[HSF] bagged Cx

[Donald Ross]

I have seen severe Cx spasm after MVR relieved at cath with  
nitroglycerine.
Don
On 23/01/2007, at 11:48 AM, DukeB60 at aol.com wrote:

> 68 yo Caucasian female with severe AI,  severe MR and severe TR  
> with dilated
> annulae of each.  She was is AF  for years.  Cors were normal as  
> was the LVEF.
>  PAP elevated  but not bad.
>     At surgery, done last Thursday, she also  had a previously  
> unrecognized
> ascending aortic dilation at 4.2 cm. so I elected  to replace her  
> ascending
> aorta as well with a Hemashield graft.   Initially I attempted to  
> repair the
> aortic valve with the 28mm  Hemashield graft to reposition the ST  
> junction
> (annulus measured 25mm on  TEE) along with shortening of the non- 
> coronary cusp, which
> didn't coapt in the  center, but ultimately she still had 2+ AI so  
> I replaced
> the aortic valve  with a Magna pericardial.  The leaflets were  
> somewhat
> thickened and  sclerotic so a long term repair was probably  
> unlikely anyway so I
> had no  problem with that.
>     I put in a 28mm Physio ring in the Mitral to  completely  
> eliminate the MR
> and a 30mm MC3 ring in the Tricuspid to completely  eliminate the  
> TR even
> though she had a pacer lead for her VVI pacer. (confirmed  on post- 
> op echo in
> addition to intra-op TEE.  Also LV is normal  now)  I also did a  
> full Maze and
> came off pump with atrial contraction and  AV paced with bi-atral  
> epicardial
> wires as she had an AV nodal ablation years  ago with a VVI pacer  
> for her chronic
> AF.  She remains with atrial  capture of the epicardial pacer on  
> POD # 3.  At
> surgery I also over  sewed the LA appendage with a linear simple  
> double
> layer, as always.
>     My question is as to how I bagged the Cx. coronary  inasmuch as  
> when we
> tried to come off pump she had lots of VT/VF and severe  lateral  
> and inferior
> wall motion abnormalities on TEE which got better only  after a  
> vein graft to
> the OM and the PD of her very left dominant  system.
>     I implanted the mitral ring with non-pledgeted  horizontal  
> mattress
> sutures in the annulus and didn't think I took bites that  deep and  
> routinely close
> the LA appendage with the double layer simple suture  but with one  
> or the
> other must have gotten the Cx.  There was plenty of  room between  
> the appendage
> and the mitral ring so it wasn't at all technically  difficult.
>     I have heard of encircling the Cx. with  deep sutures around a  
> calcified
> mitral annulus but never with a very routine and  seemingly easy  
> mitral
> annuloplasy ring.  The other possibility is an  embolic etiology  
> but the annulus
> wasn't very calcified so I doubt that.
>     Any one have thoughts about bagging the  Cx. with seemingly  
> superficial
> sutures.  She is doing great now as  demonstrated on the post-op  
> TTE and
> hopefully EP will convert her  pacer to a DDD instead of the VVI  
> with the success of
> the Maze but I'm puzzled  as to the obvious Cx. occlusion and am  
> interested
> in others' thoughts.
>
>
>           Ed
>
> Edward P.  Raines, M.D., J.D.
> BryanLGH Cardiothoracic Surgery
> BryanLGH Medical Center  East
> 1600 South 48th Str.
> Lincoln, Nebraska 68506
> Office:  402-481-8430
> Cell: 402-730-9242
> Fax:  402-481-8429
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