heart prior to cross clamping.
Prasanna
alerno, Tomas wrote:
> Prevention is the key word for the development of RV failure during surgery. All myocardial protective strategies do not afford full protection to the RV (and neither to the LV), which is subjected to warmer temperatures of the environment and poor deliver of cardioplegia. And most surgeons, who rely on cold cardioplegia, do not even measure myocardial temperatures!   Continuous perfusion (beating heart surgery, as I have described) avoids this problem all together.
>  
> RV failure in the face of AVR should be suspicious of occlusion (for a variety of reasons) of the RCA, and in previous reports, we recommended bypassing that artery should the situation occur for unexplained reasons.
>  
> Nothing worse that a poorly protected RV in face of pulmonary hypertension. Treatment after the injury has occurred usually results in poor outcome.  
>
> ________________________________
>
> From: openheart-l-bounces@lists.hsforum.com on behalf of Tea Acuff
> Sent: Thu 11/30/2006 10:24 PM
> To: OpenHeart-L@lists.hsforum.com
> Subject: Re: [HSF] RV failure management strategies
>
>
>
> It seems to me that proper treatment of RV failure likely depends on its etiology and is largely unrelated to RV effects itself. I am of the belief that acute ischemic RV failure is a contradiction for almost any indication of LV revascularization. The treatment is volume to the LV which is in turn deadly to the ischemic LV. I used the Amed device, which unfortunately got pushed into the Embolex venture for economic and ultimately fatal device reasons, for about 50 OPCABs and was impressed in its small size and 50-60cc internal volume in supporting CO in the contorted RV even when the LV was not working. RVs unlike LVs do seem to have the capacity to recover if LV filling can be maintained in the ischemic/ failing R ventricle. Fontan physiology seems to suggest the same argument. I don't know if models of primary RV failure exist as isolated RV and even RV valvular problems are rare. Almost all surgical treatments of the LV temporarily worsen the resistance to flow faced by
>  the RV except if the LV can be markedly improved. In other words I think the question itself is largely misstated. Kind of like asking how can one get better pacing when the patients is in electromechanical dissociation (to use old descriptives.) 
> This kind of BS reasoning is one looking for counter arguments (and better understanding).
> Tea
>
>
> ----- Original Message ----
> From: prasannasimha <prasannasimha@gmail.com>
> To: "OpenHeart-L@lists.hsforum.com" <OpenHeart-L@lists.hsforum.com>; ccm <ccm-l@ccm-l.org>
> Sent: Thursday, November 30, 2006 8:40:26 PM
> Subject: [HSF] RV failure management strategies
>
>
> Can the list members enumerate their management strategies for RV failure.
> This is for two reasons. _ one for th3e Wiki and presently
> I have  a patient who was in low output  and taken for a semi emergency
> MVR with maze with TV plasty. Patient had RV dysfunction and congestive
> hepatopathy. Had a difficult wean - LV good but RV function was pretty
> poor. Patient is in coagulopathy which seems to have decreased .No
> mechanical problem on epicardial echo.
> Patient has an open chest and has adequate CI (PA cath with CCO) has a
> high PVR and low SVR and is requiring multiple inotropes (Dopa = Dobut
> +Adrenaline + Norad +Milrinone and Vasopressin on one hand and multiple
> vasodilators on the other (getting constrictors via the central lumen of
> the IABP and dilators via the PA catheter) . I put the IABP as the
> patient has OK CI but low pressures due to a vasoplegic state and was
> worried that the coronary flow may not be adequate creating a vicious
> spiral 9and is helping in maintaining pressures).
> Funny thing is patient has bilateral dilated and fixed pupils but has
> actually woken up once !! (On an infusion of morphine + Ketamine)
> Prasanna
> _______________________________________________
> OpenHeart-L mailing list
>
> Send postings to:
> OpenHeart-L@lists.hsforum..com
>
> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
> http://mmp.cjp.com/mailman/listinfo/openheart-l
>
> All messages transmitted by the OpenHeart-L are subject to the policies and
> disclaimers posted at:
> http://www.hsforum.com/listdisclaim
> -----------------------------------------
> _______________________________________________
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>
> Send postings to:
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>   


From Hgrmd at aol.com  Fri Dec  1 07:07:21 2006
From: Hgrmd at aol.com (Hgrmd@aol.com)
Date: Fri Dec  1 07:07:37 2006
Subject: [HSF] RV failure management strategies
Message-ID: <d0d.3670e0f.32a174f9@aol.com>

Prasanna,
  Ketamine gives the dilated pupils.
Hal
From prasannasimha at gmail.com  Fri Dec  1 17:40:33 2006
From: prasannasimha at gmail.com (prasannasimha)
Date: Fri Dec  1 07:10:43 2006
Subject: [HSF] RV failure management strategies
In-Reply-To: <d0d.3670e0f.32a174f9@aol.com>
References: <d0d.3670e0f.32a174f9@aol.com>
Message-ID: <45701BB9.2030600@gmail.com>

Possible but usually they are reactive !! (And I use Ketamine as an 
infusion often especially in vasoplegic patients)
Prasanna
Hgrmd@aol.com wrote:
> Prasanna,
>   Ketamine gives the dilated pupils.
> Hal
> _______________________________________________
> OpenHeart-L mailing list
>
> Send postings to:
>  OpenHeart-L@lists.hsforum.com
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> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
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>
> All messages transmitted by the OpenHeart-L are subject to the policies and 
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> -----------------------------------------
>
>
>   

From GoldmanS at MLHS.ORG  Fri Dec  1 07:09:54 2006
From: GoldmanS at MLHS.ORG (Goldman, Scott)
Date: Fri Dec  1 07:12:12 2006
Subject: [HSF] RV failure management strategies
References: <456F961A.3080207@gmail.com>
Message-ID: <6764E7F21669F64C81BBE14C902CDEDD042BB750@TLH-MAIL.ad.mlhs.org>

Try Natracor, Flolan, iNO and/or Viagra 


-----Original Message-----
From: openheart-l-bounces@lists.hsforum.com on behalf of prasannasimha
Sent: Thu 11/30/2006 9:40 PM
To: OpenHeart-L@lists.hsforum.com; ccm
Subject: [HSF] RV failure management strategies
 
Can the list members enumerate their management strategies for RV failure.
This is for two reasons. _ one for th3e Wiki and presently
I have  a patient who was in low output  and taken for a semi emergency 
MVR with maze with TV plasty. Patient had RV dysfunction and congestive 
hepatopathy. Had a difficult wean - LV good but RV function was pretty 
poor. Patient is in coagulopathy which seems to have decreased .No 
mechanical problem on epicardial echo.
Patient has an open chest and has adequate CI (PA cath with CCO) has a 
high PVR and low SVR and is requiring multiple inotropes (Dopa = Dobut 
+Adrenaline + Norad +Milrinone and Vasopressin on one hand and multiple 
vasodilators on the other (getting constrictors via the central lumen of 
the IABP and dilators via the PA catheter) . I put the IABP as the 
patient has OK CI but low pressures due to a vasoplegic state and was 
worried that the coronary flow may not be adequate creating a vicious 
spiral 9and is helping in maintaining pressures).
Funny thing is patient has bilateral dilated and fixed pupils but has 
actually woken up once !! (On an infusion of morphine + Ketamine)
Prasanna
_______________________________________________
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From prasannasimha at gmail.com  Fri Dec  1 17:44:32 2006
From: prasannasimha at gmail.com (prasannasimha)
Date: Fri Dec  1 07:14:42 2006
Subject: [HSF] RV failure management strategies
In-Reply-To: <6764E7F21669F64C81BBE14C902CDEDD042BB750@TLH-MAIL.ad.mlhs.org>
References: <456F961A.3080207@gmail.com>
	<6764E7F21669F64C81BBE14C902CDEDD042BB750@TLH-MAIL.ad.mlhs.org>
Message-ID: <45701CA8.4080902@gmail.com>

Flolan  = prostacyclin ?
Prasanna

Goldman, Scott wrote:
> Try Natracor, Flolan, iNO and/or Viagra 
>
>
> -----Original Message-----
> From: openheart-l-bounces@lists.hsforum.com on behalf of prasannasimha
> Sent: Thu 11/30/2006 9:40 PM
> To: OpenHeart-L@lists.hsforum.com; ccm
> Subject: [HSF] RV failure management strategies
>  
> Can the list members enumerate their management strategies for RV failure.
> This is for two reasons. _ one for th3e Wiki and presently
> I have  a patient who was in low output  and taken for a semi emergency 
> MVR with maze with TV plasty. Patient had RV dysfunction and congestive 
> hepatopathy. Had a difficult wean - LV good but RV function was pretty 
> poor. Patient is in coagulopathy which seems to have decreased .No 
> mechanical problem on epicardial echo.
> Patient has an open chest and has adequate CI (PA cath with CCO) has a 
> high PVR and low SVR and is requiring multiple inotropes (Dopa = Dobut 
> +Adrenaline + Norad +Milrinone and Vasopressin on one hand and multiple 
> vasodilators on the other (getting constrictors via the central lumen of 
> the IABP and dilators via the PA catheter) . I put the IABP as the 
> patient has OK CI but low pressures due to a vasoplegic state and was 
> worried that the coronary flow may not be adequate creating a vicious 
> spiral 9and is helping in maintaining pressures).
> Funny thing is patient has bilateral dilated and fixed pupils but has 
> actually woken up once !! (On an infusion of morphine + Ketamine)
> Prasanna
> _______________________________________________
> OpenHeart-L mailing list
>
> Send postings to:
>  OpenHeart-L@lists.hsforum.com
>
> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
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> -----------------------------------------
>
>   
> ------------------------------------------------------------------------
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> -----------------------------------------
From GoldmanS at MLHS.ORG  Fri Dec  1 07:15:38 2006
From: GoldmanS at MLHS.ORG (Goldman, Scott)
Date: Fri Dec  1 07:16:39 2006
Subject: [HSF] RV failure management strategies
References: <456F961A.3080207@gmail.com><6764E7F21669F64C81BBE14C902CDEDD042BB750@TLH-MAIL.ad.mlhs.org>
	<45701CA8.4080902@gmail.com>
Message-ID: <6764E7F21669F64C81BBE14C902CDEDD042BB751@TLH-MAIL.ad.mlhs.org>

yes inhaled


-----Original Message-----
From: openheart-l-bounces@lists.hsforum.com on behalf of prasannasimha
Sent: Fri 12/1/2006 7:14 AM
To: OpenHeart-L@lists.hsforum.com
Subject: Re: [HSF] RV failure management strategies
 
Flolan  = prostacyclin ?
Prasanna

Goldman, Scott wrote:
> Try Natracor, Flolan, iNO and/or Viagra 
>
>
> -----Original Message-----
> From: openheart-l-bounces@lists.hsforum.com on behalf of prasannasimha
> Sent: Thu 11/30/2006 9:40 PM
> To: OpenHeart-L@lists.hsforum.com; ccm
> Subject: [HSF] RV failure management strategies
>  
> Can the list members enumerate their management strategies for RV failure.
> This is for two reasons. _ one for th3e Wiki and presently
> I have  a patient who was in low output  and taken for a semi emergency 
> MVR with maze with TV plasty. Patient had RV dysfunction and congestive 
> hepatopathy. Had a difficult wean - LV good but RV function was pretty 
> poor. Patient is in coagulopathy which seems to have decreased .No 
> mechanical problem on epicardial echo.
> Patient has an open chest and has adequate CI (PA cath with CCO) has a 
> high PVR and low SVR and is requiring multiple inotropes (Dopa = Dobut 
> +Adrenaline + Norad +Milrinone and Vasopressin on one hand and multiple 
> vasodilators on the other (getting constrictors via the central lumen of 
> the IABP and dilators via the PA catheter) . I put the IABP as the 
> patient has OK CI but low pressures due to a vasoplegic state and was 
> worried that the coronary flow may not be adequate creating a vicious 
> spiral 9and is helping in maintaining pressures).
> Funny thing is patient has bilateral dilated and fixed pupils but has 
> actually woken up once !! (On an infusion of morphine + Ketamine)
> Prasanna
> _______________________________________________
> OpenHeart-L mailing list
>
> Send postings to:
>  OpenHeart-L@lists.hsforum.com
>
> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
> http://mmp.cjp.com/mailman/listinfo/openheart-l
>
> All messages transmitted by the OpenHeart-L are subject to the policies and 
> disclaimers posted at:
> http://www.hsforum.com/listdisclaim
> -----------------------------------------
>
>   
> ------------------------------------------------------------------------
>
> _______________________________________________
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>
> Send postings to:
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-----------------------------------------

