[HSF] Todays complication !! and a HSF Guest

[prasannasimha]

Tea, I spent some time trying to understand the Arkansas thing. The only 
people I know from Arkansas are Bill Clinton and Hal
Prasanna
Tea Acuff wrote:
> 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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