(OT)Re: [HSF] Valve Dysfunction - failure of Closure

Tue Dec 12 21:05:39 EST 2006

Michael - is that postVAD depression going on ?? ;-)
Prasanna

Michael Firstenberg wrote:
> I think if you need ECMO that emergently then it is usually futile - 
> in part
> once people know that you provide that service then every 80 year/old
> demented patient with end-stage cancer who codes gets an ECMO-consult.
> Sometimes not having something instantly available at least gives 
> rational
> people time to think of a rational plan while people are driving in.
>
> Just my humble thoughts.
>
>
> -michael
>
>
> On 12/12/06, Tea Acuff <tacuff at swbell.net> wrote:
>>
>> An interesting recommendation. Not only do we not have a perfusionist
>> 24x7, we do not have OR nurses, surgeons, assistants, etc. Further we 
>> would
>> have had to pay a perfusionist for the past ten years without ever 
>> having
>> seen this "indication" for ECMO.
>> tea
>>
>>
>> ----- Original Message ----
>> From: prasannasimha <prasannasimha at gmail.com>
>> To: OpenHeart-L at lists.hsforum.com
>> Sent: Tuesday, December 12, 2006 6:55:58 AM
>> Subject: Re: [HSF] Valve Dysfunction - failure of Closure
>>
>>
>> Probably the only way to salvage such patients realistically is if you
>> follow a protocol  of keeping an ECMO circuit primed and ready 24X7X12
>> ads is done in Boston children's Hospital so that CPB becomes an
>> essential part of any failed CODE. How many hospitals have the
>> capability and actually practice having such a setup with an available
>> perfusionist ready on call 24X7X12.
>> Dr Richard Jonas  had once commented (when he was there) that providing
>> this was becoming difficult there due to  the lower number of foreign
>> medical graduates joining their program (due to Visa problems) and
>> lesser number of Residents joining cardiac (especially pediatric)
>> cardiac surgery.
>> How many readers have this facility ?
>> We do not have it.
>> Prasanna
>> prasannasimha wrote:
>> > Nasser opening the chest in the ICU should never be an issue it would
>> > have been a part of the management but whether it would have altered
>> > the outcome is questionable. More important was the rapid institution
>> > of bypass by whatever means.
>> > As far as Percut CPB is concerned, I was referring to the option if
>> > some sheath or A line was in place. Exchanging over a guide wire even
>> > with a fully arrested patient would then not be a problem. Even with
>> > this, venting the distending heart is still paramount as we are
>> > crushing away the muscle with every beat against a closed door.
>> > We had a bad experience  like this (around 10 years back) but occurred
>> > in the OR and was salvaged. My colleague  had operated on a case when
>> > this situation you described happened.
>> > When we went back on CPB we saw that  one of the sutures was slightly
>> > longer and was above the equator of the sewing rim. This permitted one
>> > of the suture ends to insinuate itself in the hinge mechanism and was
>> > remedied by tucking this suture and fixing it with 6/0 away from the
>> > sewing rim.
>> > The rule thereafter in MVR - place the sutures below the equator of
>> > the sewing rim in AVR (ie such that any suture ends would point
>> > radially away) and leave no redundant ends. I stress that to all my
>> > students and we stopped seeing that problem again.
>> > Prasanna
>> > Nasser F. Abou'Seada wrote:
>> >> 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
>> >>>>
>> >>>> _______________________________________________
>> >>>> OpenHeart-L mailing list
>> >>>>
>> >>>> Send postings to:
>> >>>>  OpenHeart-L at lists.hsforum.com
>> >>>>
>> >>>> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
>> >>>> http://mmp.cjp.com/mailman/listinfo/openheart-l
>> >>>>
>> >>>> All messages transmitted by the OpenHeart-L are subject to the
>> >>>> policies
>> >>>>
>> >> and
>> >>
>> >>>> disclaimers posted at:
>> >>>> http://www.hsforum.com/listdisclaim
>> >>>> -----------------------------------------
>> >>>>
>> >>>>
>> >>>>
>> >>>>
>> >>> _______________________________________________
>> >>> OpenHeart-L mailing list
>> >>>
>> >>> Send postings to:
>> >>>  OpenHeart-L at lists.hsforum.com
>> >>>
>> >>> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
>> >>> http://mmp.cjp.com/mailman/listinfo/openheart-l
>> >>>
>> >>> All messages transmitted by the OpenHeart-L are subject to the
>> policies
>> >>>
>> >> and
>> >>
>> >>> disclaimers posted at:
>> >>> http://www.hsforum.com/listdisclaim
>> >>> -----------------------------------------
>> >>>
>> >>
>> >> _______________________________________________
>> >> OpenHeart-L mailing list
>> >>
>> >> Send postings to:
>> >>  OpenHeart-L at lists.hsforum.com
>> >>
>> >> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
>> >> http://mmp.cjp.com/mailman/listinfo/openheart-l
>> >>
>> >> All messages transmitted by the OpenHeart-L are subject to the
>> >> policies and disclaimers posted at:
>> >> http://www.hsforum.com/listdisclaim
>> >> -----------------------------------------
>> >>
>> >>
>> >>
>> >
>> > _______________________________________________
>> > OpenHeart-L mailing list
>> >
>> > Send postings to:
>> > OpenHeart-L at lists.hsforum.com
>> >
>> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:
>> > http://mmp.cjp.com/mailman/listinfo/openheart-l
>> >
>> > All messages transmitted by the OpenHeart-L are subject to the
>> > policies and disclaimers posted at:
>> > http://www.hsforum.com/listdisclaim
>> > -----------------------------------------
>> >
>> >
>>
>> _______________________________________________
>> OpenHeart-L mailing list
>>
>> Send postings to:
>> OpenHeart-L at lists.hsforum.com
>>
>> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
>> http://mmp.cjp.com/mailman/listinfo/openheart-l
>>
>> All messages transmitted by the OpenHeart-L are subject to the policies
>> and
>> disclaimers posted at:
>> http://www.hsforum.com/listdisclaim
>> -----------------------------------------
>> _______________________________________________
>> OpenHeart-L mailing list
>>
>> Send postings to:
>> OpenHeart-L at lists.hsforum.com
>>
>> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
>> http://mmp.cjp.com/mailman/listinfo/openheart-l
>>
>> All messages transmitted by the OpenHeart-L are subject to the policies
>> and
>> disclaimers posted at:
>> http://www.hsforum.com/listdisclaim
>> -----------------------------------------
>>
> _______________________________________________
> OpenHeart-L mailing list
>
> Send postings to:
> OpenHeart-L at lists.hsforum.com
>
> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
> http://mmp.cjp.com/mailman/listinfo/openheart-l
>
> All messages transmitted by the OpenHeart-L are subject to the 
> policies and disclaimers posted at:
> http://www.hsforum.com/listdisclaim
> -----------------------------------------
>