From Hgrmd at aol.com  Fri Dec  1 07:16:43 2006
From: Hgrmd at aol.com (Hgrmd@aol.com)
Date: Fri Dec  1 07:17:04 2006
Subject: [HSF] RV failure management strategies
Message-ID: <3ba.514a21.32a1772b@aol.com>

Look, Prasanna, I'm not going to argue about whether the patients eyes are  
truly fixed and dilated.  If they are, by definition, the patient is brain  
dead.  However, I've seen plenty of cases where the nurses said the pupils  were 
"fixed and dilated" after receiving epi during a resuscitation, only to  
observe complete neurologic recovery within a few hours.  Obviously, the  pupils 
are quite dilated from a pharmacologic origin, and they  probably imperceptibly 
constrict with light. 
Hal 
From prasannasimha at gmail.com  Fri Dec  1 17:41:16 2006
From: prasannasimha at gmail.com (psimha)
Date: Fri Dec  1 07:18:02 2006
Subject: [HSF] RV failure management strategies
In-Reply-To: <d0d.3670e0f.32a174f9@aol.com>
References: <d0d.3670e0f.32a174f9@aol.com>
Message-ID: <45701BE4.1020505@sify.com>

And Hal,
Your management plan for lousy RV's
Prasanna
Hgrmd@aol.com wrote:
> Prasanna,
>   Ketamine gives the dilated pupils.
> Hal
> _______________________________________________
> OpenHeart-L mailing list
>
> Send postings to:
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> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
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>   

From Hgrmd at aol.com  Fri Dec  1 07:20:57 2006
From: Hgrmd at aol.com (Hgrmd@aol.com)
Date: Fri Dec  1 07:22:27 2006
Subject: [HSF] RV failure management strategies
Message-ID: <3c2.b2306ee.32a17829@aol.com>

Prasanna,
  For once, I largely agree with Tea and Tomas.  I suspect  inadequate 
protection in this case, for whatever reason.  Now that you are  here with a failing 
RV, drugs, volume, IABP, prayer, etc are your only  recourse.
Hal
From prasannasimha at gmail.com  Fri Dec  1 18:15:16 2006
From: prasannasimha at gmail.com (psimha)
Date: Fri Dec  1 07:51:31 2006
Subject: [HSF] RV failure management strategies
In-Reply-To: <3c2.b2306ee.32a17829@aol.com>
References: <3c2.b2306ee.32a17829@aol.com>
Message-ID: <457023DC.8030708@sify.com>


Actually the preop RV function was pretty bad preop but I thought 
correction of the left sided lesion and correcting the TR may make 
things better. Unfortunately the PA pressure continued to be pretty high 
despite low wedge and that  seems to add to the RV  problem. I did 
religiously give cardioplegia though whether that constituted 
"protection" may be debatable !! :-)
Prasanna

Hgrmd@aol.com wrote:
> Prasanna,
>   For once, I largely agree with Tea and Tomas.  I suspect  inadequate 
> protection in this case, for whatever reason.  Now that you are  here with a failing 
> RV, drugs, volume, IABP, prayer, etc are your only  recourse.
> Hal
> _______________________________________________
> OpenHeart-L mailing list
>
> Send postings to:
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> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
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>
> All messages transmitted by the OpenHeart-L are subject to the policies and 
> disclaimers posted at:
> http://www.hsforum.com/listdisclaim
> -----------------------------------------
>
>
>   

From prasannasimha at gmail.com  Fri Dec  1 18:29:04 2006
From: prasannasimha at gmail.com (prasannasimha)
Date: Fri Dec  1 08:05:50 2006
Subject: [HSF] RV failure management strategies
In-Reply-To: <3ba.514a21.32a1772b@aol.com>
References: <3ba.514a21.32a1772b@aol.com>
Message-ID: <45702718.3090102@gmail.com>

I do agree that pharmacological dilatation was the event but I hadn't 
seen such "fixed and dilated" pupils so far !! (I had personally seen it 
) And bilateral dilated fixed pupils do not necessarily diagnose brain 
death .
I got a list of non brain death causes of dilated fixed pupils !!
Prasanna
Hgrmd@aol.com wrote:
> Look, Prasanna, I'm not going to argue about whether the patients eyes are  
> truly fixed and dilated.  If they are, by definition, the patient is brain  
> dead.  However, I've seen plenty of cases where the nurses said the pupils  were 
> "fixed and dilated" after receiving epi during a resuscitation, only to  
> observe complete neurologic recovery within a few hours.  Obviously, the  pupils 
> are quite dilated from a pharmacologic origin, and they  probably imperceptibly 
> constrict with light. 
> Hal 
> _______________________________________________
> OpenHeart-L mailing list
>
> Send postings to:
>  OpenHeart-L@lists.hsforum.com
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> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
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> -----------------------------------------
>
>   
-------------- next part --------------
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From prasannasimha at gmail.com  Fri Dec  1 18:15:29 2006
From: prasannasimha at gmail.com (prasannasimha)
Date: Fri Dec  1 08:11:11 2006
Subject: [HSF] RV failure management strategies
In-Reply-To: <20061201035307.2D8797AEBC@ws5-10.us4.outblaze.com>
References: <20061201035307.2D8797AEBC@ws5-10.us4.outblaze.com>
Message-ID: <457023E9.5010009@gmail.com>

I used NO but ti was not very effective and switched to inhaled sodium 
nitroprusside.
Mechanical ventilation and blood gases have not been a problem. 
Coagulopathy was more due to severe TR with congestive hepatopathy.
She has stopped bleeding but hemodynamics are still dicey !!
RVAD is not an option in this patient for cost considerations and blood 
product availability though I would have preferred to at least use a 
Biomedicus pump support of the RV.
Prasanna
Alejandro Rey wrote:
> Sir,
>
> One of the most important things in this patient is his age as 
> well as renal function. And do you have prostaglandin or 
> nitrous oxide to low his high (?) pulmonary artery pressure 
> and how is mechanical ventilation, FiO2, Peep, and blood 
> gases. Coagulopathy is because long aortic cross clamp time 
> or long cardiopulmonary bypass or hepathic dysfunction 
> secundary to RV failure.
>
> If your patient is not very old and has good renal function 
> could have long ICU stay but good recovery, specially if you 
> support him with RVAD but cost is really high. Could you tell 
> us more about him. Good luck, you will need it.
>
> Alejandro Rey
> University of Mexico
>
>
>
>
>
>
>
>
>   
>> ----- Original Message -----
>> From: prasannasimha <prasannasimha@gmail.com>
>> To: "OpenHeart-L@lists.hsforum.com" <OpenHeart-
>>     
> L@lists.hsforum.com>, ccm <ccm-l@ccm-l.org>
>   
>> Subject: [HSF] RV failure management strategies
>> Date: Fri, 01 Dec 2006 08:10:26 +0530
>>
>>
>> Can the list members enumerate their management 
>>     
> strategies for RV failure.
>   
>> This is for two reasons. _ one for th3e Wiki and presently
>> I have  a patient who was in low output  and taken for a 
>>     
> semi 
>   
>> emergency MVR with maze with TV plasty. Patient had RV 
>>     
> dysfunction 
>   
>> and congestive hepatopathy. Had a difficult wean - LV 
>>     
> good but RV 
>   
>> function was pretty poor. Patient is in coagulopathy which 
>>     
> seems to 
>   
>> have decreased .No mechanical problem on epicardial 
>>     
> echo.
>   
>> Patient has an open chest and has adequate CI (PA cath 
>>     
> with CCO) 
>   
>> has a high PVR and low SVR and is requiring multiple 
>>     
> inotropes 
>   
>> (Dopa = Dobut +Adrenaline + Norad +Milrinone and 
>>     
> Vasopressin on one 
>   
>> hand and multiple vasodilators on the other (getting 
>>     
> constrictors 
>   
>> via the central lumen of the IABP and dilators via the PA 
>>     
> catheter) 
>   
>> . I put the IABP as the patient has OK CI but low pressures 
>>     
> due to 
>   
>> a vasoplegic state and was worried that the coronary flow 
>>     
> may not 
>   
>> be adequate creating a vicious spiral 9and is helping in 
>> maintaining pressures).
>> Funny thing is patient has bilateral dilated and fixed 
>>     
> pupils but 
>   
>> has actually woken up once !! (On an infusion of morphine 
>>     
> + 
>   
>> Ketamine)
>> Prasanna
>> _______________________________________________
>> OpenHeart-L mailing list
>>
>> Send postings to:
>> OpenHeart-L@lists.hsforum.com
>>
>> To UNSUBSCRIBE, to CHANGE email address, or to view 
>>     
> archives:
>   
>> http://mmp.cjp.com/mailman/listinfo/openheart-l
>>
>> All messages transmitted by the OpenHeart-L are subject 
>>     
> to the 
>   
>> policies and disclaimers posted at:
>> http://www.hsforum.com/listdisclaim
>> -----------------------------------------
>>     
>
>   
>
>
>   

From msfirst at gmail.com  Fri Dec  1 09:10:03 2006
From: msfirst at gmail.com (Michael Firstenberg)
Date: Fri Dec  1 09:10:12 2006
Subject: [HSF] RV failure management strategies
In-Reply-To: <456F961A.3080207@gmail.com>
References: <456F961A.3080207@gmail.com>
Message-ID: <54A9E6C9-0DA5-4741-BA15-3A50562B72F3@gmail.com>

Something does not quiet sound right with his hemodynamics - and  
maybe I need to think about this more and look at the actual numbers.
But, if your RV is failing - which it sounds like it is, then you  
would have low preload delivered to the left heart and this should  
(please all corrected me if I am wrong) result in a higher SVR as a  
systemic compensatory measure.

Coming into this a little late (missed some of the other comments)
1) Is your patient septic - and maybe the overall cardiac function  
can not keep up enough
     there may be a little zosyo-penia or the vanco receptors may not  
be adequately saturated.
2) What is the renal function?
     From what you are describing, probably poor - are you on CVVH yet?
     If not - I am a firm believer of the voodoo of dialysis of "evil  
humors"
     If this is truly right heart failure - maybe getting volume off  
acutely (even on tons of drugs) may bring you to a more favorable  
part of the Starling curve
     I have a little experience with acute ultra-filtration  (even  
with "marginal urine output") is sucking some of these people dry  
which works!
        May cause ARF (which should improve with time?) - but your  
current path will most likely knock out the beans forever
        (better to have a live patient on dialysis than a potential  
kidney donor?)
3) You said "open chest" and patient actually woke up.
      Is it correct to assume that he/she is pharm. paralyized?
     I have also seen more than a few patients with "lap-pad"  
tamponade.  Even though the chest is open, there are too many or a  
few stratigically placed pads (particularly if they are placed for  
bleeding) than compress the RV.
4) Fixed-dilated pupils?
     Hmmm - no idea, but it aint over til its over
    I am sure we have all seen comatose patients wake up quite  
contrary to the Glascow data (which I am sure have a reprint  
somewhere knowing you - read: compliment)
5) Acute adrenal insuff.  ->  when in doubt, steroids
     I had a medical school professor who said that no one should die  
without the benefits of steroids.

There seems to be a lot going on with your very sick patient and I  
tossed out a few "kitchen" sink ideas.
      yes, a RVAD/Ecmo may help - but does not solve all of your problem
     though with an open chest an RA-RV circuit with stuff you have  
around may be enough.

I have seen a few recent "mazes" in otherwise healthy hearts have  
similar problems - not sure what to make of it - anyone else?



