[HSF] RV failure management strategies

Sat Dec 2 08:17:56 EST 2006

I agree but the method of electrocautery maze which I use is actually a 
method that doesn't "extend " the Xclamp time because the first half is 
done while the heart is beating and the second half (the left ) is done 
during periods of cardioplegia delivery (I have published it in the HSF 
journal and is not a cut and sew technique and uses monopolar cautery). 
If I have a problem in hemodynamics in sinus rhythm I cannot think it 
will be better with Afib. (Incidentally your country mate Dr Ovidio 
Garcia Villareal has used my Afib technique and has made a video that 
has been posted on the HSF website) - Ovidio doesn't seem to be active 
in the forum of late - Ovidio - are you there ?)
 The TV plasty was done on a beating heart (goretex strip and not ring)
Prasanna

Alejandro Rey wrote:
> 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.
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