[HSF] RV failure management strategies

[prasannasimha]

I thought of possibility of air (though my heart was pretty well 
vigorously beating after release of the clamp) when I started having 
problems I did think of possible RCA embolism though there were no ST's 
I had given retrograde and  I usually extend it for one minute after 
removing the X clamp so since retrograde was going on air in the 
coronaries may have been less likely. I had given a period of hyper 
perfusion when things started going wrong (to push possible air "down 
the coronaries) and a 20 mic adrenaline bolus to "shatter" the bubbles 
with hyper contraction.
Clot embolism to the RCA is a distinct possibility. Any way how do we 
fix a trash heart in this setting ? (I can think of using a retrograde 
to "flush " the system as has been described in coronaries) if the 
embolism is pretty distal things would be pretty bad. (Incidentally the 
RV was pink when the X clamp was removed and spontaneous contraction 
returned )
At the end of the day it may have even been a poor RV that was just 
"doggone bad" !!
Prasanna

Rwmfglycar at aol.com wrote:
> Sorry about your case Prasanna. A few random comments:
> I documented a case once in which R coronary air embolism occurred (in the  
> days before we worked out how to prevent that).
> The RV dilated and started to contract poorly. Tric Regurg appeared. The  
> Cardiac output and the RV systolic pressure fell substantially (and  
> simultaneously). Return to bypass and using high aortic pressure to drive the  air through 
> while the RV was being supported produced complete recovery. 
> I think you said you saw LA thrombus preoperatively but it had disappeared.  
> Could the thrombus that disappeared from the LA have embolized the RCA?
> Tom Salerno mentioned RCA obstruction in conjunction with aortic valve  
> repl.as a mechanism.
> The paradoxical rise in PA resistance that we have all seen in these cases  
> has many more pharmacological remedies than it once had. In one young patient 
> in  whom the preop  systemic level PA pressures went to suprasystemic post op I 
>  was able to manage without ever closing the chest  by keeping the  patient 
> on bypass for 9 further hours, checking hourly on the level of PA  resistance 
> until it dropped to a tolerable level. She was wide awake the  next day. At 
> that time we had none of the modern agents.
> In my experience any time there is Tric. Regurg. preop there is reduced RV  
> function already.
> Fixing the Tric will help but in the patients with sick ventricles the  
> function does not necessarily and certainly not immediately recover; this means  
> that intense concentration on RV function in the bypass weaning process is  
> essential, with great attention paid to titrating the R ventricular filling  
> pressures, the R ventricular dimensions and contractility and the cardiac  output. 
> There are times when the RV performance will determine outcome. I  am sure 
> this does not apply to you but I have seen the systemic pressure being  used as 
> the mark of satisfactory performance the inevitable consequence  being RV 
> collapse a while later.
> Yours
> Bob.
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