Good luck - keep us up to date


-michael



On Nov 30, 2006, at 9:40 PM, prasannasimha wrote:

> Can the list members enumerate their management strategies for RV  
> failure.
> This is for two reasons. _ one for th3e Wiki and presently
> I have  a patient who was in low output  and taken for a semi  
> emergency MVR with maze with TV plasty. Patient had RV dysfunction  
> and congestive hepatopathy. Had a difficult wean - LV good but RV  
> function was pretty poor. Patient is in coagulopathy which seems to  
> have decreased .No mechanical problem on epicardial echo.
> Patient has an open chest and has adequate CI (PA cath with CCO)  
> has a high PVR and low SVR and is requiring multiple inotropes  
> (Dopa = Dobut +Adrenaline + Norad +Milrinone and Vasopressin on one  
> hand and multiple vasodilators on the other (getting constrictors  
> via the central lumen of the IABP and dilators via the PA  
> catheter) . I put the IABP as the patient has OK CI but low  
> pressures due to a vasoplegic state and was worried that the  
> coronary flow may not be adequate creating a vicious spiral 9and is  
> helping in maintaining pressures).
> Funny thing is patient has bilateral dilated and fixed pupils but  
> has actually woken up once !! (On an infusion of morphine + Ketamine)
> Prasanna
> _______________________________________________
> OpenHeart-L mailing list
>
> Send postings to:
> OpenHeart-L@lists.hsforum.com
>
> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
> http://mmp.cjp.com/mailman/listinfo/openheart-l
>
> All messages transmitted by the OpenHeart-L are subject to the  
> policies and disclaimers posted at:
> http://www.hsforum.com/listdisclaim
> -----------------------------------------

From prasannasimha at gmail.com  Fri Dec  1 20:13:21 2006
From: prasannasimha at gmail.com (prasannasimha)
Date: Fri Dec  1 09:43:33 2006
Subject: [HSF] RV failure management strategies
In-Reply-To: <54A9E6C9-0DA5-4741-BA15-3A50562B72F3@gmail.com>
References: <456F961A.3080207@gmail.com>
	<54A9E6C9-0DA5-4741-BA15-3A50562B72F3@gmail.com>
Message-ID: <45703F89.8060805@gmail.com>

Michael,
She was a case of severe calcific MS with LA clot severe TR with pretty 
bad RV function. She was on inotropes prior to surgery and was in low 
output. She had a TIA and so was taken semi-emergently. She could not 
lie down and was urgently intubated and required  rapid institution of 
CPB. Surgery was pretty uneventful (No clot was seen in the LA and I 
presume it had embolized during the TIA) and the heart was contracting 
well as long as not loaded. While loading  The situation was good LV 
contractility, RV poor EF (on Echo) . Low LAP and high transpulmonary 
gradient. We initially managed by giving pulmonary vasodilators etc and 
had to give systemic vasoconstrictors to maintain the SVR which was low 
Tried to use iNO - did not help . We could wean off CPB and she was 
pretty coagulopathic and after the usual burn and stitch for a couple of 
hours (ill advisedly) closed her and had to immediately open her due to 
tamponade due to a clot over the PA. Kept the chest open.
At present she is still on multiple inotropes. CI is wavering between 
2.4- 3.0. Bleeding seems to have stopped . I had opened up everything 
and washed the pericardium and sutured a plastic sheet back.
No evidence of sepsis.
I also like to "run em dry" and actually the patient is passing good 
urine and I have a PD catheter with mini-cycling to reduce edema.though 
she requires a CVP of around 12-14 to maintain hemodynamics. Her creat 
is pretty normal and her only abnormal parameter  are her platelets and 
bilirubn which is marginally high (probably going to keep rizing further!!)
I usually do not paralyze all open chests and keep them on Morphine and 
Ketamine infusions which usually deeply anesthetises them without the 
need to paralyze them. I have seen this been done with pediatric 
patients and they argue that "micromovements" is actually good in 
mobilizing tissue  edema by lymphatics.
(Patients actually do not move around when on the infusion but have 
preserved muscular tone if you get what I mean) though I do give them a 
relaxant if they breath spontaneously and this causes incoordination 
which they rarely do. One of my residents had lowered the drug infusion 
temporarily to see the CNS status !! That is how I know she was "awakable"
Did give her a shot of Methypred but no use.
RVAD in her is impractical for "practical" reasons. I have an IABP in 
place. I cannot do a bail out Glenn because her PVR is high.
At present following a wait and watch till edema comes down .
Prasanna




Michael Firstenberg wrote:
> Something does not quiet sound right with his hemodynamics - and maybe 
> I need to think about this more and look at the actual numbers.
> But, if your RV is failing - which it sounds like it is, then you 
> would have low preload delivered to the left heart and this should 
> (please all corrected me if I am wrong) result in a higher SVR as a 
> systemic compensatory measure.
>
> Coming into this a little late (missed some of the other comments)
> 1) Is your patient septic - and maybe the overall cardiac function can 
> not keep up enough
>     there may be a little zosyo-penia or the vanco receptors may not 
> be adequately saturated.
> 2) What is the renal function?
>     From what you are describing, probably poor - are you on CVVH yet?
>     If not - I am a firm believer of the voodoo of dialysis of "evil 
> humors"
>     If this is truly right heart failure - maybe getting volume off 
> acutely (even on tons of drugs) may bring you to a more favorable part 
> of the Starling curve
>     I have a little experience with acute ultra-filtration  (even with 
> "marginal urine output") is sucking some of these people dry which works!
>        May cause ARF (which should improve with time?) - but your 
> current path will most likely knock out the beans forever
>        (better to have a live patient on dialysis than a potential 
> kidney donor?)
> 3) You said "open chest" and patient actually woke up.
>      Is it correct to assume that he/she is pharm. paralyized?
>     I have also seen more than a few patients with "lap-pad" 
> tamponade.  Even though the chest is open, there are too many or a few 
> stratigically placed pads (particularly if they are placed for 
> bleeding) than compress the RV.
> 4) Fixed-dilated pupils?
>     Hmmm - no idea, but it aint over til its over
>    I am sure we have all seen comatose patients wake up quite contrary 
> to the Glascow data (which I am sure have a reprint somewhere knowing 
> you - read: compliment)
> 5) Acute adrenal insuff.  ->  when in doubt, steroids
>     I had a medical school professor who said that no one should die 
> without the benefits of steroids.
>
> There seems to be a lot going on with your very sick patient and I 
> tossed out a few "kitchen" sink ideas.
>      yes, a RVAD/Ecmo may help - but does not solve all of your problem
>     though with an open chest an RA-RV circuit with stuff you have 
> around may be enough.
>
> I have seen a few recent "mazes" in otherwise healthy hearts have 
> similar problems - not sure what to make of it - anyone else?
>
>
>
> Good luck - keep us up to date
>
>
> -michael
>
>
>
> On Nov 30, 2006, at 9:40 PM, prasannasimha wrote:
>
>> Can the list members enumerate their management strategies for RV 
>> failure.
>> This is for two reasons. _ one for th3e Wiki and presently
>> I have  a patient who was in low output  and taken for a semi 
>> emergency MVR with maze with TV plasty. Patient had RV dysfunction 
>> and congestive hepatopathy. Had a difficult wean - LV good but RV 
>> function was pretty poor. Patient is in coagulopathy which seems to 
>> have decreased .No mechanical problem on epicardial echo.
>> Patient has an open chest and has adequate CI (PA cath with CCO) has 
>> a high PVR and low SVR and is requiring multiple inotropes (Dopa = 
>> Dobut +Adrenaline + Norad +Milrinone and Vasopressin on one hand and 
>> multiple vasodilators on the other (getting constrictors via the 
>> central lumen of the IABP and dilators via the PA catheter) . I put 
>> the IABP as the patient has OK CI but low pressures due to a 
>> vasoplegic state and was worried that the coronary flow may not be 
>> adequate creating a vicious spiral 9and is helping in maintaining 
>> pressures).
>> Funny thing is patient has bilateral dilated and fixed pupils but has 
>> actually woken up once !! (On an infusion of morphine + Ketamine)
>> Prasanna
>> _______________________________________________
>> OpenHeart-L mailing list
>>
>> Send postings to:
>> OpenHeart-L@lists.hsforum.com
>>
>> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
>> http://mmp.cjp.com/mailman/listinfo/openheart-l
>>
>> All messages transmitted by the OpenHeart-L are subject to the 
>> policies and disclaimers posted at:
>> http://www.hsforum.com/listdisclaim
>> -----------------------------------------
>
> _______________________________________________
> OpenHeart-L mailing list
>
> Send postings to:
> OpenHeart-L@lists.hsforum.com
>
> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
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> -----------------------------------------
>
From msfirst at gmail.com  Fri Dec  1 09:57:58 2006
From: msfirst at gmail.com (Michael Firstenberg)
Date: Fri Dec  1 09:58:05 2006
Subject: [HSF] RV failure management strategies
In-Reply-To: <45703F89.8060805@gmail.com>
References: <456F961A.3080207@gmail.com>
	<54A9E6C9-0DA5-4741-BA15-3A50562B72F3@gmail.com>
	<45703F89.8060805@gmail.com>
Message-ID: <03BF6AFC-947F-4B4C-BDEE-6A3E9F03EA04@gmail.com>

Hmmmm,
Sounds like my kinda case - want to ship her to me?

How come you dont want to run a RA-PV pump?

Low platelets?
HITTs?

Just curious - how are you going to feed her?
    I know a few people who like TPN (yuck yuck yuck) with open  
chests to make nursing care easier and safer.

Although, sounds like you are making progress -> winning the battle,  
stay the course.


-michael



On Dec 1, 2006, at 9:43 AM, prasannasimha wrote:

> Michael,
> She was a case of severe calcific MS with LA clot severe TR with  
> pretty bad RV function. She was on inotropes prior to surgery and  
> was in low output. She had a TIA and so was taken semi-emergently.  
> She could not lie down and was urgently intubated and required   
> rapid institution of CPB. Surgery was pretty uneventful (No clot  
> was seen in the LA and I presume it had embolized during the TIA)  
> and the heart was contracting well as long as not loaded. While  
> loading  The situation was good LV contractility, RV poor EF (on  
> Echo) . Low LAP and high transpulmonary gradient. We initially  
> managed by giving pulmonary vasodilators etc and had to give  
> systemic vasoconstrictors to maintain the SVR which was low Tried  
> to use iNO - did not help . We could wean off CPB and she was  
> pretty coagulopathic and after the usual burn and stitch for a  
> couple of hours (ill advisedly) closed her and had to immediately  
> open her due to tamponade due to a clot over the PA. Kept the chest  
> open.
> At present she is still on multiple inotropes. CI is wavering  
> between 2.4- 3.0. Bleeding seems to have stopped . I had opened up  
> everything and washed the pericardium and sutured a plastic sheet  
> back.
> No evidence of sepsis.
> I also like to "run em dry" and actually the patient is passing  
> good urine and I have a PD catheter with mini-cycling to reduce  
> edema.though she requires a CVP of around 12-14 to maintain  
> hemodynamics. Her creat is pretty normal and her only abnormal  
> parameter  are her platelets and bilirubn which is marginally high  
> (probably going to keep rizing further!!)
> I usually do not paralyze all open chests and keep them on Morphine  
> and Ketamine infusions which usually deeply anesthetises them  
> without the need to paralyze them. I have seen this been done with  
> pediatric patients and they argue that "micromovements" is actually  
> good in mobilizing tissue  edema by lymphatics.
> (Patients actually do not move around when on the infusion but have  
> preserved muscular tone if you get what I mean) though I do give  
> them a relaxant if they breath spontaneously and this causes  
> incoordination which they rarely do. One of my residents had  
> lowered the drug infusion temporarily to see the CNS status !! That  
> is how I know she was "awakable"
> Did give her a shot of Methypred but no use.
> RVAD in her is impractical for "practical" reasons. I have an IABP  
> in place. I cannot do a bail out Glenn because her PVR is high.
> At present following a wait and watch till edema comes down .
> Prasanna
>
>
>
>
> Michael Firstenberg wrote:
>> Something does not quiet sound right with his hemodynamics - and  
>> maybe I need to think about this more and look at the actual numbers.
>> But, if your RV is failing - which it sounds like it is, then you  
>> would have low preload delivered to the left heart and this should  
>> (please all corrected me if I am wrong) result in a higher SVR as  
>> a systemic compensatory measure.
>>
>> Coming into this a little late (missed some of the other comments)
>> 1) Is your patient septic - and maybe the overall cardiac function  
>> can not keep up enough
>>     there may be a little zosyo-penia or the vanco receptors may  
>> not be adequately saturated.
>> 2) What is the renal function?
>>     From what you are describing, probably poor - are you on CVVH  
>> yet?
>>     If not - I am a firm believer of the voodoo of dialysis of  
>> "evil humors"
>>     If this is truly right heart failure - maybe getting volume  
>> off acutely (even on tons of drugs) may bring you to a more  
>> favorable part of the Starling curve
>>     I have a little experience with acute ultra-filtration  (even  
>> with "marginal urine output") is sucking some of these people dry  
>> which works!
>>        May cause ARF (which should improve with time?) - but your  
>> current path will most likely knock out the beans forever
>>        (better to have a live patient on dialysis than a potential  
>> kidney donor?)
>> 3) You said "open chest" and patient actually woke up.
>>      Is it correct to assume that he/she is pharm. paralyized?
>>     I have also seen more than a few patients with "lap-pad"  
>> tamponade.  Even though the chest is open, there are too many or a  
>> few stratigically placed pads (particularly if they are placed for  
>> bleeding) than compress the RV.
>> 4) Fixed-dilated pupils?
>>     Hmmm - no idea, but it aint over til its over
>>    I am sure we have all seen comatose patients wake up quite  
>> contrary to the Glascow data (which I am sure have a reprint  
>> somewhere knowing you - read: compliment)
>> 5) Acute adrenal insuff.  ->  when in doubt, steroids
>>     I had a medical school professor who said that no one should  
>> die without the benefits of steroids.
>>
>> There seems to be a lot going on with your very sick patient and I  
>> tossed out a few "kitchen" sink ideas.
>>      yes, a RVAD/Ecmo may help - but does not solve all of your  
>> problem
>>     though with an open chest an RA-RV circuit with stuff you have  
>> around may be enough.
>>
>> I have seen a few recent "mazes" in otherwise healthy hearts have  
>> similar problems - not sure what to make of it - anyone else?
>>
>>
>>
>> Good luck - keep us up to date
>>
>>
>> -michael
>>
>>
>>
>> On Nov 30, 2006, at 9:40 PM, prasannasimha wrote:
>>
>>> Can the list members enumerate their management strategies for RV  
>>> failure.
>>> This is for two reasons. _ one for th3e Wiki and presently
>>> I have  a patient who was in low output  and taken for a semi  
>>> emergency MVR with maze with TV plasty. Patient had RV  
>>> dysfunction and congestive hepatopathy. Had a difficult wean - LV  
>>> good but RV function was pretty poor. Patient is in coagulopathy  
>>> which seems to have decreased .No mechanical problem on  
>>> epicardial echo.
>>> Patient has an open chest and has adequate CI (PA cath with CCO)  
>>> has a high PVR and low SVR and is requiring multiple inotropes  
>>> (Dopa = Dobut +Adrenaline + Norad +Milrinone and Vasopressin on  
>>> one hand and multiple vasodilators on the other (getting  
>>> constrictors via the central lumen of the IABP and dilators via  
>>> the PA catheter) . I put the IABP as the patient has OK CI but  
>>> low pressures due to a vasoplegic state and was worried that the  
>>> coronary flow may not be adequate creating a vicious spiral 9and  
>>> is helping in maintaining pressures).
>>> Funny thing is patient has bilateral dilated and fixed pupils but  
>>> has actually woken up once !! (On an infusion of morphine +  
>>> Ketamine)
>>> Prasanna
>>> _______________________________________________
>>> OpenHeart-L mailing list
>>>
>>> Send postings to:
>>> OpenHeart-L@lists.hsforum.com
>>>
>>> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
>>> http://mmp.cjp.com/mailman/listinfo/openheart-l
>>>
>>> All messages transmitted by the OpenHeart-L are subject to the  
>>> policies and disclaimers posted at:
>>> http://www.hsforum.com/listdisclaim
>>> -----------------------------------------
>>
>> _______________________________________________
>> OpenHeart-L mailing list
>>
>> Send postings to:
>> OpenHeart-L@lists.hsforum.com
>>
>> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
>> http://mmp.cjp.com/mailman/listinfo/openheart-l
>>
>> All messages transmitted by the OpenHeart-L are subject to the  
>> policies anddisclaimers posted at:
>> http://www.hsforum.com/listdisclaim
>> -----------------------------------------
>>
> _______________________________________________
> OpenHeart-L mailing list
>
> Send postings to:
> OpenHeart-L@lists.hsforum.com
>
> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
> http://mmp.cjp.com/mailman/listinfo/openheart-l
>
> All messages transmitted by the OpenHeart-L are subject to the  
> policies and disclaimers posted at:
> http://www.hsforum.com/listdisclaim
> -----------------------------------------

