[HSF] A case: cardiac rupture

[Homayoun Jalali]

Dear Roberto,
 
Just a note to say that I usually do same as Bob. I do put pledgeted
stiches over the rupture but then cover it with a patch of bovine
pericardium stitched to the non infarcted area. I fill the gap between
the myocardium and the patch with bioglue. This is often enough for
small ruptures but not a major one like that of your patient. The big
ones have to be patched from inside but depending on their location
access to them can be quite tricky. If you have to open the LV itself it
can't be the best for those freshly infarcted hearts.
 
I found the idea of an LVAD for a few days quite interesting too.
Except that they have to remain on heparin?
 
As far as your patient goes looks like you did the best possible.
 
With kind regards,
 
Homayoun Jalali


>>> battr at medizin.uni-leipzig.de 19/10/2006 1:06:10 am >>>
Dear Members,



Woman born  1952, was  studied In a foreign Hospital  because of
haemopericardium of unknown origin. CT: No dissection,
haemopericardium.
There she was  punctured and send then  to HZL.   In Leipzig she got
ECG ,
almost normal, CKMB normal, troponin was not done, and went directly to
cath
lab: LAD 99% stenotic, RCA 2-3 stenosis 70%, CX 50%. She got another
punction for tamponade, unsuccessful. Then the interventionist, under
reanimation,   called me for inferior drainage. I did a  5 cm incision
and
drained it ( lot of clots and 200 blood). With good pressure, I send
her to
OR. During the transport, she was  again 2 times reanimated.  In OR, we
put
her on pump. The aorta was ok. I closed 3 bleeding sites. One at the
marginal angle of RV,  and two bleeding strongly between Diagonal and
obtuse
marginal branches. These were stitched with 4/0 Prolene with pledget.
Also
there was a haematoma in the region of the sulcus, at the region  of 
AV
groove. I thought as diagnosis   1. status after heart reanimation or
2.
acute infarction. I added   2 vein bypasses   to LAD and PD. (no
mammary
because of reanimation and sternal fracture). If it was an infarction,
why
there, the CX was only 50% stenosed!.  I added glue and tachosyl as for
a
coronary sinus rupture. 

After going out off bypass, came blood from the sutured zone, where
the
pledgets were stitched, now the muscle looked a little disrupted. .
Again 20
minutes on bypass, I added 2 teflon felt strips sutured with 3/0
Prolene as
it were an aneurysma. It Bleeded diffuse, again Bioglue, etc. I added
an
IABP as she was long reanimated and got That suture.  Quick time was
7%. I
left the chest open and with packing, she received everything to
favour
coagulation, inclusive factor 7.  At night she was reoperated by
Michael
Borger, he had to stitch again with Teflon, again packing. Bleeding
stopped
12 hours after. The ventricle had good contractions on echo. No more
bleeding. One day after (may be a decision  error) ,she was again
reoperated
with intention to close the chest. After taking out the gauzes she
began to
bleed again. We poured 3 pistols of bioglue and tabotamp and so on.
Bleeding
stopped and the chest was left open. At night the heart ruptured , she
was
carried gain to OR, and there  died there at 3.00 AM. 

Questions: experience from the members, what would have done different
those
with experience, etc.

Diagnosis: 1.
infarction->haemopericardium->puntions->tamponade->reanimation->cardiac
rupture, etc against    2. other cause of haemopericardium and the rest
is
iatrogenic.

Roberto 

_______________________________________________
OpenHeart-L mailing list

Send postings to:
OpenHeart-L at lists.hsforum.com 

To UNSUBSCRIBE, to CHANGE email address, or to view archives:
http://mmp.cjp.com/mailman/listinfo/openheart-l 

All messages transmitted by the OpenHeart-L are subject to the policies
and 
disclaimers posted at:
http://www.hsforum.com/listdisclaim 
-----------------------------------------



*****************************************************************
This email, including any attachments sent with it, is
confidential and for the sole use of the intended recipient(s).
This confidentiality is not waived or lost, if you receive it and
you are not the intended recipient(s), or if it is transmitted/
received in error.

Any unauthorised use, alteration, disclosure, distribution or
review of this email is strictly prohibited.  The information
contained in this email, including any attachment sent with
it, may be subject to a statutory duty of confidentiality if it
relates to health service matters.

If you are not the intended recipient(s), or if you have
received this email in error, you are asked to immediately
notify the sender by telephone collect on Australia
+61 1800 198 175 or by return email.  You should also
delete this email, and any copies, from your computer
system network and destroy any hard copies produced.

If not an intended recipient of this email, you must not copy,
distribute or take any action(s) that relies on it; any form of
disclosure, modification, distribution and/or publication of this
email is also prohibited.

Although Queensland Health takes all reasonable steps to
ensure this email does not contain malicious software,
Queensland Health does not accept responsibility for the
consequences if any person's computer inadvertently suffers
any disruption to services, loss of information, harm or is
infected with a virus, other malicious computer programme or
code that may occur as a consequence of receiving this
email.

Unless stated otherwise, this email represents only the views
of the sender and not the views of the Queensland Government.
****************************************************************