AW: AW: [HSF] Posterior aortic bleed and Coronarybutton tears.

Wed Oct 11 07:22:00 EDT 2006

Prasanna ... I do concur with you ..... both options seem very realizable
... an open online wiki might be a good start ... certainly will need
editing ..... 

NFA

> -----Original Message-----
> From: openheart-l-bounces at lists.hsforum.com [mailto:openheart-l-
> bounces at lists.hsforum.com] On Behalf Of prasannasimha
> Sent: Wednesday, October 11, 2006 5:07 AM
> To: OpenHeart-L at lists.hsforum.com
> Subject: Re: AW: AW: [HSF] Posterior aortic bleed and Coronarybutton
tears.
> 
> Seriously why can't we  write a book ? I bet with a collaborative
> experience of the interested HSF members we would make a very wonderful
> "world wise" book.
> In fact we can post questions too in case of doubts / also add opinions
> of HSF members. - It would be a unique kind of book. If any members are
> interested we can coordinate it. Those who would like to be involved can
> email me and I think Dr Levinson could  also guide us with his knowledge
> of publishing etc. Probably we could name it the " The Heart Surgery
> Forum Textbook of Complications in Cardiac surgery" ??? It would be
> having the weight of over 2000 Members !!!]
> As each chapter is being written we can pose the relevant questions and
> then make up the article and edit.(In addition to culling references etc
> etc). Roberto can make the German translation and others could probably
> help in translating it to their relevant languages too.
> Dr Levinson, would Cardine Jennings be interested ?
> The other possibility is to make a Wiki and keep it online ?
> Prasanna
> 
> Dr. Roberto Battellini wrote:
> > Let´s write our own book,hehe
> > Roberto
> >
> > -----Ursprüngliche Nachricht-----
> > Von: openheart-l-bounces at lists.hsforum.com
> > [mailto:openheart-l-bounces at lists.hsforum.com] Im Auftrag von
prasannasimha
> > Gesendet: Mittwoch, 11. Oktober 2006 02:36
> > An: OpenHeart-L at lists.hsforum.com
> > Betreff: Re: AW: [HSF] Posterior aortic bleed and Coronarybutton tears.
> >
> > I have access only to two books on complications in cardiac surgery -
> > One is by Waldhausen and the other by Khonsari.
> > Unfortunately both don't mention this !!
> > Prasanna
> > Dr. Roberto Battellini wrote:
> >
> >> Prasanna,
> >> text book writers have never complications, so they can´t describe
them.
> >> Read books about "complications in cardiac surgery".
> >> Roberto
> >>
> >> -----Ursprüngliche Nachricht-----
> >> Von: openheart-l-bounces at lists.hsforum.com
> >> [mailto:openheart-l-bounces at lists.hsforum.com] Im Auftrag von
> >>
> > prasannasimha
> >
> >> Gesendet: Dienstag, 10. Oktober 2006 13:48
> >> An: OpenHeart-L at lists.hsforum.com
> >> Betreff: Re: [HSF] Posterior aortic bleed and Coronarybutton tears.
> >>
> >> Thanks to all the HSFers.
> >> Patient is stable ,extubated.and tubes are out and is requiring still
> >> some nitroprusside to control her pressures . I have started ACE and
> >> beta blockers. I presume that hypertension could damage in some ways
the
> >> new autograft (plus the bleeding risk).
> >> I promise myself that I will do  a double layer for all inaccessible
> >> anastomosis but somehow forget it till I have bleeding - and then I do
> >> it till I forget - pretty pathological of me. :-)
> >> It is surprising that a dehisced coronary button is rarely discussed in
> >> a text book and I was thinking that I was the only person to have
> >> screwed up a coronary button !! The thing is that this forum brings out
> >> real world problems which many a time are not discussed. There is one
> >> advantage of a 12 hr global time shift - I was getting immediate
> >> suggestions from all around the world while I was maintaining a vigil
> >> with the phone nest to me at home waiting for another reexploration
> >> call. I had lots of information to freshen my battle plan.Luckily I did
> >> not have to use any of it but forewarned is forearmed.
> >> Prasanna
> >> Incidentally as an Image of the week I have enclosed a picture of the
> >> Ross immediately after weaning from CPB. I really could not take
> >> intraoperative pictures as there were too many problems occurring
> >> (abnormal location of coronaries etc etc) and I wanted to just get out
!!
> >> Prasanna
> >> Homayoun Jalali wrote:
> >>
> >>
> >>> 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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