[HSF] "loose runner"

Nasser F. Abou'Seada nfaabouseada at gmail.com
Tue Oct 10 12:11:27 EDT 2006 

Dear Roberto 
what exactly is meant by " Yacoub fixing his aortic sutures when changing
the side" ... would you elaborate more on the technique please ?

NFA

> -----Original Message-----
> From: openheart-l-bounces at lists.hsforum.com [mailto:openheart-l-
> bounces at lists.hsforum.com] On Behalf Of Dr. Roberto Battellini
> Sent: Tuesday, October 10, 2006 4:10 AM
> To: OpenHeart-L at lists.hsforum.com
> Subject: [HSF] "loose runner"
> 
> 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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