[HSF] "loose runner"

Tue Oct 10 11:09:31 EDT 2006

Homayoun,

you are right, I forgot. Many times the loose sutures bleed, the solution is
what you say. I saw Yacoub fixing his aortic sutures when changing the side
to avoid this.
Roberto

-----Ursprüngliche Nachricht-----
Von: openheart-l-bounces at lists.hsforum.com
[mailto:openheart-l-bounces at lists.hsforum.com] Im Auftrag von Homayoun
Jalali
Gesendet: Dienstag, 10. Oktober 2006 07:30
An: OpenHeart-L at lists.hsforum.com
Betreff: Re: [HSF] Posterior aortic bleed and Coronarybutton tears.

Prasanna,

For the Venticulo-Autograft anastomosis I use a strip of non treated
autologous pericardium sandwiched between the prolene and the tissues. I
also often do a second runner between the yellow rim of fatty tissue at
the base of the autograft and the native aortic annulus. I understand
some will be concerned that the second runner may loosen the first layer
but in my hands this 2 layer anastomosis has worked very well so far. I
learned this from prof. Daenen in Belgium.

By the way most bleeding I have seen from the ventriculo-arterial
anastomosis have been related to a loose runner. I have then put a
stitch under the runner somewhere I can see it well and pulled it up
before fixing it.

Glad to see your patient is heading the right way.

Homayoun Jalali

>>> prasannasimha at gmail.com 10/10/2006 11:49:40 am >>>
Humayoun,
Do you also add a "washer" of teflon  to the anastomosis in adults in 
this case?
(Incidentally the posterior bleed was from the root ie ventriculo auto

graft junction and not the posterior button).
Prasanna
Homayoun Jalali wrote:
> Prasanna,
>  
> In these situations I am worried about 2 things: The tension put on
the
> anastomosis between the (neo)aorta and the short residual coronary
> button and the fact that I have to suture a disintegrating  fragile
> coronary tissue  to a much thicker aorta (not as bad with an
autograft).
> The way I usually handle this is to reconstruct a coronary button of
> good length by suturing a small patch of autologous or bovine
> pericardium to the remainder of the coronary ostia. Next I
anastomose
> the reconstructed button to the (neo)aorta without any tension. This
has
> worked well for me in redo allografts, Ross and switches.
>  
> As far as the posterior bleeding goes I don't blame you for not
wanting
> to spend more hours in the operating room but you know well that if
it
> bleeds again you may well have to take the aortic anastomosis down
and
> reinspect your coronary suture lines. If you have an anastomosis
under
> tension or if there is a contained rupture posteriorly it will get
> bigger with time and it may compress the left main.
>  
> I have not used GRF glue for years. You can safely use tisseel or
> similar for coronary buttons. I have not had any problems with
bioglue
> so far but only very rarely put it near coronary ostias.
>  
> If she is still OK You obviously don't need to do anything anymore.
> With these sort of patients I usually get an angio or MRI a few
months
> down the track to check on the ostias but I understand not every one
has
> to be as obsessional. All coronary ostias I have reconstructed so
far
> have been normally patent when checked.
>  
> With kind regards,
>  
> Homayoun Jalali
>
>
>   
>>>> prasannasimha at gmail.com 10/10/2006 4:54:07 am >>>
>>>>         
>
> Today I did a Ross and had a peculiar set of problems. I would like
to
>
> know how the forum members would approach this.
> Basically the case was a lady with a bicuspid aortic valve with 
> endocarditis with large vegetations. The line of cusp closure was 
> anteroposterior and the pulmonary valve was tricuspid so I managed to

> get a homograft and did a Ross . When I opened the aorta I found the

> Left ostium could be dissected with a good margin of tissue but the 
> right was very much adjacent to the annulus. Like in an arterial 
> switch 
> I took the RCA button taking a part of the annulus with it and I
> thought 
> I had a decent margin. I did not make a separate button for the Left

> main ostium but left it as a tongue of the distal aorta as originally

> described by Dr Sampath Kumar of AIIMS Delhi.
> I went ahead with the autograft implantation and when the time came
for
>
> implantation of the RCA button when I lifted the button the annular 
> strip just sheared off partially and I was not even pulling !! I was

> left with an unpleasant task of reattaching that piece with fine
> sutures 
> and then implanted the button but even then my bites were
terrifyingly
>
> close to the RCA ostium.
> I would like to know how members would handle this situation
especially
>
> if the button was torn at the ostium or extended into it . One
obvious
>
> answer would be to oversew and do a CABG if the patient was old
enough.
>
> Any other methods ?
> Patient has been weaned easily and in fact on vasodilators despite a

> ridiculously long cross clamp time.
> She was pretty dry on closing  but started to bleed later on and I 
> re-explored her. She was bleeding from the posterior root anastomosis

> only if her pressures went above 110 mmHg systolic. It would stop
with
>
> decreased pressure. I presume some conformational change was
occurring
>
> of the root at higher pressures leading to the bleeding. Any way I 
> avoided going back on CPB and could suture the area of the leak with

> induced hypotension to 50 mm Hg transiently. I packed that area with

> some Surgicel (I was toying of placing some fat and covering the
whole
>
> area with pericardium but was worried if the let main may get 
> compressed.and came out and am keeping my fingers crossed. So far 
> bleeding has not occurred and I am using sedation and controlling the

> pressure pretty aggressively. Has any one used GRF glue in that area
> and 
> if so is it safe near the left main ?
> Any other tips / tricks to manage posterior aortic bleeds ? I have
once
>
> managed this by obliterating the transverse sinus with a series of
> purse 
> string sutures.
> Prasanna
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