[HSF] Trip to Croatia

[prasannasimha]

On the invitation of Bojan Biocina, I had been to Hospital Dubrava , 
Zagreb ,Croatia.
I had the opportunity to see and experience another culture and interact 
with  surgeons from another land.
All the members of the cardiac surgical team are avid followers of the HSF.
We did  quite a few interesting cases.(repairs, adult congenital and 
redo's).
I had the opportunity to demonstrate the electrocautery maze there and 
also the use of indigenous rings using material that they had at hand ( 
used split pieces of Goretex tube grafts) which are excellent.
We had  a redo post subaortic membrane resection. I did an initial mini 
Konno procedure and when we weaned I found an unacceptable gradient . On 
analysis of the TEE I saw the appearance of new SAM, mitral 
regurgitation and gradient in the upper part which failed to disappear 
with removal of all inotropes and volume loading (which was previously 
"Open" and so we went back and I did an extensive "Morrow" type" of 
resection after which the gradient came down to 15 mm Hg on pressure 
recording, the SAM and MR also disappeared.

There was another very sick lady who had multiple surgeries (OMV via a 
left thoracotomy ( bioprostheses and a SE valve implantation). The last 
surgery was the SE implantation and she now had major paravalvar leak, 
TR and also AFib. She was extremely sick and I was really wondering 
whether she needed emergent surgery at night.She also had left 
diaphragmatic paralysis and so we decided not to use a right thoracotomy 
in case we damage the right phrenic too !! As per my usual protocol , I 
did her with femoral arterial and venous cannula in place and backed up 
volume into the reservoir to allow the BP to drop to the 60's  while 
opening the sternum allowing the heart to fall back. I had given 
instructions to go on CPB if there is persistent difficulty in 
maintaining hemodynamics . With this method I am able to dissect the RV 
easily and can immediately go on CPB when the dissection becomes 
difficult.(With this  we can combine the advantages of both limiting CPB 
and using it to advantage when we want things to "collapse" as the 
situation demands.
We dissected most of the "required" area  without CPB and then went on 
CPB. Due to left diaphragmatic elevation the RA was in the position of 
the  regular LA (the heart was torted - we had seen that too in the CT). 
We used a balloon cannula for the SVC and that did not matter so much as 
we had vacuum assist. We  endoclamped the aorta with a Foley balloon   
after beating heart TV repair and right emaze lesions.
On opening the LA transeptally, we found that the surgeon who did the 
redo had used a continuous suture (3 suture Prolene technique) and the 
prolene had unraveled off one third the annulus. I did not explant the 
valve as there was no evidence of endocarditis and I did not have to 
patch the annulus (we were contemplating either valve reimplantation or 
patching the paravalvar leak with a double patch initially) as the 
mechanism was clear as I could see the frayed suture broken in the 
middle !!- there was also no evidence of previous endocarditis.
Using liberal felt supplemetation and mattress sutures the leak was 
closed (In the meanwhile the balloon burst so I used intermittent 
dropping of flows at 22 Deg as this patient had AR (not requiring 
replacement   but significant enough to trouble us !!). The leak was 
tested intraop as thereAR leak allowed easy visualization of the 
original leak and also after suturing).
We were able to come off CPB uneventfuly and she is extubated and doing 
well !!

Other cases done included 2 repairs including bileaflet prolapse 
(myxomatous) one ascending aortic replacement with David procedure  and 
also I got to see a Mitrofast implantation- incidentally this patient on 
table had billeaflet prolapse so I placed artificial anterior chords and 
Bojan placed the Mitrofast and we got good coaptation.
I did an elective  MVR on a lady who had some suspicion of SLE but the 
Echo looked "rheumatic" on table did not fit into either and since the 
"verrucous" lesions (confined only atrially) was bileaflet in nature , I 
felt it was not wise to attempt a repair (I thought that if it was 
mainly confined to the AML , I would be able to excise that and patch 
that area) so we replaced that valve after reconfirming that the valve 
would possibly require an extensive repair with possibility of 
questionable results in the long term.

This was a good experience and with international cooperation.
This would not have been possible without the "invention" of the HSF by 
Marc Levinson and I should congratulate him for starting the list serve 
without which  this would never  been possible.
I was extremely honored to be invited to conduct the workshop and share 
my views and opinions and also to learn new approaches and solutions to 
different problems and the wonderful case mix that I got to see.
Prasanna