[HSF] Valve Dysfunction - failure of Closure

[Nasser F. Abou'Seada]

> 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< 

This exactly my question .... would it have made a difference ???? .....
configuring the problem as a valve leaflet dysfunction that needed to get
dislodged ..... till CPB could be instituted ..... 

I do totally agree with you about institution of CPB ... my main concern was
about the first preliminary step to be taken ...... otherwise .... the right
action was made .... yet not fast enough to catch on with the patient ...
!!!!

> 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.<

I do quite agree with your experience ... I had a patient like that once ...
some years ago ... with exactly the same problem .... was reopened just to
shorten and tuck the "moustaches" or "whiskers" of the knot below the
equator in an outward radial direction. 

NFA

> From: prasannasimha
> 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