[HSF] Postop cardiac syncope

[Edward Bender]

AV nodal dysfunction:  this could be intrinsic conduction system  
problems either independent of or aggravated by RCA infarct at the  
time of his PCI.  Without pre-op Holter, its impossible to know  
whether this has been occurring all along.  Regardless of the cause,  
this case brings up a good opportunity to discuss temporary wires  
after heart surgery.  One of my ex-partners at Baylor had a patient  
tamponade after wire removal.  I as yet have not this happen, placing  
two RV leads on every open heart I perform.  Sometimes I place RA  
leads when I feel AV synchrony is needed.  The way I think I have  
avoided a tear during wire removal is two-fold:
1.  Place the wires so that they get pulled out with no fulcrum on  
the RV.  In other words the direction that the wires get pulled out  
of the RV are the same as they are put in.
2.  If there is some resistance to removal, or the patient is fully  
anticoagulated, or if I have to sew the lead in place for hemostasis  
due to a bleeding epicardial vessel or perhaps too deep a RV stitch,  
I just cut off the wires and let the cut ends retract underneath the  
skin.

Ed Bender, MD


On Apr 12, 2007, at 9:51 PM, Tea Acuff wrote:

> I would be interested in suggestions for a recent case, both to see  
> how people think and perhaps to find a novel answer(s).
>
> The case.
>
> A seventy four year old male presented about 2-3 week ago with ST  
> elevation inferior MI, which was aborted with a DES to the main  
> RCA. This helped significantly since he had only a diagonal and  
> high OM patent on the left with poor filling of occluded LAD and PL  
> with moderate left main. He also had a 95% mid PDA and probably 70%  
> proximal PDA. LVgram not done then. Very dominate RCA. He was sent  
> home.
>
> Patient readmitted at two weeks after stopping Plavix for 4 days.  
> TEE periop minimal inf LV dysfunction and mild MR. Had uneventful  
> OPCAB with Lima to LAD, but even proximal LAD was 1mm or less as  
> was PL of circ. RSV to Diag and RSV to OM, large PL of RCA and to  
> endartectomized mid PDA. Extubed at or shortly after arrival to  
> ICU. Bleeding 200-300 ccs first shift; no Swan Ganz. Was up in  
> chair at 6-8 hours post op at shift change on moderate levo for BP  
> (presumed vasoplagia by good ICU nurse) when his monitor went off  
> and he was slumped over in chair. No meds and pushed on chest with  
> resumed BP and NSR. CRX, Hct, K, ABG okay. I came in (about 40  
> minutes later), he had had 3rd degree HB with out ventricular  
> response and had had another episode without syncope. I weaned levo  
> and gave some colloid which stabilized. Since he had no pacer wires  
> I got the cardiologist (probably could have found a pacing SG and  
> done it myself) and put in a VVI pacer the next morning despite  
> NSR. No
>  evidence of periop MI.
>
> How should I think about preventing any of this in the future or  
> should I just say that everything worked properly? (Patient is  
> afterall okay.)
> Does this happen at home when we think that they acutely occluded  
> their grafts?
> Has anyone seen sudden and brief 3rd degree HB with otherwise NSR  
> without clear ischemia? I don't remember ever seeing it exactly  
> like this.
> What really happened? Or better yet what would you do to prove what  
> you thought happened?
> Would anyone do anything different after his first syncope/arrest?
>
> tea
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