From prasannasimha at gmail.com  Fri Dec  1 20:44:08 2006
From: prasannasimha at gmail.com (prasannasimha)
Date: Fri Dec  1 10:14:19 2006
Subject: [HSF] RV failure management strategies
In-Reply-To: <03BF6AFC-947F-4B4C-BDEE-6A3E9F03EA04@gmail.com>
References: <456F961A.3080207@gmail.com>	<54A9E6C9-0DA5-4741-BA15-3A50562B72F3@gmail.com>	<45703F89.8060805@gmail.com>
	<03BF6AFC-947F-4B4C-BDEE-6A3E9F03EA04@gmail.com>
Message-ID: <457046C0.1000502@gmail.com>

 Why not an RA PA pump - Michael - her RA was plain friable and took 
plenty of time just to get hemostasis. (She was having a sky high CVP 
with blubbery tissues when I opened her initially itself) . I think I 
will have a mess if I touch her RA and PA now. She is still oozing at 
her puncture sites so heparinising her would be a big challenge for me. 
Blood products are difficult to obtain too so having her on RVAD would 
be ending in exsanguinating her in the situation I am in. At least now I 
have some things in control even if not really OK.
Prasanna

Michael Firstenberg wrote:
> Hmmmm,
> Sounds like my kinda case - want to ship her to me?
>
> How come you dont want to run a RA-PV pump?
>
> Low platelets?
> HITTs?
>
> Just curious - how are you going to feed her?
>    I know a few people who like TPN (yuck yuck yuck) with open chests 
> to make nursing care easier and safer.
>
> Although, sounds like you are making progress -> winning the battle, 
> stay the course.
>
>
> -michael
>
>
>
> On Dec 1, 2006, at 9:43 AM, prasannasimha wrote:
>
>> Michael,
>> She was a case of severe calcific MS with LA clot severe TR with 
>> pretty bad RV function. She was on inotropes prior to surgery and was 
>> in low output. She had a TIA and so was taken semi-emergently. She 
>> could not lie down and was urgently intubated and required  rapid 
>> institution of CPB. Surgery was pretty uneventful (No clot was seen 
>> in the LA and I presume it had embolized during the TIA) and the 
>> heart was contracting well as long as not loaded. While loading  The 
>> situation was good LV contractility, RV poor EF (on Echo) . Low LAP 
>> and high transpulmonary gradient. We initially managed by giving 
>> pulmonary vasodilators etc and had to give systemic vasoconstrictors 
>> to maintain the SVR which was low Tried to use iNO - did not help . 
>> We could wean off CPB and she was pretty coagulopathic and after the 
>> usual burn and stitch for a couple of hours (ill advisedly) closed 
>> her and had to immediately open her due to tamponade due to a clot 
>> over the PA. Kept the chest open.
>> At present she is still on multiple inotropes. CI is wavering between 
>> 2.4- 3.0. Bleeding seems to have stopped . I had opened up everything 
>> and washed the pericardium and sutured a plastic sheet back.
>> No evidence of sepsis.
>> I also like to "run em dry" and actually the patient is passing good 
>> urine and I have a PD catheter with mini-cycling to reduce 
>> edema.though she requires a CVP of around 12-14 to maintain 
>> hemodynamics. Her creat is pretty normal and her only abnormal 
>> parameter  are her platelets and bilirubn which is marginally high 
>> (probably going to keep rizing further!!)
>> I usually do not paralyze all open chests and keep them on Morphine 
>> and Ketamine infusions which usually deeply anesthetises them without 
>> the need to paralyze them. I have seen this been done with pediatric 
>> patients and they argue that "micromovements" is actually good in 
>> mobilizing tissue  edema by lymphatics.
>> (Patients actually do not move around when on the infusion but have 
>> preserved muscular tone if you get what I mean) though I do give them 
>> a relaxant if they breath spontaneously and this causes 
>> incoordination which they rarely do. One of my residents had lowered 
>> the drug infusion temporarily to see the CNS status !! That is how I 
>> know she was "awakable"
>> Did give her a shot of Methypred but no use.
>> RVAD in her is impractical for "practical" reasons. I have an IABP in 
>> place. I cannot do a bail out Glenn because her PVR is high.
>> At present following a wait and watch till edema comes down .
>> Prasanna
>>
>>
>>
>>
>> Michael Firstenberg wrote:
>>> Something does not quiet sound right with his hemodynamics - and 
>>> maybe I need to think about this more and look at the actual numbers.
>>> But, if your RV is failing - which it sounds like it is, then you 
>>> would have low preload delivered to the left heart and this should 
>>> (please all corrected me if I am wrong) result in a higher SVR as a 
>>> systemic compensatory measure.
>>>
>>> Coming into this a little late (missed some of the other comments)
>>> 1) Is your patient septic - and maybe the overall cardiac function 
>>> can not keep up enough
>>>     there may be a little zosyo-penia or the vanco receptors may not 
>>> be adequately saturated.
>>> 2) What is the renal function?
>>>     From what you are describing, probably poor - are you on CVVH yet?
>>>     If not - I am a firm believer of the voodoo of dialysis of "evil 
>>> humors"
>>>     If this is truly right heart failure - maybe getting volume off 
>>> acutely (even on tons of drugs) may bring you to a more favorable 
>>> part of the Starling curve
>>>     I have a little experience with acute ultra-filtration  (even 
>>> with "marginal urine output") is sucking some of these people dry 
>>> which works!
>>>        May cause ARF (which should improve with time?) - but your 
>>> current path will most likely knock out the beans forever
>>>        (better to have a live patient on dialysis than a potential 
>>> kidney donor?)
>>> 3) You said "open chest" and patient actually woke up.
>>>      Is it correct to assume that he/she is pharm. paralyized?
>>>     I have also seen more than a few patients with "lap-pad" 
>>> tamponade.  Even though the chest is open, there are too many or a 
>>> few stratigically placed pads (particularly if they are placed for 
>>> bleeding) than compress the RV.
>>> 4) Fixed-dilated pupils?
>>>     Hmmm - no idea, but it aint over til its over
>>>    I am sure we have all seen comatose patients wake up quite 
>>> contrary to the Glascow data (which I am sure have a reprint 
>>> somewhere knowing you - read: compliment)
>>> 5) Acute adrenal insuff.  ->  when in doubt, steroids
>>>     I had a medical school professor who said that no one should die 
>>> without the benefits of steroids.
>>>
>>> There seems to be a lot going on with your very sick patient and I 
>>> tossed out a few "kitchen" sink ideas.
>>>      yes, a RVAD/Ecmo may help - but does not solve all of your problem
>>>     though with an open chest an RA-RV circuit with stuff you have 
>>> around may be enough.
>>>
>>> I have seen a few recent "mazes" in otherwise healthy hearts have 
>>> similar problems - not sure what to make of it - anyone else?
>>>
>>>
>>>
>>> Good luck - keep us up to date
>>>
>>>
>>> -michael
>>>
>>>
>>>
>>> On Nov 30, 2006, at 9:40 PM, prasannasimha wrote:
>>>
>>>> Can the list members enumerate their management strategies for RV 
>>>> failure.
>>>> This is for two reasons. _ one for th3e Wiki and presently
>>>> I have  a patient who was in low output  and taken for a semi 
>>>> emergency MVR with maze with TV plasty. Patient had RV dysfunction 
>>>> and congestive hepatopathy. Had a difficult wean - LV good but RV 
>>>> function was pretty poor. Patient is in coagulopathy which seems to 
>>>> have decreased .No mechanical problem on epicardial echo.
>>>> Patient has an open chest and has adequate CI (PA cath with CCO) 
>>>> has a high PVR and low SVR and is requiring multiple inotropes 
>>>> (Dopa = Dobut +Adrenaline + Norad +Milrinone and Vasopressin on one 
>>>> hand and multiple vasodilators on the other (getting constrictors 
>>>> via the central lumen of the IABP and dilators via the PA catheter) 
>>>> . I put the IABP as the patient has OK CI but low pressures due to 
>>>> a vasoplegic state and was worried that the coronary flow may not 
>>>> be adequate creating a vicious spiral 9and is helping in 
>>>> maintaining pressures).
>>>> Funny thing is patient has bilateral dilated and fixed pupils but 
>>>> has actually woken up once !! (On an infusion of morphine + Ketamine)
>>>> Prasanna
>>>> _______________________________________________
>>>> OpenHeart-L mailing list
>>>>
>>>> Send postings to:
>>>> OpenHeart-L@lists.hsforum.com
>>>>
>>>> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
>>>> http://mmp.cjp.com/mailman/listinfo/openheart-l
>>>>
>>>> All messages transmitted by the OpenHeart-L are subject to the 
>>>> policies and disclaimers posted at:
>>>> http://www.hsforum.com/listdisclaim
>>>> -----------------------------------------
>>>
>>> _______________________________________________
>>> OpenHeart-L mailing list
>>>
>>> Send postings to:
>>> OpenHeart-L@lists.hsforum.com
>>>
>>> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
>>> http://mmp.cjp.com/mailman/listinfo/openheart-l
>>>
>>> All messages transmitted by the OpenHeart-L are subject to the 
>>> policies anddisclaimers posted at:
>>> http://www.hsforum.com/listdisclaim
>>> -----------------------------------------
>>>
>> _______________________________________________
>> OpenHeart-L mailing list
>>
>> Send postings to:
>> OpenHeart-L@lists.hsforum.com
>>
>> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
>> http://mmp.cjp.com/mailman/listinfo/openheart-l
>>
>> All messages transmitted by the OpenHeart-L are subject to the 
>> policies and disclaimers posted at:
>> http://www.hsforum.com/listdisclaim
>> -----------------------------------------
>
> _______________________________________________
> OpenHeart-L mailing list
>
> Send postings to:
> OpenHeart-L@lists.hsforum.com
>
> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
> http://mmp.cjp.com/mailman/listinfo/openheart-l
>
> All messages transmitted by the OpenHeart-L are subject to the 
> policies anddisclaimers posted at:
> http://www.hsforum.com/listdisclaim
> -----------------------------------------
>
From prasannasimha at gmail.com  Fri Dec  1 20:39:01 2006
From: prasannasimha at gmail.com (prasannasimha)
Date: Fri Dec  1 10:34:55 2006
Subject: [HSF] RV failure management strategies
In-Reply-To: <03BF6AFC-947F-4B4C-BDEE-6A3E9F03EA04@gmail.com>
References: <456F961A.3080207@gmail.com>	<54A9E6C9-0DA5-4741-BA15-3A50562B72F3@gmail.com>	<45703F89.8060805@gmail.com>
	<03BF6AFC-947F-4B4C-BDEE-6A3E9F03EA04@gmail.com>
Message-ID: <4570458D.80201@gmail.com>

