[HSF] Aortic purse strings in thin large aortas.

[jbflegejr at aol.com]

I was calling the stab wound an incision, in fact it is even if small 
and by vertical I mean linear or in line with the aorta. John

-----Original Message-----
From: prasannasimha at gmail.com
To: OpenHeart-L at lists.hsforum.com
Sent: Sun, 3 Dec 2006 10:15 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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