[HSF] severe AS

[erdinç naseri]

Dear members,
opinion is requested regarding the following case:
73 Y/O male with chest pain.
CAG:RCA 40% stenotic ,otherwise normal
TTE:severe AS( 0.7 cmm2,Max gradient 108,LVPWd 20mm),MR mild,PAP 40 
Taken to the operation yesterday .Cannulated by a junior colleague of mine but couldn't put retrograde cardio cannulae. When I attended he was 30 degrees and in VF.Defibrilation attempted  several times but useless.Immediate cross clamping and aortotomy with antegrade tepid blood cardioplegia arrest.Arrested immediately and continued to 28 degrees.Tried to put retro transatrialy but unsuccessful . attempted external application of retrograde  to coronary sinus but no way.Aortic valve rocky hard .It took 20 minutes  for complete excision and decalcification. (Ventriculoaortic continuity geopardized around all commisures).24 mm annular diameter by sizer.Direct cannulation of the coronary ostia and antegrade  continous hyperkalemic cold blood.LMCA was around 3 mm in diameter.İmplanted a Sorin Soprano( supra annular) 22 mm with pledgeted sutures( on the ventricular side) in anatomic position( horns in the commissures).Aortotomy closed by  interposition of 2 cm wide graft in between to reduce the tension on suture line.X clamp 61 minutes. Declamp but no effective cardiac activity for 15 minutes.LV distended and VT unresponsive to defibrilation. Started  to sump the LA ( usually don't do it while declamped)..Lv distention continued .ASked for TEE ( done by cardiologists) but a technical problem happended in the probe  .Reclamped and gave one dose of hot shot.Declamped with cardiac silence for 5 minutes" a nd then the story began again.Reclamped and cooled to 26 degrees and opened aortotomy.Coronary ostia open  but LMC ostium just behind the sewing ring.Explanted the valve and put 19 mm Carbomedics with the same suture technic.Closure of aortotomy with  patch.Hot shot and declamped. Cardiac activity returned in 30 minutes and weaned from CPB  with minimal inotrope.
erdinc