[HSF] Posterior aortic bleed and Coronarybutton tears.

[Nasser F. Abou'Seada]

> 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.

Dear Prasanna 
I would have used a modified Cabrol's technique, utilizing SVG. 

> She was bleeding from the posterior root anastomosis
> only if her pressures went above 110 mmHg systolic. It would stop with
> decreased pressure.

I used to keep the pressure low, insert a long pack of dry gauze, pack well,
away from coronary buttons - patients receiving platelets conc. and fresh
blood- to re-explore and remove the back later on, 18-24 hours later.

Incidentally:  
what was your rationale in doing a Ross for this lady ? .... 
Do you have an access to homografts ???? .. 
House made ? or imported ? ..... 
method of preservation ?

NFA

> -----Original Message-----
> From: openheart-l-bounces at lists.hsforum.com [mailto:openheart-l-
> bounces at lists.hsforum.com] On Behalf Of prasannasimha
> Sent: Monday, October 09, 2006 2:54 PM
> To: OpenHeart-L at lists.hsforum.com
> Subject: [HSF] Posterior aortic bleed and Coronarybutton tears.
> 
> 
> 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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