[HSF] Cardiac arrest after redo CABG in a young patient

Tue Dec 4 20:19:54 EST 2007

I agree - once arrest is witnessed survival is possible after long periods of *effective* CPR - i have one such patient I reported few months ago after 45 minutes of CPR and he was discharged from hospital neurologically intact. My caveat though - and this is where I agree with prassanna - is that the prolonged CPR must include a period of internal CPR (and chest exploration to reverse precipitating causes) in any post op patient with unexpected arrest. Until proven otherwise the cause of the arrest has to be assumed to be a surgical mishap or complication so I believe efforts should be made to exclude such. If the arrest was witnessed then I would open on arrival unless there was overriding reason not to do so. I would not rely on TEE in this setting in particular as incredibly difficult to perform or interpret this study with chest compressions in progress.

I would still vote for a non-aggressive approach in a scenario where I arrive 30 minutes into a code as recovery then is extremely unlikely. The logistics of assembling an OR team mean that unless arrest occurs during working hours, the chances of operative salvage are very low. I do not think I would place any form of mechanical support in your patient as survival to become a transplant candidate is practically impossible. It would be extremely unusual to transplant someone with a dead heart (we have all tried to get them there with ECMO, BiVAD etc but multiorgan failure or brain injury usually wins) - i suspect this is partly because the heart rarely dies in isolation. Given the rarity of reoperative CABG these days I suspect this patient though young has advanced coronary disease with ischemic cardiomyopathy or poor distal vessels and may well have been best considered or transplant ab initio but certainly not at this point. 

ECMO does cost a lot of money though. At least in our institution the manpower costs of keeping ECMO running (24 bedside perfusionist) are considerable.

Ani

> To: OpenHeart-L at lists.hsforum.com> Subject: Re: [HSF] Cardiac arrest after redo CABG in a young patient> From: zzhoumd at pol.net> Date: Tue, 4 Dec 2007 19:22:02 +0000> CC: > > Ani,> > Clinically and by TEE, it did not look like tamponade. He is in sustained asystole and by pacer, the QRS is ugly. By the time I decide to take someone back, it is already 15-20 minutes. In a non working day, it usually takes 20-30 minutes to have someone come from home. Usually by the the time, the patient is probably brain dead. If I thought the tamponade is like, I would have opened him in ICU.> > The most important thing here is brain function even if you can get heart back. He has no other significant medical conditions.> > Will you quit after 30 minutes witness CPR in a 50 year old who is potential candidate for transplant even the heart is not recoverable. I see people woke up even with longer CPR. I have also seen people never woke up even with short arrest. > > Fem fem ECMO is inexpensive (about UDS 1000 for equipment). I think it is a good way to buy sometime for accessment of brain function. Without opening the chest, the bleeding is not problem.> > Z Zhou > > > > Sent via BlackBerry by AT&T> > -----Original Message-----> From: Ani Anyanwu <anianyanwu at hotmail.com>> > Date: Tue, 4 Dec 2007 17:45:45 > To:<openheart-l at lists.hsforum.com>> Subject: RE: [HSF] Cardiac arrest after redo CABG in a young patient> > > > No patient in cardiac surgery should die without having> inspected the heart (radical statement but may be life saving occasionaly)> Prasanna> > I had a mentor who trained in India who used to say the same thing so must be a dictum in the indian surgical school! After 30 minutes of external CPR would you still reopen? Effective CPR in a cardiac patient by this means for prolonged periods, without identification and treatment of a known cause (none identified in this case), is likely not recoverable (as seen here as patient should have woken up by now). Assuming one arrived 30 minutes into the 'code' then there may be a case for doing nothing. Certainly though, if I am to go the extent of ECMO (very unlikely), I would first open the chest to exclude tamponade (and also to see if there is anything I can do to achieve cardiac recovery post-ECMO.> > PS - hope to meet you in Leipzig later in the week.> > Ani> > > > > Date: Tue, 4 Dec 2007 07:11:41 +0100> From: prasannasimha at gmail.com> To: OpenHeart-L at lists.hsforum.com> Subject: Re: [HSF] Cardiac arrest after redo CABG in a young patient> CC: > > No investigation is fool proof including TEE for tamponade. I have seen> cases where the cardiologists swore that there was no collection but there> was alocal tamponade compressing a graft causing LCOS which was relieved by> On Dec 4, 2007 5:41 AM, <zzhoumd at pol.net> wrote:> > > To forum members,> >> > This weekend I was on call. One of my partners patients developed cardiac> > arrest. He is only 57 year old had redo CABGx5 4 days ago. Weight about> > 300LB. After 30 minutes CPR, he is still asystole. Considering his young> > age, I placed him on ECMO. I thought about BiVAD, but I just do not know if> > his brain will come back. Just wonder if anybody will do anything different.> > I did not reexplore him as TEE show no tampnade and he has no more conduit.> >> > Thanks!> >> > Z Zhou> > Sent via BlackBerry by AT&T> >_______________________________________________> > 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> > -----------------------------------------> >> > > > -- > Prasanna Simha M>_______________________________________________> 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> -----------------------------------------> _________________________________________________________________> Telly addicts unite!> http://www.searchgamesbox.com/tvtown.shtml_______________________________________________> 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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