[HSF] TR after CABG

[Tea Acuff]

I probaly should let Bill comment, but this was not persistent left SVC, but (solitary) left SVC. As you wondered this probably favors a congential lesion instead postulating a second etiologic condition, perhaps a form frust Epstiens.
Nice job with a "novel" problem. Are you credentialed for this procedure?

tea


----- Original Message ----
From: Donald Ross <donross at bigpond.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Tuesday, December 11, 2007 10:59:40 PM
Subject: Re: [HSF] TR after CABG

Thank you all for your help and advice.
Hal, The PVI was done this way because the case was an opcab with  
incidental AF and my limited experience with this method had been  
good. I used to use the cryocath but it is more  time consuming and  
not so reliable probably because of the continuous warming of the  
endothelium by normal PV blood flow. ( She is in SR now.)
Michael, I will watch for welding of the PV; it didn't occur in this  
case.

There was a recath in this case as soon as the troponin rose,  
combined with a CI of less than 1.0
It showed patency if ima and T-vein graft to PLCx but no flow to the  
small OM branch and I suspect  there may have been a small infarct  
despite normal EKG and LV ( max troponin 2.9 ?? how much troponin  
generated by PVI and LA appendage resection.)

At operation today I put a cannula into the IVC ( there was no SVC)  
opened the RA ( beating heart ) and put a second cannula into the  
coronary sinus ( #7 cuffed ET tube.. didn't need to blow up cuff )  
and got a lovely dry field.
The valve was probably congenitally abnormal with fusion of anterior  
and posterior leaflets. The other leafelts were a bit thickened but  
not rheumatic looking. There was obvious failure of coaptation.
The origin of the coronary sinus was 5cm from the valve with the RA  
extending over the septum a bit like an Epstein's  but definitely no  
atrialisation of the ventricle.

Our valve repair guru, Manu Mathur, helped me install a 28 mm  
tricuspid ring and I closed a  hole where the leaflets were fused..  
probably unnecessary and at the conclusion there was no TR.

My explanation:
Some congenital TV defect with barely coapting leaflets pushed over  
the hill by the high PA pressure after surgery +/- small infarct and  
not able to correct itself when all the pressures were back to normal.
PRE OP TEE







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