[HSF] Acute dissection - what now?

Mon Aug 13 12:19:14 EDT 2007

Actually, if we are limited to the binary mortality (dead/alive), having a live patient means exactly "doing no harm". Whether it was by error, plan or shrewdness and how we decide that is a different discussion.
tea

----- Original Message ----
From: Ani Anyanwu <anianyanwu at hotmail.com>
To: openheart-l at lists.hsforum.com
Sent: Monday, August 13, 2007 6:22:35 AM
Subject: RE: [HSF] Acute dissection - what now?

True, but what we need to establish is whether patients survive because of what we do or whether they are lucky to survive in spite of what we do. That we end up with a live patient does not necessarily mean the patient had appropriate therapy. That a patient is alive does not mean we have 'done no harm'. I can recall some patients that are lucky to be alive in spite of what I did to them - humans in a hospital are not the easiest of animals to kill.

We actually had a 50 year old morbidly obese type A dissection treated by one of my colleagues 3 weeks ago. She was treated expectantly initially without surgical repair. On day 5 of medical management she became paraplegic. She died some days later without surgery. 

Obviously both strategies (immediate surgical repair Vs delayed repair or medical therapy) have a casualty rate. The question which we need to answer is which results in a higher rate of survival - it is this that will determine how we will manage these cases in the future.

Ani

> Date: Sun, 12 Aug 2007 20:28:19 -0700> From: tacuff at swbell.net> Subject: Re: [HSF] Acute dissection - what now?> To: OpenHeart-L at lists.hsforum.com> CC: > > And I thought I was the only one looking for a side door when the room was obviously burning down around me. First do no harm. Second finish the operation with a live patient. > > tea> > > ----- Original Message ----> From: David Harris <drdharris at yahoo.co.uk>> To: OpenHeart-L at lists.hsforum.com> Sent: Sunday, August 12, 2007 4:05:02 PM> Subject: Re: [HSF] Acute dissection - what now?> > > 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> > >> >> > _______________________________________________> > >> > 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:> > > === 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> _______________________________________________> 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
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