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

Tea Acuff tacuff at swbell.net
Wed Oct 11 19:11:00 EDT 2006 

One of the best meetings that i ever attended (and I mentioned that John Flege was at my first in a recent post) was a group of 15-20 surgeons all who presented a death and what they learned and addressed criticism, sympathy , and good natured ridicule directed at them. It was an annual ski meeting (or beach) that developed many honest friendships across academic and regional boundaries.
tea


----- Original Message ----
From: Michael Firstenberg <msfirst at gmail.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Wednesday, October 11, 2006 6:31:05 PM
Subject: Re: AW: AW: AW: [HSF] Posterior aortic bleed and Coronarybutton tears.


Great idea

I couple of years back I got a copy of "Near Misses in Cardiac  
Surgery" (dont remember the author) but it contained little patient  
histories and answers of how to get out of trouble or the best route  
to helping the patient.  This may be an interesting way of presenting  
the topics (also remember HIPPA and our legal friends).  Maybe even  
different "answers" to the same problem?

michael


On Oct 11, 2006, at 9:33 AM, Dr. Roberto Battellini wrote:

> Prasanna,
> your idea is great.
> In Germany all the cardiac surgeons publish in English, the German  
> Magazine
> "The thoracic and Cardiovascular Surgeon" is written in English.  
> Even in
> Brazil they publish now in English. It could be a dynamic book.
> We have to clear how must we send our cases report and who are  
> going to
> collect them: Mark and Prasanna?
> 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 10:07
> An: OpenHeart-L at lists.hsforum.com
> Betreff: 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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