[HSF] Valve Dysfunction - failure of Closure

[Nasser F. Abou'Seada]

Dear Prasanna thanks for your quick reply. 
I do concur with you about the -supposed to be- management. only one point
.... by the time the patient was taken to the OR it had been already late
.... it'd take almost 15 minutes to move the patient, disconnect lines, rush
to OR -same corridor- get patient draped, open the skin, cut sternal wires
.. get patient lines connected .. and during the period of opening the chest
there is effectively no CPR ..... !! ... also during the period of trying to
cannulate the aorta ... !!!

to my mind Percutaneous cannulation would take longer time ... especially
with hypotension .... and collapsed femoral vessels ... that is in case the
cannulae are readily available .... 

I do agree with your thoughts about giving a thrust to the chest to dislodge
the dysfunctional leaflet ...... yet it did not work .... 

my query, thought It was not done ..... should that patient have been opened
on bed just to expose the aorta and a manual thrust given to the aorta just
to dislodge the dysfunctional leaflet out of position ??? ... as a quick
maneuver to buy time till cannulation in OR ir feasible at leisure !!

Unfortunately what I figured was not done ... and classical maneuvers were
tried .... leading -to my mind- to loss of time ......
I'm not sure whether what I have thought would have been successful ....
however .... we lost the patient at the end ...!!

NFA

> -----Original Message-----
> From: openheart-l-bounces at lists.hsforum.com [mailto:openheart-l-
> bounces at lists.hsforum.com] On Behalf Of prasannasimha
> Sent: Tuesday, December 12, 2006 4:28 AM
> To: OpenHeart-L at lists.hsforum.com
> Subject: Re: [HSF] Valve Dysfunction - failure of Closure
> 
> Nasser,
> That was obviously some form of acute prosthetic dysfunction.
> Electromechanical dissociation when documented in the absence of
> tamponade is diagnostic of this and that is what has happened to your
> patient.
> Sometimes a short burst of CPR  dislodges the leaflet only to be
> entrapped again. The only thing that can be done is to place the patient
> emergently on CPB.
> Emergent placement in a hypotensive aorta can be difficult because
> pushing the cannula in through the small hole may actually push the
> aorta towards the posterior wall rather than allowing intraluminal
> placement. In this case it is better to have one wide purse string, cut
> all the older purse strings , dilate the aortic incision with an artery
> forceps and visually place the cannula in. Hurrying only makes the
> situation worse. The RA can then be stabbed and the effluent can be use
> for sucker bypass to establish partial CPB till formal venous
> cannulation can be done.
> Another alternative is to consider fem fem bypass with percut cannulae
> if femoral vascular access is easily available (for eg though the
> arterial line a guide wire can be placed and similarly through the
> jugular a venous cannula may be placed - this is subject to the cannulae
> being easily available.
> One very important thing in prosthetic dysfunction in closed position is
> to vent the heart as soon as possible or else the heart muscle will be
> very severely injured (if it hasn't occurred already)
> I have added cannulation of the hypotensive aorta in the Wiki.
>
http://ctsurgcomplications.wikia.com/index.php?title=Complications_related_t
o_Arteri
> al_cannulation&action=edit&section=5
> Prasanna
> 
> Nasser F. Abou'Seada wrote:
> > I'd like to ask for the opinion of the forum members in a case of an
adult
> > male patient, postoperative day 1, after AVR for rheumatic AVD,
Mechanical
> > bileaflet prosthesis, simple procedure, totally stable, off ventilator,
> > speaking, to be transferred to HDU next morning. He was reported from
CSICU
> > as being speechless for 2-3 seconds, during which his eyes were widely
open,
> > gazing upwards, then returns back in 2-3 seconds totally normal. blood
> > pressure curve on monitor disappeared for a second.
> > What is to be done ??
> >
> > in a few minutes, before doing the ECHO, the attack was repeated twice
in a
> > minute.
> > ?? reaction ???
> >
> > in a few minutes the attack was repeated but never resolved back. Heart
> > beating, No clicking valve on auscultation, pressure curve up and down.
> >
> > Patient was re-intubated. CPR started,
> > What is to be done then ??
> >
> > Hanging of the valve leaflets with failure to close was suspected first
> > time. Echo -ready next room- was requested, yet second attack happened
> > before echo was done.
> > Third time, the patient never came back, heart was beating vigorously,
no BP
> > curve, no clicking of the valve. rapid intubation with CPR initiated,
yet
> > never came back ....
> > Faculty on call took the patient immediately to OR .... where the chest
was
> > opened and patient was tried to be got on bypass ..... the aorta was so
soft
> > to be cannulated ..... precious minutes were lost during trials of
> > cannulation. Pupils were dilated fixed already when aorta was cannulated
at
> > last. Patient never made it back.
> >
> > Opinions about what should have been done ....?? ...... comments ????
> >
> > NFA
> >
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