[HSF] Todays complication !! and a HSF Guest

Fri Nov 3 06:30:12 EST 2006

That was my plan B (suturing from inside.) I had arrested the heart 
specifically so that I could go in if the initial suture failed. 
Luckily  I got away from it.
Hal you will have to contribute to the pulmonary vein injury chapter of 
the complicationsincardiacsurgery wiki !!
Prasanna
hgrmd at aol.com wrote:
> Prasanna,
>   Don't you just love it when this kind of crap happens with company around?  I'm sure you did a good job of externally repairing the hole, but I generally would reclamp and repair it from the inside.  It's a lot more trouble, but this ensures that you don't narrow the vein.  If I wound like an expert, it's because I did it once or twice while doing pulmonary vein isolation.  Both patients did fine.
> Hal 
>  
>  
> -----Original Message-----
> From: prasannasimha at gmail.com
> To: OpenHeart-L at lists.hsforum.com
> Sent: Thu, 2 Nov 2006 1:20 PM
> Subject: [HSF] Todays complication !! and a HSF Guest
>
>
> Our own HSF's Chandrashekar Ramaih had come to my Hospital today and for his treat I had kept a case for OMV/MVR = emaze with a large LA body clot (huge one) and another case of rheumatic MR for repair. 
> It was so nice to meet another person from HSF. I must thank Dr Levinson for starting this list that enabled people to meet across the globe. 
> (I have met Don Ross, Ben Bidstrup apart from our group from India like Ravishankar and Anurag Garg whom I meet in our national conference yearly). 
>  
> As usual when a guest comes something has to go wrong. The OMV was not good and I had to replace the valve (after the LA thrombectomy and an e maze). That was not so much a problem . (The valve was not a great choice for OMV but we anted to give her a chance) 
> When I released the cross clamp , I was a bit worried about some blood welling up laterally and had a peep and saw some bleeding there and lo behold I saw a hole in the Left superior pulmonary vein. 
> In retrospect, this case had required extraction of clots from the pulmonary veins and Chand had commented at the beginning when I was delamellating the clot that the LA was very thin and I had agreed . I had removed the clot etc etc (very large clot _ I am not sure If Chand had photographed it) any way I think that while I was sucking out and washing the LA and the Pulmonary veins I must have pocked the PV with a sucker and perforated it. The tear started to extend towards the LA body when I was trying to evaluate it .It required a reapplication of the cross clamp, a short period of circ arrest to allow good visualization (and as usual when a guest comes - the Heating Cooling unit had to promptly conk off and the heart would not easily stop !!) Any way after a few pledgetted 5/0 sutures and a bit of prayers and a bit of glue the bleeding was controlled and we have had an uneventful post op so far. 
> I have now done 56 (I got the count wrong as last week I had done another body clot) giant LA body clots with emaze and never encountered this problem so far !! 
> Any other suggestions ? 
> At least the second repair which required some amount of commissurotomy ,posterobasal chordal release, Anterior chordal shortening and an annuloplasty was uneventful. It would have been tragic if two attempts at conservative mitral valve surgery had ended in a replacement - especially in front of a visitor :-) !! 
> Question - how would you manage friable papery tearing tissues ? especially in that position. 
> I used a DPRS suture to flip the heart and called for assistance to gently retract the heart. I ran an initial 5/0 and then placed pericardial pledgetted sutures serially at residual bleeding points. I then placed some glue over it. 
> My other possible plans were to suture over the whole area a piece of pericardium or use the LA appendage as a bung of tissue to cork the hole. 
> Incidentally any one else who wants to come to my institute for a visit - you are all welcome !! 
> Chandrashekar will be giving a lecture on VAD's and Robotics to us on Saturday and we are looking forward to it. 
>  
> Prasanna 
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