[HSF] Aortic purse strings in thin large aortas.

[jbflegejr at aol.com]

Your point about reducing the arterial blood pressure while tying the 
suture is most important. To do this, I apply a clamp to the inferior 
vena cava, when the systolic pressure is around 70, cinch the knot and 
release the clamp at the same time, the whole sequence taking about 15 
seconds. I think that a transverse incision is safer than a vertical 
incision; former has less bursting force on the closure. Another way of 
reducing the blood pressure, particularly when it is very high, is 
ventricular pacing at a rapid rate, say 150, which will usually 
abruptly produce a fall in pressure and is quickly reversible. John 
Flege

-----Original Message-----
From: prasannasimha at gmail.com
To: OpenHeart-L at lists.hsforum.com
Sent: Sat, 2 Dec 2006 10:38 PM
Subject: Re: [HSF] Aortic purse strings in thin large aortas.

    I use 3/0 for adults and 4/0 or 5/0 in children depending on the 
size (2 purse strings) I put a third Z stitch after cannula removal. I 
haven't had any real major problems with this. I do use a 
pericardial/Teflon pledget on my third Z stitch if there is bleeding. 
  One important thing is that if there is bleeding it is important to 
cut open the surrounding adventitia to prevent a "blue bleb" 
dissection. The subsequent bites can imbricate this lifted adventitial 
along with a pledget as something like a reverse Floten flap. 
  I do disagree with the pledget causing bleeding underneath concept. I 
have had some of my teachers say this and was not using pledgets but 
later realized they were wrong. Precisely placed pledgetted sutures can 
be a god send . They also minimize cutting through if the aorta is 
thin. 
  One little trick is to make a longer strip of pericardium (roughly 
more than double the regular pledget. Use one end as a pledget and take 
the needles through the tissue and then pass the needles into the 
remaining part of the pericardium. This folds up the pericardium and 
acts as a local patch which works very well. I hope this description 
can be translated into the mind's eye. This has worked many a time when 
there has been bleeding. 
  Caveats to managing this are to reduce the pressure - head up and SNP 
usually works and it is good to get the pressures below 90 and better 
still in the 60's.But if the dP/dT is really high based on the 
vigorousness of cardiac contractions temporary rapid ventricular pacing 
at 180 -200 beats or a short period of fibrillation - defibrillation 
may be used conveniently. 
  If it still persist there is tension on the aorta and then you must 
consider patching it - either with a large piece of pericardium over 
the whole area or femoral bypass with open patching - something which 
all of us should pray we needn't have to do. 
  The best thing even in thin aortae is to avoid piercing through and 
through when taking a purse string. Care taken initially goes a really 
long way. 
  A Marfan aorta must be pledgetted. It just hasn't got intrinsic 
strength of its own. 
 
 Prasanna 
 
 sekhar le wrote: 
  > We use 5/0 prolene for all aortic purse strings. We use finer > 
sutures with the idea that needle holes of bigger sutures cause more > 
bleeding before they are not tied. 
  > we do not use pledgets with the idea that when there is bleeding the 
> pledgets obscure the exact source of bleeding. 
 > 
  > With this approach we do not have problems in normal sized aortas > 
but we do have occasional problems in thin large aortas. 
 > 
 > I would like to know what others use for large thin aortas. 
 > 
 > 
 > Dr Sekhar 
 > 
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