[HSF] Valve Dysfunction - failure of Closure

[Nasser F. Abou'Seada]

Dear Roberto 
I quite agree with you regarding No 3 and No 4 ..... we've done that many
times in other situations .... yet in this case in particular I think the
attending was not mentally swift enough as to face the situation in SECONDS
... partly as the patient was OK to be transferred to HDU next morning ....
and partly cause he went classically .... CPR and transfer to OR ... losing
precious time ....

my question is ... would it had been different should the patient have been
opened on bed just to thrust the aortic annulus to dislodge the
dysfunctional leaflet ???? ... CPB could have been instituted then at pace
???

NFA

> From: Dr. Roberto Battellini
> Nasser,
> you are right, I forgot to tell, Nr 3 in HZL in desperate situations is to
> bring the pump to ICU and do all that there. Sometimes it is the only way,
> but another Nr 4 is to take the bed to OR and do the reop on patient bed
in
> OR. We have done all that.
> 
> As our mostly implanted valves are biological and also all valve patients
> are TEE controlled, inclusively the coronary ostiae, air, function, leaks,
> gradients, we do not see this problem.
> Roberto
> 
> Von: 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
> 
> > 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