[HSF] MR and Ischemia

[Nasser F. Abou'Seada]

thanks prasanna ..... nice clue to many events ...

NFA

> -----Original Message-----
> From: openheart-l-bounces at lists.hsforum.com [mailto:openheart-l-
> bounces at lists.hsforum.com] On Behalf Of prasannasimha
> Sent: Sunday, November 12, 2006 8:55 PM
> To: OpenHeart-L at lists.hsforum.com
> Subject: Re: [HSF] MR and Ischemia
> 
> Hal,
> Drugs used during induction can induce hypotension that can become a
> vicious spiral especially if the patient has "reactive coronaries".
> Was the patient receiving Propofol . Was it a short time after Heparin
> was being given. Propofol can cause intense bradycardia and hypotension
> if Atropine /Glyco is not given when the sternum is spread- hypotension
> - coronary malperfusion - spiraling ST's which are global and due to low
> output - low coronary flow (not always due to spasm). Hypotension
> Systolic or vasodilatation with low diastolic pressures will lead to a
> net decreased coronary flow establishing a vicious cycle.
> An occasional patient on drugs which are protein bound - like beta
> blockers can have a sudden rise in free drug concentration due to
> Heparin displacing the bound drug and this can cause hypotension leading
> to a vicious spiral.
> If the patients ECG normalized with institution of  perfusion , it
> proves that critical reduction in cardiac out put was a major issue -
> most likely a cause rather than an effect. What instituted the fall in
> cardiac output has to be determined and that is very likely to be drug
> induced in this case - Remember the patient never had symptoms due to
> Angina when awake .SAM rarely occurs pre-correction unless there is HOCM.
> Did she have major acceleration or deceleration in her heart rate at
> that time ?
> PS - All members we have a page called
> http://ctsurgcomplications.wikia.com/wiki/Crash_on_induction
> in the Wiki !!
> Hal it was written a few days back - note the statement - the aorta may
> become floppy - your term - the "pressure became increasingly soft" I am
> sure you meant- aorta. That points to the fact that there is severe
> hypotension (primary myocardial), unrecognised hypovolemia or extreme
> vasodilatation .
> 
> Prasanna
> Hgrmd at aol.com wrote:
> > Dear Members,
> >   Last week, I was referred a 72 yo lady with pulmonary edema  secondary
to
> > severe MR.  She had a flail posterior leaflet, mod TR, no AI,  EF 50%,
normal
> > coronaries, and chronic AF. Last Friday, I planned to do a mitral
repair,
> > tricuspid repair, and Cox-maze.  Everything seemed to be going to  plan.
However,
> > as I was placing pursestrings for cannulation, the pressure  became
> > increasingly soft.  It was refractory to volume and pressors.   I
noticed the
> > precordial ST's skyrocketed  and became "tombstone".  I  was having a
"code
> brown"
> > thinking that the cardiologist and I must have missed  some major occult
coronary
> > stenosis.  I crashed on pump, and the ST's  normalized after a few
minutes.  I
> > did uneventful mitral/tricuspid repairs  and a Cox-maze.  She came off
easily
> > with perfect TEE results.  As of  this morning, she was comfortably
sitting
> > in a chair on 3/l nasal cannula.   What do you think caused the probable
severe
> > global ischemia?  I've never  seen that before.
> > Hal
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