[HSF] type A dissection

[erdinç naseri]

Dear all,
First I have to correct one thing about the previous CABG of the patient.a 
sequential vein graft to LAD and D1 had been used for revascularization and 
not Lima.(LAD,D1;OM1;RCA).Perop Echo:Aortic insuffiency +++,EF 
35%,Anterolateral hypokinesia,İnferior akinesia
Yesterday we operated the patient in the following sequence:
1.Right axillary arterial cannulation through an 8 mm gortex graft
2.Right femoral venous cannulation by a two staged venous  cannulae
3.Put IABP  through L femoral artery.CPB and sternotomy uneventful
4.Release the adhesions( rocky hard) and left atrial vent placement
5.Isolation of the arch vessels and distal ascending aorta for X clamp
6.Cooling to 25 degree and X clamp
7.Aortotomy: dissection involving left coronary ostium and not further and R 
and non coronasry cusps proximally and up to the origin of L subclavian 
artery distally.
8.Direct antegrade  blood cardiplegia to L ostium and the ostia of all 3 
venous graft which were open and free of dissection.(R coronary ostium 
occluded)
9.L coronary ostium less than 1 cm from annulus.Vein graft to ostium of L 
coronary.start continous cardioplegia through vein and the other ostia.
10.Valved conduit replacement of the aortic root(29 mm valve)
11.TCA and ACP through R axillary artery(R radial pressure above 55 mm)  and 
L Carotid
12.Open distal hemiarch replacment in 12 minutes
13.Resume CPB and put X clamp on the graft and start rewarming and stop  
antegrde cardioplegia
14.Vein graft and aortic buttons to the graft by adding vein grafts except 
the RCA one which was suitable for direct anastomsis.,
15.Deairing and remove X clamp at 29 degrees.(X clamp time 73 minutes)
16.Unable to wean .Start ADrenaline and dopamine and low dose NTG.IABP 1/1
17.150 minutes of trying to wean.Unsuccessful.Sad outcome.
Thanks for input
Erdinc Naseri