[HSF] Todays complication !! and a HSF Guest

[Tea Acuff]

Prasanna,
 Are you sure you are not from Arkansas?
Tea


----- Original Message ----
From: prasannasimha <prasannasimha at gmail.com>
To: "OpenHeart-L at lists.hsforum.com" <OpenHeart-L at lists.hsforum.com>
Sent: Thursday, November 2, 2006 12:20:34 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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