[HSF] Trans PA injury

Fri Nov 3 09:09:31 EST 2006

in fact it had been a simple case .... TOF ... VSD, Infundibular PS,
Valvular PS, .....  fixed via trans-ventricular approach ..... VSD was patch
closed, Infundibular stenosis resected, valvular PS was released from BELOW
with a fine scissor ......... the assistant wanted to open the MPA to
release the commissural attachment of the P Valve to the PA wall .... and do
commissurotomy under vision .... yet .. as it appeared so simple ... the
operator was sufficed with just a quick transventricular release of the P
Valve leaflets. ... 

Coming off bypass .... the pericardial well was slowly "filling" with blood
.... the source of which could never be identified ..... all suture lines
were perfect and dry ..... blood just filling in slowly from below .... !!!

Giving no ear to re-cross clamp and look from inside, - apparently there
were no suspected reason to- spending too much time to put many teflonized
sutures here and there at the posterior surface of the heart -where blood
appeared to be trickling from- .... asking for assistance of another
professor who scrubbed in to help ... never wanting to lose time on
re-clamping .... !! ... .. going on the same concept of not re-cross
clamping.... putting in more and more teflonized stitches ..... venting off
the LV and everting the heart to look at the direct posterior surface of the
heart .... blood looked as if coming from a spot just inferior to the
transverse sinus .... a teflonized stitch there was enough to apparently
stop the bleeding ..... ! 

of course the real reason was that the BP was down ... and the heart empty
by venting .... so bleeding stopped .... blood was becoming so thin ....
long bypass time .... and patient passed off OT  ........ ....... I did an
autopsy before closing .... opened the MPA to find a tear in the posterior
wall of the MPA ....... through which blood was PERCULATING ... just to
appear in the pericardial well as if from the posterior wall of LV ...
......... ALL THE teflonized stitches were in fact just in the ADVENTITIA
....... serving no purpose .... except for false arrogance of claimed help
.... !!!!! 

apparently the injury was an un-intended un-observed one .. inflicted when
the PV was incised from BELOW .... where the tip of the scissors just
inflicted a tear in the MPA posterior wall intima and part on the media
..... nothing was apparent from the OUTSIDE at all ....... not even
accessible ..... 

the lesson was to ALWAYS trust no dogma .... always think and look all
aspects of a problem .... always cross clamp and inspect UNDER VISION to
save time ... and life ... !!!! ... a few more minutes of cross claming and
fixing the problem under vision would do no harm .... yet would either fix
the problem or else exclude a hidden probable cause. 

I have read about no such complication before ... neither heard .. ????
clumsiness ???? ..possibly ... lack of sound judgment .... probably .....
stupid ignorant arrogance ??? .... certainly ... !!!

NFA

> From: prasannasimha
> Was it a cross clamp induced injury of the LA or a posterior injury trans
PA
> Prasanna

> Nasser F. Abou'Seada wrote:
> > 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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