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

[Nasser F. Abou'Seada]

a wonderful productive idea ..... can be collected and edited from HSF ... 

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: Wednesday, October 11, 2006 3:26 AM
> To: OpenHeart-L at lists.hsforum.com
> Subject: AW: AW: [HSF] Posterior aortic bleed and Coronarybutton tears.
> 
> 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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