Would gladly. At present don't have an ABG machine running (conked off 
and the machine coming in is stuck in the Airport) so have to send any 
ABG's to a hospital 2 Kms away !! When problems occur they come in droves.
Platelets are low - possibility of HIT so on heparin less flushes and I 
believe it is still pretty premature to call it HITTS. Don't ask about 
all those assays - just not available !!
I trophic feed these patients initially.I then progress to continuous 
tube feeds as tolerated. No TPN - extremely expensive and so use it only 
when cornered and even then it is usually a combo.
Incientally(though it is not practical) would there be any use RVADing 
the patient so late ?
Prasanna

Michael Firstenberg wrote:
> Hmmmm,
> Sounds like my kinda case - want to ship her to me?
>
> How come you dont want to run a RA-PV pump?
>
> Low platelets?
> HITTs?
>
> Just curious - how are you going to feed her?
>    I know a few people who like TPN (yuck yuck yuck) with open chests 
> to make nursing care easier and safer.
>
> Although, sounds like you are making progress -> winning the battle, 
> stay the course.
>
>
> -michael
>
>
>
> On Dec 1, 2006, at 9:43 AM, prasannasimha wrote:
>
>> Michael,
>> She was a case of severe calcific MS with LA clot severe TR with 
>> pretty bad RV function. She was on inotropes prior to surgery and was 
>> in low output. She had a TIA and so was taken semi-emergently. She 
>> could not lie down and was urgently intubated and required  rapid 
>> institution of CPB. Surgery was pretty uneventful (No clot was seen 
>> in the LA and I presume it had embolized during the TIA) and the 
>> heart was contracting well as long as not loaded. While loading  The 
>> situation was good LV contractility, RV poor EF (on Echo) . Low LAP 
>> and high transpulmonary gradient. We initially managed by giving 
>> pulmonary vasodilators etc and had to give systemic vasoconstrictors 
>> to maintain the SVR which was low Tried to use iNO - did not help . 
>> We could wean off CPB and she was pretty coagulopathic and after the 
>> usual burn and stitch for a couple of hours (ill advisedly) closed 
>> her and had to immediately open her due to tamponade due to a clot 
>> over the PA. Kept the chest open.
>> At present she is still on multiple inotropes. CI is wavering between 
>> 2.4- 3.0. Bleeding seems to have stopped . I had opened up everything 
>> and washed the pericardium and sutured a plastic sheet back.
>> No evidence of sepsis.
>> I also like to "run em dry" and actually the patient is passing good 
>> urine and I have a PD catheter with mini-cycling to reduce 
>> edema.though she requires a CVP of around 12-14 to maintain 
>> hemodynamics. Her creat is pretty normal and her only abnormal 
>> parameter  are her platelets and bilirubn which is marginally high 
>> (probably going to keep rizing further!!)
>> I usually do not paralyze all open chests and keep them on Morphine 
>> and Ketamine infusions which usually deeply anesthetises them without 
>> the need to paralyze them. I have seen this been done with pediatric 
>> patients and they argue that "micromovements" is actually good in 
>> mobilizing tissue  edema by lymphatics.
>> (Patients actually do not move around when on the infusion but have 
>> preserved muscular tone if you get what I mean) though I do give them 
>> a relaxant if they breath spontaneously and this causes 
>> incoordination which they rarely do. One of my residents had lowered 
>> the drug infusion temporarily to see the CNS status !! That is how I 
>> know she was "awakable"
>> Did give her a shot of Methypred but no use.
>> RVAD in her is impractical for "practical" reasons. I have an IABP in 
>> place. I cannot do a bail out Glenn because her PVR is high.
>> At present following a wait and watch till edema comes down .
>> Prasanna
>>
>>
>>
>>
>> Michael Firstenberg wrote:
>>> Something does not quiet sound right with his hemodynamics - and 
>>> maybe I need to think about this more and look at the actual numbers.
>>> But, if your RV is failing - which it sounds like it is, then you 
>>> would have low preload delivered to the left heart and this should 
>>> (please all corrected me if I am wrong) result in a higher SVR as a 
>>> systemic compensatory measure.
>>>
>>> Coming into this a little late (missed some of the other comments)
>>> 1) Is your patient septic - and maybe the overall cardiac function 
>>> can not keep up enough
>>>     there may be a little zosyo-penia or the vanco receptors may not 
>>> be adequately saturated.
>>> 2) What is the renal function?
>>>     From what you are describing, probably poor - are you on CVVH yet?
>>>     If not - I am a firm believer of the voodoo of dialysis of "evil 
>>> humors"
>>>     If this is truly right heart failure - maybe getting volume off 
>>> acutely (even on tons of drugs) may bring you to a more favorable 
>>> part of the Starling curve
>>>     I have a little experience with acute ultra-filtration  (even 
>>> with "marginal urine output") is sucking some of these people dry 
>>> which works!
>>>        May cause ARF (which should improve with time?) - but your 
>>> current path will most likely knock out the beans forever
>>>        (better to have a live patient on dialysis than a potential 
>>> kidney donor?)
>>> 3) You said "open chest" and patient actually woke up.
>>>      Is it correct to assume that he/she is pharm. paralyized?
>>>     I have also seen more than a few patients with "lap-pad" 
>>> tamponade.  Even though the chest is open, there are too many or a 
>>> few stratigically placed pads (particularly if they are placed for 
>>> bleeding) than compress the RV.
>>> 4) Fixed-dilated pupils?
>>>     Hmmm - no idea, but it aint over til its over
>>>    I am sure we have all seen comatose patients wake up quite 
>>> contrary to the Glascow data (which I am sure have a reprint 
>>> somewhere knowing you - read: compliment)
>>> 5) Acute adrenal insuff.  ->  when in doubt, steroids
>>>     I had a medical school professor who said that no one should die 
>>> without the benefits of steroids.
>>>
>>> There seems to be a lot going on with your very sick patient and I 
>>> tossed out a few "kitchen" sink ideas.
>>>      yes, a RVAD/Ecmo may help - but does not solve all of your problem
>>>     though with an open chest an RA-RV circuit with stuff you have 
>>> around may be enough.
>>>
>>> I have seen a few recent "mazes" in otherwise healthy hearts have 
>>> similar problems - not sure what to make of it - anyone else?
>>>
>>>
>>>
>>> Good luck - keep us up to date
>>>
>>>
>>> -michael
>>>
>>>
>>>
>>> On Nov 30, 2006, at 9:40 PM, prasannasimha wrote:
>>>
>>>> Can the list members enumerate their management strategies for RV 
>>>> failure.
>>>> This is for two reasons. _ one for th3e Wiki and presently
>>>> I have  a patient who was in low output  and taken for a semi 
>>>> emergency MVR with maze with TV plasty. Patient had RV dysfunction 
>>>> and congestive hepatopathy. Had a difficult wean - LV good but RV 
>>>> function was pretty poor. Patient is in coagulopathy which seems to 
>>>> have decreased .No mechanical problem on epicardial echo.
>>>> Patient has an open chest and has adequate CI (PA cath with CCO) 
>>>> has a high PVR and low SVR and is requiring multiple inotropes 
>>>> (Dopa = Dobut +Adrenaline + Norad +Milrinone and Vasopressin on one 
>>>> hand and multiple vasodilators on the other (getting constrictors 
>>>> via the central lumen of the IABP and dilators via the PA catheter) 
>>>> . I put the IABP as the patient has OK CI but low pressures due to 
>>>> a vasoplegic state and was worried that the coronary flow may not 
>>>> be adequate creating a vicious spiral 9and is helping in 
>>>> maintaining pressures).
>>>> Funny thing is patient has bilateral dilated and fixed pupils but 
>>>> has actually woken up once !! (On an infusion of morphine + Ketamine)
>>>> Prasanna
>>>> _______________________________________________
>>>> OpenHeart-L mailing list
>>>>
>>>> Send postings to:
>>>> OpenHeart-L@lists.hsforum.com
>>>>
>>>> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
>>>> http://mmp.cjp.com/mailman/listinfo/openheart-l
>>>>
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>>>> policies and disclaimers posted at:
>>>> http://www.hsforum.com/listdisclaim
>>>> -----------------------------------------
>>>
>>> _______________________________________________
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>>>
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>> _______________________________________________
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> _______________________________________________
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From ebender001 at charter.net  Fri Dec  1 07:39:10 2006
From: ebender001 at charter.net (ebender001@charter.net)
Date: Fri Dec  1 10:39:28 2006
Subject: [HSF] RV failure management strategies
Message-ID: <284604891.1164987550219.JavaMail.root@fepweb01>

It sounds like its going to be mechanical support or death.  I understand the reluctance to re-cannulate the right atrium, so use a long venous cannula throught the femoral or jugular vein.  I question the fear of cannulating the pulmonary artery with a small bore tube and suitably pledgeted purse string(s).  I also think that the RVAD flows don't need to be that high (1-2 liters per minute) with a centrifugal pump.  Heparinization at low levels should also be suitable.  On the other hand, if this is irreversable pulmonary vascular disease then your goose is cooked (American idiom).

