[HSF] Acute dissection - what now?

[Ani Anyanwu]

Odd how our rules change and how we become more accepting and non-critical of deviations from accepted standards of care, when the deviation comes from another surgeon. 
 
I bet that if a similar patient with an MI complicating a type A  had undergone a PCI to RCA and percutaneous drainage of the pericardial space and then was sent to the CCU for 4 days with the dissection left untreated, we would all be screaming murder.
 
I have actually seen 3 type A's managed by colleagues in the last year where surgery was not undertaken immediately - one also had a staged procedure, one was not operated for six weeks - and all did well. Maybe it is time for us to revisit the UAB paradigm.
 
Ani



> To: OpenHeart-L at lists.hsforum.com> Subject: Re: [HSF] Acute dissection - what now?> Date: Sun, 12 Aug 2007 13:26:34 -0400> From: hgrmd at aol.com> CC: > > > 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> > > _______________________________________________> > > 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> > > -----------------------------------------> > >> > >> > > > > > > _______________________________________________> > 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> > -----------------------------------------> > > > > 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> _______________________________________________> 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> -----------------------------------------> > > ________________________________________________________________________> AOL now offers free email to everyone. Find out more about what's free from AOL at AOL.com.> _______________________________________________> 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> -----------------------------------------
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