[HSF] Acute dissection - what now?

Sun Aug 12 23:05:02 EDT 2007

I must say I have been a bit worried not having
repaired the rest yet! The dreaded phone call has not
happened yet! However, I was worried the guy does not
wake up, and would still prefer to see him wake up a
bit more before proceeding further. Overall the
operative mortality of these patients in general 
remains high!!

We need to also figure out what kills these patients
in the acute stage...tamponade, coronary occlusion he
does not have any more. His aortic valve is
miraculously intact...The outer layer of the aorta
looks strong, and I could not see where it leaked.
But I agree I should not wait much longer.....
Dave

--- Ben Bidstrup <benjamin.bidstrup at bigpond.com>
wrote:

> 
> It is something 1/3, 1/3, 1/3.
> The first third die in a day, the second in a week
> and the third over 
> the next few months.
> 
> 
> 
> >Dave,
> >
> >? I've never seen or heard of staging an acute
> dissection, but your 
> >strategy seems to be working so far.? I suspect if
> you had tried to 
> >fix the whole thing acutely, the patient would have
> died from RV 
> >failure.? Still, I would think it's a small
> minority of acute Type A 
> >dissections that can be staged.? If I'm not
> mistaken, the mean 
> >survival of untreated Type A's is only a couple of
> days.
> >
> >
> >
> >Hal
> >
> >
> >-----Original Message-----
> >From: David Harris <drdharris at yahoo.co.uk>
> >To: OpenHeart-L at lists.hsforum.com
> >Sent: Sun, 12 Aug 2007 12:45 pm
> >Subject: Re: [HSF] Acute dissection - what now?
> >
> >
> >
> >
> >Hi Prasannah,
> >
> >There was no definite site on the aorta, and the
> aorta
> >was not thinned out and ready to rupture like I
> have
> >usually seen. The adventitia was slightly thickened
> /
> >inflamed. There was a small amount of liquid 
> blood,
> >and clots, which were around the whole ventricle.
> >Posterior clots were removed only once we were on
> >pump.
> >
> >I took him back on 9 Aug for formal closure of the
> >chest so we could wean and extubate (I had left the
> >sternum open to prevent any compression of the RV,
> >which looked horrid at that stage). By this stage
> the
> >RV looked normal, the aorta did not look worse
> (45mm)
> >externally, and echo showed no extension of
> >dissection. He was extubated yesterday, and is
> still
> >delirious / confused. Kidneys are working, creat
> now
> >330mmol/l. I guess I should plan for later this
> week?
> >
> >Dave
> >--- psimha <prasannasimha at gmail.com> wrote:
> >
> >>  Dave,
> >>  How did he Tamponade ?
> >>  Prasanna
> >>  David Harris wrote:
> >>  > 60 yr old male presents with `acute coronary
> >>  syndrome`
> >>  > to physician, inferior infarct pattern.
> >>  >
> >>  > Cardiac cath done next day. L side normal, RCA
> >>  > blocked. Aortic valve intact. Aortic
> dissection
> >>  then
> >>  > diagnosed. CT confirms that it extends from
> RCA to
> >>  > below brachiocephalic.
> >>  >
> >>  > Patient then referred to me: dehydrated,
> obtunded,
> >>  > creatinine 570mmol/l, anuric.
> >>  >
> >>  > Arrests soon after, resuscitated. BP 50 - 60
> >>  systolic
> >>  > for 30 mins. Taken to OR for salvage. Put on
> pump
> >>  > (cannulated innominate) to keep him alive.
> >>  Tamponade
> >>  > relieved, vein graft on beating heart to prox
> RCA.
> >>  > Aorta looks stable (not thinned out - yet)
> >>  > Weaned with difficulty with IABP.
> >>  >
> >>  > Now on 40%, ventilated, GCS 10, passing good
> >>  urine,
> >>  > creatinine 500. Timing for full repair?
> Attempt
> >>  cross
> >>  > clamp during repair?
> >>  >
> >>  >
> >>  >
> >>  > Dr. David G. Harris, FCS, MMED,
> >>  > Cardiothoracic Surgeon       
> >>  > Suite 207                               
> >>  > Kuils River Private Hospital,       
> >>  > PO Box 1200, Kuils River, 7579, Cape Town,
> South
> >>  Africa.           
> >>  > Tel +27-21-9006411            
> >>  > Fax +27-21-9006412      Mobile +27-83-3309587
> >>  >
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> >
> >
> >Dr. David G. Harris, FCS, MMED,
> >Cardiothoracic Surgeon       
> >Suite 207                               
> >Kuils River Private Hospital,       
> >PO Box 1200, Kuils River, 7579, Cape Town, South
> Africa.           
> >Tel +27-21-9006411            
> >Fax +27-21-9006412      Mobile +27-83-3309587
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=== message truncated ===

Dr. David G. Harris, FCS, MMED,
Cardiothoracic Surgeon        
Suite 207                                
Kuils River Private Hospital,        
PO Box 1200, Kuils River, 7579, Cape Town, South Africa.            
Tel +27-21-9006411             
Fax +27-21-9006412      Mobile +27-83-3309587