Ed Bender, MD


---- prasannasimha <prasannasimha@gmail.com> wrote: 
>  Why not an RA PA pump - Michael - her RA was plain friable and took 
> plenty of time just to get hemostasis. (She was having a sky high CVP 
> with blubbery tissues when I opened her initially itself) . I think I 
> will have a mess if I touch her RA and PA now. She is still oozing at 
> her puncture sites so heparinising her would be a big challenge for me. 
> Blood products are difficult to obtain too so having her on RVAD would 
> be ending in exsanguinating her in the situation I am in. At least now I 
> have some things in control even if not really OK.
> Prasanna
> 
> Michael Firstenberg wrote:
> > Hmmmm,
> > Sounds like my kinda case - want to ship her to me?
> >
> > How come you dont want to run a RA-PV pump?
> >
> > Low platelets?
> > HITTs?
> >
> > Just curious - how are you going to feed her?
> >    I know a few people who like TPN (yuck yuck yuck) with open chests 
> > to make nursing care easier and safer.
> >
> > Although, sounds like you are making progress -> winning the battle, 
> > stay the course.
> >
> >
> > -michael
> >
> >
> >
> > On Dec 1, 2006, at 9:43 AM, prasannasimha wrote:
> >
> >> Michael,
> >> She was a case of severe calcific MS with LA clot severe TR with 
> >> pretty bad RV function. She was on inotropes prior to surgery and was 
> >> in low output. She had a TIA and so was taken semi-emergently. She 
> >> could not lie down and was urgently intubated and required  rapid 
> >> institution of CPB. Surgery was pretty uneventful (No clot was seen 
> >> in the LA and I presume it had embolized during the TIA) and the 
> >> heart was contracting well as long as not loaded. While loading  The 
> >> situation was good LV contractility, RV poor EF (on Echo) . Low LAP 
> >> and high transpulmonary gradient. We initially managed by giving 
> >> pulmonary vasodilators etc and had to give systemic vasoconstrictors 
> >> to maintain the SVR which was low Tried to use iNO - did not help . 
> >> We could wean off CPB and she was pretty coagulopathic and after the 
> >> usual burn and stitch for a couple of hours (ill advisedly) closed 
> >> her and had to immediately open her due to tamponade due to a clot 
> >> over the PA. Kept the chest open.
> >> At present she is still on multiple inotropes. CI is wavering between 
> >> 2.4- 3.0. Bleeding seems to have stopped . I had opened up everything 
> >> and washed the pericardium and sutured a plastic sheet back.
> >> No evidence of sepsis.
> >> I also like to "run em dry" and actually the patient is passing good 
> >> urine and I have a PD catheter with mini-cycling to reduce 
> >> edema.though she requires a CVP of around 12-14 to maintain 
> >> hemodynamics. Her creat is pretty normal and her only abnormal 
> >> parameter  are her platelets and bilirubn which is marginally high 
> >> (probably going to keep rizing further!!)
> >> I usually do not paralyze all open chests and keep them on Morphine 
> >> and Ketamine infusions which usually deeply anesthetises them without 
> >> the need to paralyze them. I have seen this been done with pediatric 
> >> patients and they argue that "micromovements" is actually good in 
> >> mobilizing tissue  edema by lymphatics.
> >> (Patients actually do not move around when on the infusion but have 
> >> preserved muscular tone if you get what I mean) though I do give them 
> >> a relaxant if they breath spontaneously and this causes 
> >> incoordination which they rarely do. One of my residents had lowered 
> >> the drug infusion temporarily to see the CNS status !! That is how I 
> >> know she was "awakable"
> >> Did give her a shot of Methypred but no use.
> >> RVAD in her is impractical for "practical" reasons. I have an IABP in 
> >> place. I cannot do a bail out Glenn because her PVR is high.
> >> At present following a wait and watch till edema comes down .
> >> Prasanna
> >>
> >>
> >>
> >>
> >> Michael Firstenberg wrote:
> >>> Something does not quiet sound right with his hemodynamics - and 
> >>> maybe I need to think about this more and look at the actual numbers.
> >>> But, if your RV is failing - which it sounds like it is, then you 
> >>> would have low preload delivered to the left heart and this should 
> >>> (please all corrected me if I am wrong) result in a higher SVR as a 
> >>> systemic compensatory measure.
> >>>
> >>> Coming into this a little late (missed some of the other comments)
> >>> 1) Is your patient septic - and maybe the overall cardiac function 
> >>> can not keep up enough
> >>>     there may be a little zosyo-penia or the vanco receptors may not 
> >>> be adequately saturated.
> >>> 2) What is the renal function?
> >>>     From what you are describing, probably poor - are you on CVVH yet?
> >>>     If not - I am a firm believer of the voodoo of dialysis of "evil 
> >>> humors"
> >>>     If this is truly right heart failure - maybe getting volume off 
> >>> acutely (even on tons of drugs) may bring you to a more favorable 
> >>> part of the Starling curve
> >>>     I have a little experience with acute ultra-filtration  (even 
> >>> with "marginal urine output") is sucking some of these people dry 
> >>> which works!
> >>>        May cause ARF (which should improve with time?) - but your 
> >>> current path will most likely knock out the beans forever
> >>>        (better to have a live patient on dialysis than a potential 
> >>> kidney donor?)
> >>> 3) You said "open chest" and patient actually woke up.
> >>>      Is it correct to assume that he/she is pharm. paralyized?
> >>>     I have also seen more than a few patients with "lap-pad" 
> >>> tamponade.  Even though the chest is open, there are too many or a 
> >>> few stratigically placed pads (particularly if they are placed for 
> >>> bleeding) than compress the RV.
> >>> 4) Fixed-dilated pupils?
> >>>     Hmmm - no idea, but it aint over til its over
> >>>    I am sure we have all seen comatose patients wake up quite 
> >>> contrary to the Glascow data (which I am sure have a reprint 
> >>> somewhere knowing you - read: compliment)
> >>> 5) Acute adrenal insuff.  ->  when in doubt, steroids
> >>>     I had a medical school professor who said that no one should die 
> >>> without the benefits of steroids.
> >>>
> >>> There seems to be a lot going on with your very sick patient and I 
> >>> tossed out a few "kitchen" sink ideas.
> >>>      yes, a RVAD/Ecmo may help - but does not solve all of your problem
> >>>     though with an open chest an RA-RV circuit with stuff you have 
> >>> around may be enough.
> >>>
> >>> I have seen a few recent "mazes" in otherwise healthy hearts have 
> >>> similar problems - not sure what to make of it - anyone else?
> >>>
> >>>
> >>>
> >>> Good luck - keep us up to date
> >>>
> >>>
> >>> -michael
> >>>
> >>>
> >>>
> >>> On Nov 30, 2006, at 9:40 PM, prasannasimha wrote:
> >>>
> >>>> Can the list members enumerate their management strategies for RV 
> >>>> failure.
> >>>> This is for two reasons. _ one for th3e Wiki and presently
> >>>> I have  a patient who was in low output  and taken for a semi 
> >>>> emergency MVR with maze with TV plasty. Patient had RV dysfunction 
> >>>> and congestive hepatopathy. Had a difficult wean - LV good but RV 
> >>>> function was pretty poor. Patient is in coagulopathy which seems to 
> >>>> have decreased .No mechanical problem on epicardial echo.
> >>>> Patient has an open chest and has adequate CI (PA cath with CCO) 
> >>>> has a high PVR and low SVR and is requiring multiple inotropes 
> >>>> (Dopa = Dobut +Adrenaline + Norad +Milrinone and Vasopressin on one 
> >>>> hand and multiple vasodilators on the other (getting constrictors 
> >>>> via the central lumen of the IABP and dilators via the PA catheter) 
> >>>> . I put the IABP as the patient has OK CI but low pressures due to 
> >>>> a vasoplegic state and was worried that the coronary flow may not 
> >>>> be adequate creating a vicious spiral 9and is helping in 
> >>>> maintaining pressures).
> >>>> Funny thing is patient has bilateral dilated and fixed pupils but 
> >>>> has actually woken up once !! (On an infusion of morphine + Ketamine)
> >>>> Prasanna
> >>>> _______________________________________________
> >>>> OpenHeart-L mailing list
> >>>>
> >>>> Send postings to:
> >>>> OpenHeart-L@lists.hsforum.com
> >>>>
> >>>> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
> >>>> http://mmp.cjp.com/mailman/listinfo/openheart-l
> >>>>
> >>>> All messages transmitted by the OpenHeart-L are subject to the 
> >>>> policies and disclaimers posted at:
> >>>> http://www.hsforum.com/listdisclaim
> >>>> -----------------------------------------
> >>>
> >>> _______________________________________________
> >>> OpenHeart-L mailing list
> >>>
> >>> Send postings to:
> >>> OpenHeart-L@lists.hsforum.com
> >>>
> >>> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
> >>> http://mmp.cjp.com/mailman/listinfo/openheart-l
> >>>
> >>> All messages transmitted by the OpenHeart-L are subject to the 
> >>> policies anddisclaimers posted at:
> >>> http://www.hsforum.com/listdisclaim
> >>> -----------------------------------------
> >>>
> >> _______________________________________________
> >> OpenHeart-L mailing list
> >>
> >> Send postings to:
> >> OpenHeart-L@lists.hsforum.com
> >>
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> >>
> >> All messages transmitted by the OpenHeart-L are subject to the 
> >> policies and disclaimers posted at:
> >> http://www.hsforum.com/listdisclaim
> >> -----------------------------------------
> >
> > _______________________________________________
> > OpenHeart-L mailing list
> >
> > Send postings to:
> > OpenHeart-L@lists.hsforum.com
> >
> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:
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> >
> > All messages transmitted by the OpenHeart-L are subject to the 
> > policies anddisclaimers posted at:
> > http://www.hsforum.com/listdisclaim
> > -----------------------------------------
> >
> _______________________________________________
> OpenHeart-L mailing list
> 
> Send postings to:
>  OpenHeart-L@lists.hsforum.com
> 
> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
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> disclaimers posted at:
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> -----------------------------------------

From prasannasimha at gmail.com  Fri Dec  1 22:43:58 2006
From: prasannasimha at gmail.com (prasannasimha)
Date: Fri Dec  1 12:14:12 2006
Subject: [HSF] RV failure management strategies
In-Reply-To: <284604891.1164987550219.JavaMail.root@fepweb01>
References: <284604891.1164987550219.JavaMail.root@fepweb01>
Message-ID: <457062D6.5080807@gmail.com>

