[HSF] Trans PA injury [OT]

Nasser F. Abou'Seada nfaabouseada at gmail.com
Fri Nov 3 17:35:54 EST 2006 

I guess I have been lucky to have been exposed to dozens of these
complications ...... some intended by virtue of Commission ... -essentially
out of ignorance or imprudence-..... some by Virtue of Omission  .... some
in spite of careful vigilance ...    

- I guess the third type is what one would gain his hard-earned experience
through ..... - The second type is what one would gain through observation
of / consultation with other colleagues  .... 
- The first type is .... what one should be grateful to those who have
earned him such hard-priced experience .... !! .... something one would
never learn at centers of excellence ... !!!

NFA

> -----Original Message-----
> From: openheart-l-bounces at lists.hsforum.com [mailto:openheart-l-
> bounces at lists.hsforum.com] On Behalf Of psimha
> Sent: Friday, November 03, 2006 10:10 AM
> To: OpenHeart-L at lists.hsforum.com
> Subject: Re: [HSF] Trans PA injury
> 
> 
> Case to be added in the managing bleeding in
> complicationsincardiacsurgery - PA injury section.
> I am getting a bit irritated with Wikia -still no information from
> them.Istant gratificatin is the rule in the Internet age !!
> 
> Prasanna
> PrasannaNasser F. Abou'Seada wrote:
> > 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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