[HSF] Valve Dysfunction - failure of Closure

[Nasser F. Abou'Seada]

Dear Prasanna ..
I quite agree with you ... 
yet not most of the times you keep an already primed circuit ready ... 
We do have the facility ... 
yet INHO the problem is in that we did not expect the events on such
scenario .... so precious vital minutes were lost ...trying to figure out
the best decision to be made ... . yet I totally concur with you .... 

NFA

> From: prasannasimha
> 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