[HSF] Valve Dysfunction - failure of Closure

[Nasser F. Abou'Seada]

Dear Roberto 
1) The pace of events was too rapid to look for TEE .... 
2) by the time patient was taken to OR,  time was lost ..... !!!
3) I quite agree with you about speedy emergency cannulation with the chest
open ... needs 2 stabs, a mosquito and an extra pair of hands .... however
.... this requires the surgeon to be THERE .... with cannula in hand,
scalpel in other hand .... cannulae in place .... then it would take a
minute .... getting to get all that ready ... would take 10-15 minutes ... a
big difference .... and ..... it was done ... yet failed ...!!

4) I quite concur with you regarding the second technique .... that would
require having the luxury of having the patient stable -even by CPR- ....
which apparently was not the case .... 

NFA

> From: Dr. Roberto Battellini
> To both, Nasser and Prasanna,
> 1. the first thing to do was TEE, if possible. 2. the second was correct,
to
> take the patient to OR, discard tamponade, put the patient on pump and
check
> the valve. If I have 2 assistants, after resternotomy I don´t make any
> purse, just open the aorta with scalpel, cannulate the aorta with a stab,
> then giving the cannula to one assistant, and proceed with right atrium
like
> Prasanna wrote. All this needs 10 minutes, which may be a long time
> sometimes, so.. .
> 2. Another way in HZL is to cannulate femorals while another team is
> reanimating the chest. It´s up to the surgeon to choice upon this 2
methods.
> 
> Dear Prasanna, I tried to comment your cannulation on wiki, but I need a
> code number, how can I get it?
> Roberto
> 
> -----Ursprüngliche Nachricht-----
> Von: openheart-l-bounces at lists.hsforum.com
> [mailto:openheart-l-bounces at lists.hsforum.com] Im Auftrag von
prasannasimha
> Gesendet: Dienstag, 12. Dezember 2006 10:28
> An: OpenHeart-L at lists.hsforum.com
> Betreff: 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_Arterial_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