[HSF] Todays complication !! and a HSF Guest

Fri Nov 3 08:30:58 EST 2006

You were lucky as you could have determined the real source of bleeding ....
others may not have your luck ... -nor competence- ..and judgment 

NFA

> -----Original Message-----
> From: openheart-l-bounces at lists.hsforum.com [mailto:openheart-l-
> bounces at lists.hsforum.com] On Behalf Of prasannasimha
> Sent: Friday, November 03, 2006 7:54 AM
> To: OpenHeart-L at lists.hsforum.com
> Subject: Re: [HSF] Todays complication !! and a HSF Guest
> 
> I think I could suture it from outside only because I used a short
> period of circ arrest (around 5 minutes) allowing precise visualization
> in what would have been inherently a "pool of blood" . I still say I was
> lucky.
> I do agree that suturing from inside is very attractive but would have
> not been very easy either - the LA was pretty large so precise suturing
> trans LA may also have been difficult too. (with the tissue overhanging
> etc etc)
> 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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