[HSF] RV failure management strategies

Sat Dec 2 10:36:47 EST 2006

Sir,

I am sorry for your case. Teaching for me is simple. In 
difficult cases -never do more than enough-. I would rather 
amiodarone in place of maze procedure, it take much more 
aortic cross clamp time. Doble valves take 60 minutes of Ao 
XC time and if your go for MV replacement and TV plasty, 
any, De Vega of Mac Kay or both with heart beating your 
time could be 30 or  40 minutes with cardiac arrest. I was 
trained with Dr Denton A Cooley al THI, and something that I 
learned -of hundred of things learned- was Short Ao XC 
times has better results and there is not better myocardial 
protection than ... Short times. In sick patients -Do Not Do 
More Than Enough-. Prevention of complications is allways 
better than treating them.

Alejandro Rey
University of Mexico.

> ----- Original Message -----
> From: prasannasimha <prasannasimha at gmail.com>
> To: OpenHeart-L at lists.hsforum.com
> Subject: Re: [HSF] RV failure management strategies
> Date: Sat, 02 Dec 2006 07:02:06 +0530
> 
> 
> 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.
> > _______________________________________________
> > OpenHeart-L mailing list
> >
> > Send postings to:
> >  OpenHeart-L at 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 at 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
> -----------------------------------------

>

-- 
_______________________________________________
http://mail.mexico.com
¡Disponible Ya! Utiliza el Outlook y Outlook Express para bajar tus correos por solo US$24.95 al año

Now available! Download your mail into your computer with Outlook and Outlook Express US$24.95/yr