[HSF] Valve Dysfunction - failure of Closure

Tue Dec 12 16:03:23 EST 2006

thank you Ben ...
more analytical thoughts ...
One has to digest what happened ... 
Still ...
do you think there would have been a difference in results should the chest
have been opened on the spot and the aortic annulus thumbed / between
fingers, to dislodge a probable stuck jammed close leaflets, or an immobile
vertically displaced leaflet ? ... just buying time till CPB could be
instituted ???
Bob ? 

NFA

> From: Ben Bidstrup
> Some more thoughts.
> One must ask, why might this happen?
> We have seen a suggestion that long suture ends can jam leaflets.
> Another might be some distortion of the annulus of the valve into which
the hinge
> mechanism is set.
> If the sutures are not evenly spaced, the ring can be stressed in such a
way as to
> allow for increased friction at the hinge(s).
> All valves have the annulus distorted in some way to insert the leaflets.
> I wonder if Bob has some comment on that.
> 
> I agree with his earlier comment that the clinical presentation is unusual
for a valve
> jamming either half open (or is it half closed).
> There is usually severe pulmonary congestion and edema with the sudden
onset of
> AR.
> If jammed completely closed then there is the same thing but no CO - very
unusual.
> At times, I have as have others seen a distended LV after release of the
cross clamp
> suggesting the valve is stuck,
> but examination of the valve does not confirm that.
> I take it the both leaflets were in position when the aorta was eventually
opened.
> 
> If he was speechless, then has this process been going on for some
minutes, leading
> to a neurological problem.
> But the arterial pressure curve would tend to negate that possibility.
> Why then did external massage or if the chest has been opened, internal
massage not
> produce an output?
> 
> Was the heart distended or flaccid when the chest was opened?
> Did massage in ICU produce a waveform on the monitor ?
> 
> This is indeed a rare occurrence.
> Can one prepare for it?
> It will depend on the resources available at the unit as we have seen.
> Is a pump ready all the time?
> Is there some one who can drive it ?
> Are there the other team members available?
> I suspect that unless it was at the beginning of the day
> before the ORs had been occupied if there is more than one,
> or between cases,
> then it almost any centre a minimum of 30 minutes from the decision to
achieving
> CPB is needed.
> 
> 
> 
> 
> 
> 
> >valve type ?? .... one of the very good brand named sacred valves .....
> >!!!
> >
> >NFA
> >
> >>  -----Original Message-----
> >>  From: openheart-l-bounces at lists.hsforum.com [mailto:openheart-l-
> >> bounces at lists.hsforum.com] On Behalf Of A
> >>  Sent: Tuesday, December 12, 2006 4:12 PM
> >>  To: OpenHeart-L at lists.hsforum.com
> >>  Subject: RE: [HSF] Valve Dysfunction - failure of Closure
> >>
> >>  It all seemed so quick I am sorry about that. Years ago there was a
> >> valve  called "Duromedic" I had a similar incident with it but right
> >> on the table  as we came off and started to close the valve became
> >> stuck in the open  position back on the pump looked at the valve no
> >> reason for it to do that.  Came off again the same scenario happened.
> >> I went back on the pump and put
> >a
> >>  St. jude instead and the patient did fine. The same happened to my
> >> partner  and we called the manufacturer eventually Duromedic was
> >> taken off the
> >market
> >>  and that was one of the reasons. It is important to get in touch
> >> with the  manufacturer and inform them. By the way what was the valve
> >> type? Thanks
> >>
> >>  -----Original Message-----
> >>  From: openheart-l-bounces at lists.hsforum.com
> >>  [mailto:openheart-l-bounces at lists.hsforum.com] On Behalf Of Nasser
> >> F.  Abou'Seada
> >>  Sent: Tuesday, December 12, 2006 12:46 AM
> >>  To: OpenHeart-L at lists.hsforum.com
> >>  Subject: RE: [HSF] Valve Dysfunction - failure of Closure
> >>
> >>  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
> >>
> >>  _______________________________________________
> >>  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
> >>  -----------------------------------------
> >
> >_______________________________________________
> >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
> >-----------------------------------------
> 
> 
> --
> Ben Bidstrup FRACS FRCSEd FEBCTS
> Consultant Cardiothoracic Surgeon
> _______________________________________________
> 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
> -----------------------------------------