[HSF] Type I Aortic Dissection (or what I did this weekend)

[Tea Acuff]

Like I said, what we do amazes me. Some times, perhaps most times, we have no choice, but I am not resigned to that fate.
Sorry, Ed.
tea


----- Original Message ----
From: Edward Bender <ebender001 at charter.net>
To: OpenHeart-L <OpenHeart-L at hsforum.com>
Sent: Sunday, February 11, 2007 3:23:48 PM
Subject: [HSF] Type I Aortic Dissection (or what I did this weekend)


Here is followup on the patient I presented with previous AVR and now  
large root and aortic dissection, treated with freestyle root and  
dacron hemi-arch.  Three hours post-op, with no bleeding, woke  
suddenly, BP to 200/120, huge amount of subsequent drainage requiring  
emergent exploration.  The back of the xenograft to dacron  
anastamosis bled requiring an initial attempt at sututring off pump,  
but quickly degenerated into emergent need for cardiopulmonary  
bypass.  Repaired all bleeding areas, massive swelling, horrible  
coagulopathy (INR 5, PTT > 300, platelets 47,000).  Took back two  
more times for bleeding and tamponade.  Last night I just packed the  
area of indiscernible blood loss (posterior somewhere), with a  
hemostatic burrito (surgicel is the tortilla and avitene is the  
filling), followed by vaginal pack.  Poured the blood, factors, etc,  
and took him back this afternoon with pack removal and no bleeding.   
Good hemodynamics, but poor O2 sats and swollen like a 3 day old  
major burn patient.

The problem I have with posterior bleeding is that, often times there  
is trivial dripping of blood, but when I pull on the graft to to  
fully inspect the anastamosis (especially in the obese patient with  
cardiomegaly), it causes more bleeding and/or tearing.  Did my  
maneuvers cause the bleeding to worsen or was it there to begin  
with.  Kind of a cardiac surgery uncertainty principle (with  
apologies to Heisenberg).

Ed Bender, MD



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