Lost the battle. Was planning starting mechanical support when patients 
PA pressures shot up and became equisystemic and did not respond to iNO 
etc etc and followed by hemodynamic collapse.
Incidentally how late is late when starting RVAD. I would say earlier 
the better but how late could it still work ?
Prasanna
> It sounds like its going to be mechanical support or death.  I understand the reluctance to re-cannulate the right atrium, so use a long venous cannula throught the femoral or jugular vein.  I question the fear of cannulating the pulmonary artery with a small bore tube and suitably pledgeted purse string(s).  I also think that the RVAD flows don't need to be that high (1-2 liters per minute) with a centrifugal pump.  Heparinization at low levels should also be suitable.  On the other hand, if this is irreversable pulmonary vascular disease then your goose is cooked (American idiom).
>
> Ed Bender, MD
>
>
> ---- prasannasimha <prasannasimha@gmail.com> wrote: 
>   
>>  Why not an RA PA pump - Michael - her RA was plain friable and took 
>> plenty of time just to get hemostasis. (She was having a sky high CVP 
>> with blubbery tissues when I opened her initially itself) . I think I 
>> will have a mess if I touch her RA and PA now. She is still oozing at 
>> her puncture sites so heparinising her would be a big challenge for me. 
>> Blood products are difficult to obtain too so having her on RVAD would 
>> be ending in exsanguinating her in the situation I am in. At least now I 
>> have some things in control even if not really OK.
>> Prasanna
>>
>> Michael Firstenberg wrote:
>>     
>>> Hmmmm,
>>> Sounds like my kinda case - want to ship her to me?
>>>
>>> How come you dont want to run a RA-PV pump?
>>>
>>> Low platelets?
>>> HITTs?
>>>
>>> Just curious - how are you going to feed her?
>>>    I know a few people who like TPN (yuck yuck yuck) with open chests 
>>> to make nursing care easier and safer.
>>>
>>> Although, sounds like you are making progress -> winning the battle, 
>>> stay the course.
>>>
>>>
>>> -michael
>>>
>>>
>>>
>>> On Dec 1, 2006, at 9:43 AM, prasannasimha wrote:
>>>
>>>       
>>>> Michael,
>>>> She was a case of severe calcific MS with LA clot severe TR with 
>>>> pretty bad RV function. She was on inotropes prior to surgery and was 
>>>> in low output. She had a TIA and so was taken semi-emergently. She 
>>>> could not lie down and was urgently intubated and required  rapid 
>>>> institution of CPB. Surgery was pretty uneventful (No clot was seen 
>>>> in the LA and I presume it had embolized during the TIA) and the 
>>>> heart was contracting well as long as not loaded. While loading  The 
>>>> situation was good LV contractility, RV poor EF (on Echo) . Low LAP 
>>>> and high transpulmonary gradient. We initially managed by giving 
>>>> pulmonary vasodilators etc and had to give systemic vasoconstrictors 
>>>> to maintain the SVR which was low Tried to use iNO - did not help . 
>>>> We could wean off CPB and she was pretty coagulopathic and after the 
>>>> usual burn and stitch for a couple of hours (ill advisedly) closed 
>>>> her and had to immediately open her due to tamponade due to a clot 
>>>> over the PA. Kept the chest open.
>>>> At present she is still on multiple inotropes. CI is wavering between 
>>>> 2.4- 3.0. Bleeding seems to have stopped . I had opened up everything 
>>>> and washed the pericardium and sutured a plastic sheet back.
>>>> No evidence of sepsis.
>>>> I also like to "run em dry" and actually the patient is passing good 
>>>> urine and I have a PD catheter with mini-cycling to reduce 
>>>> edema.though she requires a CVP of around 12-14 to maintain 
>>>> hemodynamics. Her creat is pretty normal and her only abnormal 
>>>> parameter  are her platelets and bilirubn which is marginally high 
>>>> (probably going to keep rizing further!!)
>>>> I usually do not paralyze all open chests and keep them on Morphine 
>>>> and Ketamine infusions which usually deeply anesthetises them without 
>>>> the need to paralyze them. I have seen this been done with pediatric 
>>>> patients and they argue that "micromovements" is actually good in 
>>>> mobilizing tissue  edema by lymphatics.
>>>> (Patients actually do not move around when on the infusion but have 
>>>> preserved muscular tone if you get what I mean) though I do give them 
>>>> a relaxant if they breath spontaneously and this causes 
>>>> incoordination which they rarely do. One of my residents had lowered 
>>>> the drug infusion temporarily to see the CNS status !! That is how I 
>>>> know she was "awakable"
>>>> Did give her a shot of Methypred but no use.
>>>> RVAD in her is impractical for "practical" reasons. I have an IABP in 
>>>> place. I cannot do a bail out Glenn because her PVR is high.
>>>> At present following a wait and watch till edema comes down .
>>>> Prasanna
>>>>
>>>>
>>>>
>>>>
>>>> Michael Firstenberg wrote:
>>>>         
>>>>> Something does not quiet sound right with his hemodynamics - and 
>>>>> maybe I need to think about this more and look at the actual numbers.
>>>>> But, if your RV is failing - which it sounds like it is, then you 
>>>>> would have low preload delivered to the left heart and this should 
>>>>> (please all corrected me if I am wrong) result in a higher SVR as a 
>>>>> systemic compensatory measure.
>>>>>
>>>>> Coming into this a little late (missed some of the other comments)
>>>>> 1) Is your patient septic - and maybe the overall cardiac function 
>>>>> can not keep up enough
>>>>>     there may be a little zosyo-penia or the vanco receptors may not 
>>>>> be adequately saturated.
>>>>> 2) What is the renal function?
>>>>>     From what you are describing, probably poor - are you on CVVH yet?
>>>>>     If not - I am a firm believer of the voodoo of dialysis of "evil 
>>>>> humors"
>>>>>     If this is truly right heart failure - maybe getting volume off 
>>>>> acutely (even on tons of drugs) may bring you to a more favorable 
>>>>> part of the Starling curve
>>>>>     I have a little experience with acute ultra-filtration  (even 
>>>>> with "marginal urine output") is sucking some of these people dry 
>>>>> which works!
>>>>>        May cause ARF (which should improve with time?) - but your 
>>>>> current path will most likely knock out the beans forever
>>>>>        (better to have a live patient on dialysis than a potential 
>>>>> kidney donor?)
>>>>> 3) You said "open chest" and patient actually woke up.
>>>>>      Is it correct to assume that he/she is pharm. paralyized?
>>>>>     I have also seen more than a few patients with "lap-pad" 
>>>>> tamponade.  Even though the chest is open, there are too many or a 
>>>>> few stratigically placed pads (particularly if they are placed for 
>>>>> bleeding) than compress the RV.
>>>>> 4) Fixed-dilated pupils?
>>>>>     Hmmm - no idea, but it aint over til its over
>>>>>    I am sure we have all seen comatose patients wake up quite 
>>>>> contrary to the Glascow data (which I am sure have a reprint 
>>>>> somewhere knowing you - read: compliment)
>>>>> 5) Acute adrenal insuff.  ->  when in doubt, steroids
>>>>>     I had a medical school professor who said that no one should die 
>>>>> without the benefits of steroids.
>>>>>
>>>>> There seems to be a lot going on with your very sick patient and I 
>>>>> tossed out a few "kitchen" sink ideas.
>>>>>      yes, a RVAD/Ecmo may help - but does not solve all of your problem
>>>>>     though with an open chest an RA-RV circuit with stuff you have 
>>>>> around may be enough.
>>>>>
>>>>> I have seen a few recent "mazes" in otherwise healthy hearts have 
>>>>> similar problems - not sure what to make of it - anyone else?
>>>>>
>>>>>
>>>>>
>>>>> Good luck - keep us up to date
>>>>>
>>>>>
>>>>> -michael
>>>>>
>>>>>
>>>>>
>>>>> On Nov 30, 2006, at 9:40 PM, prasannasimha wrote:
>>>>>
>>>>>           
>>>>>> Can the list members enumerate their management strategies for RV 
>>>>>> failure.
>>>>>> This is for two reasons. _ one for th3e Wiki and presently
>>>>>> I have  a patient who was in low output  and taken for a semi 
>>>>>> emergency MVR with maze with TV plasty. Patient had RV dysfunction 
>>>>>> and congestive hepatopathy. Had a difficult wean - LV good but RV 
>>>>>> function was pretty poor. Patient is in coagulopathy which seems to 
>>>>>> have decreased .No mechanical problem on epicardial echo.
>>>>>> Patient has an open chest and has adequate CI (PA cath with CCO) 
>>>>>> has a high PVR and low SVR and is requiring multiple inotropes 
>>>>>> (Dopa = Dobut +Adrenaline + Norad +Milrinone and Vasopressin on one 
>>>>>> hand and multiple vasodilators on the other (getting constrictors 
>>>>>> via the central lumen of the IABP and dilators via the PA catheter) 
>>>>>> . I put the IABP as the patient has OK CI but low pressures due to 
>>>>>> a vasoplegic state and was worried that the coronary flow may not 
>>>>>> be adequate creating a vicious spiral 9and is helping in 
>>>>>> maintaining pressures).
>>>>>> Funny thing is patient has bilateral dilated and fixed pupils but 
>>>>>> has actually woken up once !! (On an infusion of morphine + Ketamine)
>>>>>> Prasanna
>>>>>> _______________________________________________
>>>>>> OpenHeart-L mailing list
>>>>>>
>>>>>> Send postings to:
>>>>>> OpenHeart-L@lists.hsforum.com
>>>>>>
>>>>>> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
>>>>>> http://mmp.cjp.com/mailman/listinfo/openheart-l
>>>>>>
>>>>>> All messages transmitted by the OpenHeart-L are subject to the 
>>>>>> policies and disclaimers posted at:
>>>>>> http://www.hsforum.com/listdisclaim
>>>>>> -----------------------------------------
>>>>>>             
>>>>> _______________________________________________
>>>>> OpenHeart-L mailing list
>>>>>
>>>>> Send postings to:
>>>>> OpenHeart-L@lists.hsforum.com
>>>>>
>>>>> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
>>>>> http://mmp.cjp.com/mailman/listinfo/openheart-l
>>>>>
>>>>> All messages transmitted by the OpenHeart-L are subject to the 
>>>>> policies anddisclaimers posted at:
>>>>> http://www.hsforum.com/listdisclaim
>>>>> -----------------------------------------
>>>>>
>>>>>           
>>>> _______________________________________________
>>>> OpenHeart-L mailing list
>>>>
>>>> Send postings to:
>>>> OpenHeart-L@lists.hsforum.com
>>>>
>>>> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
>>>> http://mmp.cjp.com/mailman/listinfo/openheart-l
>>>>
>>>> All messages transmitted by the OpenHeart-L are subject to the 
>>>> policies and disclaimers posted at:
>>>> http://www.hsforum.com/listdisclaim
>>>> -----------------------------------------
>>>>         
>>> _______________________________________________
>>> OpenHeart-L mailing list
>>>
>>> Send postings to:
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>>>
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>>>
>>> All messages transmitted by the OpenHeart-L are subject to the 
>>> policies anddisclaimers posted at:
>>> http://www.hsforum.com/listdisclaim
>>> -----------------------------------------
>>>
>>>       
>> _______________________________________________
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From msfirst at gmail.com  Fri Dec  1 12:18:45 2006
From: msfirst at gmail.com (Michael Firstenberg)
Date: Fri Dec  1 12:26:19 2006
Subject: [HSF] RV failure management strategies
In-Reply-To: <457062D6.5080807@gmail.com>
References: <284604891.1164987550219.JavaMail.root@fepweb01>
	<457062D6.5080807@gmail.com>
Message-ID: <EABCBE32-966C-4588-9AD7-B703BDBB65D6@gmail.com>

I my limited experience - it is never too late.
We had a young adult on an LVAD with a failing right heart and all of  
the systemic end-organ problems (and then some) to go along with it.   
We took him a week after his LVAD for a RVAD which helped greatly.

Your lady didnt have a PE?
   interesting with right heart failure - usually the PA pressures  
drop as the CVP goes up.  High PA pressures are not always bad as  
they tend to show some degree of functional reserve - although for  
how long, is unclear.

but you said she was oxygenating and ventilating ok?

hmmmm - very tough case


m


On Dec 1, 2006, at 12:13 PM, prasannasimha wrote:

> Lost the battle. Was planning starting mechanical support when  
> patients PA pressures shot up and became equisystemic and did not  
> respond to iNO etc etc and followed by hemodynamic collapse.
> Incidentally how late is late when starting RVAD. I would say  
> earlier the better but how late could it still work ?
> Prasanna
>> It sounds like its going to be mechanical support or death.  I  
>> understand the reluctance to re-cannulate the right atrium, so use  
>> a long venous cannula throught the femoral or jugular vein.  I  
>> question the fear of cannulating the pulmonary artery with a small  
>> bore tube and suitably pledgeted purse string(s).  I also think  
>> that the RVAD flows don't need to be that high (1-2 liters per  
>> minute) with a centrifugal pump.  Heparinization at low levels  
>> should also be suitable.  On the other hand, if this is  
>> irreversable pulmonary vascular disease then your goose is cooked  
>> (American idiom).
>>
>> Ed Bender, MD
>>
>>
>> ---- prasannasimha <prasannasimha@gmail.com> wrote:
>>>  Why not an RA PA pump - Michael - her RA was plain friable and  
>>> took plenty of time just to get hemostasis. (She was having a sky  
>>> high CVP with blubbery tissues when I opened her initially  
>>> itself) . I think I will have a mess if I touch her RA and PA  
>>> now. She is still oozing at her puncture sites so heparinising  
>>> her would be a big challenge for me. Blood products are difficult  
>>> to obtain too so having her on RVAD would be ending in  
>>> exsanguinating her in the situation I am in. At least now I have  
>>> some things in control even if not really OK.
>>> Prasanna
>>>
>>> Michael Firstenberg wrote:
>>>
>>>> Hmmmm,
>>>> Sounds like my kinda case - want to ship her to me?
>>>>
>>>> How come you dont want to run a RA-PV pump?
>>>>
>>>> Low platelets?
>>>> HITTs?
>>>>
>>>> Just curious - how are you going to feed her?
>>>>    I know a few people who like TPN (yuck yuck yuck) with open  
>>>> chests to make nursing care easier and safer.
>>>>
>>>> Although, sounds like you are making progress -> winning the  
>>>> battle, stay the course.
>>>>
>>>>
>>>> -michael
>>>>
>>>>
>>>>
>>>> On Dec 1, 2006, at 9:43 AM, prasannasimha wrote:
>>>>
>>>>
>>>>> Michael,
>>>>> She was a case of severe calcific MS with LA clot severe TR  
>>>>> with pretty bad RV function. She was on inotropes prior to  
>>>>> surgery and was in low output. She had a TIA and so was taken  
>>>>> semi-emergently. She could not lie down and was urgently  
>>>>> intubated and required  rapid institution of CPB. Surgery was  
>>>>> pretty uneventful (No clot was seen in the LA and I presume it  
>>>>> had embolized during the TIA) and the heart was contracting  
>>>>> well as long as not loaded. While loading  The situation was  
>>>>> good LV contractility, RV poor EF (on Echo) . Low LAP and high  
>>>>> transpulmonary gradient. We initially managed by giving  
>>>>> pulmonary vasodilators etc and had to give systemic  
>>>>> vasoconstrictors to maintain the SVR which was low Tried to use  
>>>>> iNO - did not help . We could wean off CPB and she was pretty  
>>>>> coagulopathic and after the usual burn and stitch for a couple  
>>>>> of hours (ill advisedly) closed her and had to immediately open  
>>>>> her due to tamponade due to a clot over the PA. Kept the chest  
>>>>> open.
>>>>> At present she is still on multiple inotropes. CI is wavering  
>>>>> between 2.4- 3.0. Bleeding seems to have stopped . I had opened  
>>>>> up everything and washed the pericardium and sutured a plastic  
>>>>> sheet back.
>>>>> No evidence of sepsis.
>>>>> I also like to "run em dry" and actually the patient is passing  
>>>>> good urine and I have a PD catheter with mini-cycling to reduce  
>>>>> edema.though she requires a CVP of around 12-14 to maintain  
>>>>> hemodynamics. Her creat is pretty normal and her only abnormal  
>>>>> parameter  are her platelets and bilirubn which is marginally  
>>>>> high (probably going to keep rizing further!!)
>>>>> I usually do not paralyze all open chests and keep them on  
>>>>> Morphine and Ketamine infusions which usually deeply  
>>>>> anesthetises them without the need to paralyze them. I have  
>>>>> seen this been done with pediatric patients and they argue that  
>>>>> "micromovements" is actually good in mobilizing tissue  edema  
>>>>> by lymphatics.
>>>>> (Patients actually do not move around when on the infusion but  
>>>>> have preserved muscular tone if you get what I mean) though I  
>>>>> do give them a relaxant if they breath spontaneously and this  
>>>>> causes incoordination which they rarely do. One of my residents  
>>>>> had lowered the drug infusion temporarily to see the CNS  
>>>>> status !! That is how I know she was "awakable"
>>>>> Did give her a shot of Methypred but no use.
>>>>> RVAD in her is impractical for "practical" reasons. I have an  
>>>>> IABP in place. I cannot do a bail out Glenn because her PVR is  
>>>>> high.
>>>>> At present following a wait and watch till edema comes down .
>>>>> Prasanna
>>>>>
>>>>>
>>>>>
>>>>>
>>>>> Michael Firstenberg wrote:
>>>>>
>>>>>> Something does not quiet sound right with his hemodynamics -  
>>>>>> and maybe I need to think about this more and look at the  
>>>>>> actual numbers.
>>>>>> But, if your RV is failing - which it sounds like it is, then  
>>>>>> you would have low preload delivered to the left heart and  
>>>>>> this should (please all corrected me if I am wrong) result in  
>>>>>> a higher SVR as a systemic compensatory measure.
>>>>>>
>>>>>> Coming into this a little late (missed some of the other  
>>>>>> comments)
>>>>>> 1) Is your patient septic - and maybe the overall cardiac  
>>>>>> function can not keep up enough
>>>>>>     there may be a little zosyo-penia or the vanco receptors  
>>>>>> may not be adequately saturated.
>>>>>> 2) What is the renal function?
>>>>>>     From what you are describing, probably poor - are you on  
>>>>>> CVVH yet?
>>>>>>     If not - I am a firm believer of the voodoo of dialysis of  
>>>>>> "evil humors"
>>>>>>     If this is truly right heart failure - maybe getting  
>>>>>> volume off acutely (even on tons of drugs) may bring you to a  
>>>>>> more favorable part of the Starling curve
>>>>>>     I have a little experience with acute ultra-filtration   
>>>>>> (even with "marginal urine output") is sucking some of these  
>>>>>> people dry which works!
>>>>>>        May cause ARF (which should improve with time?) - but  
>>>>>> your current path will most likely knock out the beans forever
>>>>>>        (better to have a live patient on dialysis than a  
>>>>>> potential kidney donor?)
>>>>>> 3) You said "open chest" and patient actually woke up.
>>>>>>      Is it correct to assume that he/she is pharm. paralyized?
>>>>>>     I have also seen more than a few patients with "lap-pad"  
>>>>>> tamponade.  Even though the chest is open, there are too many  
>>>>>> or a few stratigically placed pads (particularly if they are  
>>>>>> placed for bleeding) than compress the RV.
>>>>>> 4) Fixed-dilated pupils?
>>>>>>     Hmmm - no idea, but it aint over til its over
>>>>>>    I am sure we have all seen comatose patients wake up quite  
>>>>>> contrary to the Glascow data (which I am sure have a reprint  
>>>>>> somewhere knowing you - read: compliment)
>>>>>> 5) Acute adrenal insuff.  ->  when in doubt, steroids
>>>>>>     I had a medical school professor who said that no one  
>>>>>> should die without the benefits of steroids.
>>>>>>
>>>>>> There seems to be a lot going on with your very sick patient  
>>>>>> and I tossed out a few "kitchen" sink ideas.
>>>>>>      yes, a RVAD/Ecmo may help - but does not solve all of  
>>>>>> your problem
>>>>>>     though with an open chest an RA-RV circuit with stuff you  
>>>>>> have around may be enough.
>>>>>>
>>>>>> I have seen a few recent "mazes" in otherwise healthy hearts  
>>>>>> have similar problems - not sure what to make of it - anyone  
>>>>>> else?
>>>>>>
>>>>>>
>>>>>>
>>>>>> Good luck - keep us up to date
>>>>>>
>>>>>>
>>>>>> -michael
>>>>>>
>>>>>>
>>>>>>
>>>>>> On Nov 30, 2006, at 9:40 PM, prasannasimha wrote:
>>>>>>
>>>>>>
>>>>>>> Can the list members enumerate their management strategies  
>>>>>>> for RV failure.
>>>>>>> This is for two reasons. _ one for th3e Wiki and presently
>>>>>>> I have  a patient who was in low output  and taken for a semi  
>>>>>>> emergency MVR with maze with TV plasty. Patient had RV  
>>>>>>> dysfunction and congestive hepatopathy. Had a difficult wean  
>>>>>>> - LV good but RV function was pretty poor. Patient is in  
>>>>>>> coagulopathy which seems to have decreased .No mechanical  
>>>>>>> problem on epicardial echo.
>>>>>>> Patient has an open chest and has adequate CI (PA cath with  
>>>>>>> CCO) has a high PVR and low SVR and is requiring multiple  
>>>>>>> inotropes (Dopa = Dobut +Adrenaline + Norad +Milrinone and  
>>>>>>> Vasopressin on one hand and multiple vasodilators on the  
>>>>>>> other (getting constrictors via the central lumen of the IABP  
>>>>>>> and dilators via the PA catheter) . I put the IABP as the  
>>>>>>> patient has OK CI but low pressures due to a vasoplegic state  
>>>>>>> and was worried that the coronary flow may not be adequate  
>>>>>>> creating a vicious spiral 9and is helping in maintaining  
>>>>>>> pressures).
>>>>>>> Funny thing is patient has bilateral dilated and fixed pupils  
>>>>>>> but has actually woken up once !! (On an infusion of morphine  
>>>>>>> + Ketamine)
>>>>>>> Prasanna
>>>>>>> _______________________________________________
>>>>>>> OpenHeart-L mailing list
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From ebender001 at charter.net  Fri Dec  1 09:32:04 2006
From: ebender001 at charter.net (ebender001@charter.net)
Date: Fri Dec  1 12:32:20 2006
Subject: [HSF] RV failure management strategies
Message-ID: <337790792.1164994324808.JavaMail.root@fepweb01>

