[HSF] Valve Dysfunction - failure of Closure

[Nasser F. Abou'Seada]

Dear Bob 
thank you for your critically analyzing comment. unfortunately the event's
Haemodynamics were not recorded -though the monitors are equipped with HP
recording units, yet were not in use, in fact kept in safe by morning RN in
charge of ICU- yet the event was not described to me as an arrest. rather as
a "fit". 
Speaking to the residents on duty and the nurses, the EKG was never in
Asystole .... and never disappeared .... the Pressure curve disappeared in
first 2 events ... to appear again ..  yet the head of the patient was
always UP and the striking feature was that he looked as if gazing upwards
with his eyes .... as if in a fit "exactly same word". 

The intensivist listened to the patient and there were vigorous heart
beating  - the chest was beating- in his own words .... yet no clicking of
the valve. so I presume the valve was not stuck in a closed position ....
rather in a vertical one ..... well .... just my thoughts .... yet the facts
are that there were no asystole .... as per EKG .... there were no collapse
.... as patient was extubated and any collapse would have been easily
recognizable ... yet the observation was that he was unable to speak .... 

to my mind .... I did not apprehend the event as a neurologic deficit ....
rather than a haemodynamic event ... just what came to my mind ... ... also
between the 2 events the patient did not show any neurologic deficits ....
in fact all events happened so rapidly ... 

Yet however .... one can not trust the impressions of those who witnessed
the case .... your analysis seems very logic .... yet still ... what was the
cause ???? ... and how would that have altered the initial crucial first
step management ... !!

NFA

From: Rwmfglycar at aol.com
This case is bothering me

(1)2-3 seconds of neurologic effect accompanied by  absence of arterial
pressure is NOT caused by a valve stuck in the open  position. (I will give
corroborating evidence for this if anyone wants it  ). The only mechanism
for this is ACUTE FAILURE TO OPEN. With a bileaflet valve this has to be
BOTH LEAFLETS at  once. Jammed tilting discs can close the whole orifice;
doesn't happen with  bileaflets.

(2) Repeated episodes of ABRUPT CESSATION OF FLOW  OUT OF THE VENTRICLE
suggests an intermittent phenomenon. In other words  whatever jammed both
leaflets simultaneously during one minute must  have gone go away and come
back. This excludes clot as a  possibility.

(3) When you say the heart was "beating vigorously" do  you mean you saw
vigorous beating or you saw EKG activity? Do you by any chance have a
continuous record of the  EKG during the arrest? I wonder whether these were
periods of ASYSTOLE,  recovering spontaneously and then going into permanent
asystole.
 Bob
 
 
 
> 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. (1) 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 ??
> 
> (2)  in a few minutes, before doing the ECHO, the attack was repeated
twice
> in a
> minute.
> ?? reaction ???
> 
> (3)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.
> (3)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
> -----------------------------------------