[HSF] "loose runner"

Tue Oct 10 20:02:35 EDT 2006

Thank you ... that now makes sense to me .... I hope you'd excuse my poor
understanding .... I'm a non-native speaker of the language too . 

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 11:56 AM
> To: OpenHeart-L at lists.hsforum.com
> Subject: AW: [HSF] "loose runner"
> 
> Very simple, my problem is that English is not my mother´s language.
> Suppose you perform aorta ascendens replacement. You begin with parachute
> stitch in the posterior wall, from the middle to both sides. Somewhere you
> must stop and change to the other side. When we change side, we clamp the
> Prolene with a rubber armed moskito clamp. But we do not more tight it.
Then
> we finish the other side, and when we knot, the first side is loosened(
> locker in German).Then, the suture may bleed. The solution was given down
by
> Homayoun.
> Roberto
> 
> -----Ursprüngliche Nachricht-----
> Von: openheart-l-bounces at lists.hsforum.com
> [mailto:openheart-l-bounces at lists.hsforum.com] Im Auftrag von Nasser F.
> Abou'Seada
> Gesendet: Dienstag, 10. Oktober 2006 16:11
> An: OpenHeart-L at lists.hsforum.com
> Betreff: RE: [HSF] "loose runner"
> 
> 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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