[HSF] Todays complication !! and a HSF Guest

[Nasser F. Abou'Seada]

I have had once a problem similar to that .... assisting one of my
professors in a case with PS ..... bleeding continued from nowhere after off
clamping and off CPB ...... only at autopsy I found out the reason ...
became totally convinced that such injuries need to be THOUGHT OF ... and
anticipated and sutured FROM INSIDE ....... 

NFA

> -----Original Message-----
> From: openheart-l-bounces at lists.hsforum.com [mailto:openheart-l-
> bounces at lists.hsforum.com] On Behalf Of prasannasimha
> Sent: Thursday, November 02, 2006 8:00 PM
> To: OpenHeart-L at lists.hsforum.com
> Subject: Re: [HSF] Todays complication !! and a HSF Guest
> 
> 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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