[HSF] Aortic purse strings in thin large aortas.

Mon Dec 4 05:46:56 EST 2006

Not how to put the incision - I think most of us cannulate with a 
transverse incision isn't it ?
Prasanna
Tea Acuff wrote:
> If you use a knife, turn the knife blade.
> tea
>
>
> ----- Original Message ----
> From: prasannasimha <prasannasimha at gmail.com>
> To: OpenHeart-L at lists.hsforum.com
> Sent: Sunday, December 3, 2006 9:15:47 AM
> Subject: Re: [HSF] Aortic purse strings in thin large aortas.
>
>
> How does one cannulate with a vertical incision on the aorta - never 
> done it.
> Prasanna
>
> jbflegejr at aol.com wrote:
>   
>> 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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