Prasanna,
Sorry to hear about your loss.  Your humanism comes through your writings.  I can not say how late is too late, since I have only placed VADS (non-transplant candidates) at the time of the failure to adequately come off bypass.  However, if you can extrapolate to the Abiomed LVAD experiences, the survival goes way down if not placed at the time of the initial bypass run.

Ed Bender, MD


---- prasannasimha <prasannasimha@gmail.com> wrote: 
> Lost the battle. Was planning starting mechanical support when patients 
> PA pressures shot up and became equisystemic and did not respond to iNO 
> etc etc and followed by hemodynamic collapse.
> Incidentally how late is late when starting RVAD. I would say earlier 
> the better but how late could it still work ?
> Prasanna
> > It sounds like its going to be mechanical support or death.  I understand the reluctance to re-cannulate the right atrium, so use a long venous cannula throught the femoral or jugular vein.  I question the fear of cannulating the pulmonary artery with a small bore tube and suitably pledgeted purse string(s).  I also think that the RVAD flows don't need to be that high (1-2 liters per minute) with a centrifugal pump.  Heparinization at low levels should also be suitable.  On the other hand, if this is irreversable pulmonary vascular disease then your goose is cooked (American idiom).
> >
> > Ed Bender, MD
> >
> >
> > ---- prasannasimha <prasannasimha@gmail.com> wrote: 
> >   
> >>  Why not an RA PA pump - Michael - her RA was plain friable and took 
> >> plenty of time just to get hemostasis. (She was having a sky high CVP 
> >> with blubbery tissues when I opened her initially itself) . I think I 
> >> will have a mess if I touch her RA and PA now. She is still oozing at 
> >> her puncture sites so heparinising her would be a big challenge for me. 
> >> Blood products are difficult to obtain too so having her on RVAD would 
> >> be ending in exsanguinating her in the situation I am in. At least now I 
> >> have some things in control even if not really OK.
> >> Prasanna
> >>
> >> Michael Firstenberg wrote:
> >>     
> >>> Hmmmm,
> >>> Sounds like my kinda case - want to ship her to me?
> >>>
> >>> How come you dont want to run a RA-PV pump?
> >>>
> >>> Low platelets?
> >>> HITTs?
> >>>
> >>> Just curious - how are you going to feed her?
> >>>    I know a few people who like TPN (yuck yuck yuck) with open chests 
> >>> to make nursing care easier and safer.
> >>>
> >>> Although, sounds like you are making progress -> winning the battle, 
> >>> stay the course.
> >>>
> >>>
> >>> -michael
> >>>
> >>>
> >>>
> >>> On Dec 1, 2006, at 9:43 AM, prasannasimha wrote:
> >>>
> >>>       
> >>>> Michael,
> >>>> She was a case of severe calcific MS with LA clot severe TR with 
> >>>> pretty bad RV function. She was on inotropes prior to surgery and was 
> >>>> in low output. She had a TIA and so was taken semi-emergently. She 
> >>>> could not lie down and was urgently intubated and required  rapid 
> >>>> institution of CPB. Surgery was pretty uneventful (No clot was seen 
> >>>> in the LA and I presume it had embolized during the TIA) and the 
> >>>> heart was contracting well as long as not loaded. While loading  The 
> >>>> situation was good LV contractility, RV poor EF (on Echo) . Low LAP 
> >>>> and high transpulmonary gradient. We initially managed by giving 
> >>>> pulmonary vasodilators etc and had to give systemic vasoconstrictors 
> >>>> to maintain the SVR which was low Tried to use iNO - did not help . 
> >>>> We could wean off CPB and she was pretty coagulopathic and after the 
> >>>> usual burn and stitch for a couple of hours (ill advisedly) closed 
> >>>> her and had to immediately open her due to tamponade due to a clot 
> >>>> over the PA. Kept the chest open.
> >>>> At present she is still on multiple inotropes. CI is wavering between 
> >>>> 2.4- 3.0. Bleeding seems to have stopped . I had opened up everything 
> >>>> and washed the pericardium and sutured a plastic sheet back.
> >>>> No evidence of sepsis.
> >>>> I also like to "run em dry" and actually the patient is passing good 
> >>>> urine and I have a PD catheter with mini-cycling to reduce 
> >>>> edema.though she requires a CVP of around 12-14 to maintain 
> >>>> hemodynamics. Her creat is pretty normal and her only abnormal 
> >>>> parameter  are her platelets and bilirubn which is marginally high 
> >>>> (probably going to keep rizing further!!)
> >>>> I usually do not paralyze all open chests and keep them on Morphine 
> >>>> and Ketamine infusions which usually deeply anesthetises them without 
> >>>> the need to paralyze them. I have seen this been done with pediatric 
> >>>> patients and they argue that "micromovements" is actually good in 
> >>>> mobilizing tissue  edema by lymphatics.
> >>>> (Patients actually do not move around when on the infusion but have 
> >>>> preserved muscular tone if you get what I mean) though I do give them 
> >>>> a relaxant if they breath spontaneously and this causes 
> >>>> incoordination which they rarely do. One of my residents had lowered 
> >>>> the drug infusion temporarily to see the CNS status !! That is how I 
> >>>> know she was "awakable"
> >>>> Did give her a shot of Methypred but no use.
> >>>> RVAD in her is impractical for "practical" reasons. I have an IABP in 
> >>>> place. I cannot do a bail out Glenn because her PVR is high.
> >>>> At present following a wait and watch till edema comes down .
> >>>> Prasanna
> >>>>
> >>>>
> >>>>
> >>>>
> >>>> Michael Firstenberg wrote:
> >>>>         
> >>>>> Something does not quiet sound right with his hemodynamics - and 
> >>>>> maybe I need to think about this more and look at the actual numbers.
> >>>>> But, if your RV is failing - which it sounds like it is, then you 
> >>>>> would have low preload delivered to the left heart and this should 
> >>>>> (please all corrected me if I am wrong) result in a higher SVR as a 
> >>>>> systemic compensatory measure.
> >>>>>
> >>>>> Coming into this a little late (missed some of the other comments)
> >>>>> 1) Is your patient septic - and maybe the overall cardiac function 
> >>>>> can not keep up enough
> >>>>>     there may be a little zosyo-penia or the vanco receptors may not 
> >>>>> be adequately saturated.
> >>>>> 2) What is the renal function?
> >>>>>     From what you are describing, probably poor - are you on CVVH yet?
> >>>>>     If not - I am a firm believer of the voodoo of dialysis of "evil 
> >>>>> humors"
> >>>>>     If this is truly right heart failure - maybe getting volume off 
> >>>>> acutely (even on tons of drugs) may bring you to a more favorable 
> >>>>> part of the Starling curve
> >>>>>     I have a little experience with acute ultra-filtration  (even 
> >>>>> with "marginal urine output") is sucking some of these people dry 
> >>>>> which works!
> >>>>>        May cause ARF (which should improve with time?) - but your 
> >>>>> current path will most likely knock out the beans forever
> >>>>>        (better to have a live patient on dialysis than a potential 
> >>>>> kidney donor?)
> >>>>> 3) You said "open chest" and patient actually woke up.
> >>>>>      Is it correct to assume that he/she is pharm. paralyized?
> >>>>>     I have also seen more than a few patients with "lap-pad" 
> >>>>> tamponade.  Even though the chest is open, there are too many or a 
> >>>>> few stratigically placed pads (particularly if they are placed for 
> >>>>> bleeding) than compress the RV.
> >>>>> 4) Fixed-dilated pupils?
> >>>>>     Hmmm - no idea, but it aint over til its over
> >>>>>    I am sure we have all seen comatose patients wake up quite 
> >>>>> contrary to the Glascow data (which I am sure have a reprint 
> >>>>> somewhere knowing you - read: compliment)
> >>>>> 5) Acute adrenal insuff.  ->  when in doubt, steroids
> >>>>>