[HSF] CABG/Mitral Repair

Tue Mar 13 09:42:21 EDT 2007

An interesting and consistent line of reasoning. Keep us abreast (which is near to my heart). We only  gain from those that think and do differently from ourselves.  (This assumes that much of what we can know we don't yet, otherwise why change anything?) As for me and my provocations one of my abiding interests is how do the tools that we have and our thinking about reality (heart surgery in this case) interact. I appreciate everyone's tolerance as i "teas" this into the open with my verbal stabs. 
Tea

----- Original Message ----
From: "Salerno, Tomas" <TSalerno at med.miami.edu>
To: OpenHeart-L at lists.hsforum.com
Sent: Tuesday, March 13, 2007 10:04:42 AM
Subject: RE: [HSF] CABG/Mitral Repair

Dear Tea:

Here is an opportunity for me to discuss some of the work we are doing
in this area which might be of interest to you and the readers.

Over the years, I have recognized that the heart lung machine, a devise
that was developed to substitute (and protect) the heart and the lung,
allows for perfusion (and some protection) of all organs of the body
with two exceptions:  the heart and the lung!

This has led me over the years to develop methods to perfuse the heart
(the beating heart valvular technique that evolved over years of
research in cardioplegia). More recently, I have become very interested
in cases such as the one that you described, ie, patients with severe
CHF and pulmonary compromise who develop florid edema and white out
after surgery. In critically ill patients, with long pump runs, the
lungs are the target organ and are underperfused by the bronchial
circulation, loss of pulsatile flow and sometimes, low flows.
Considering this,  for very high risk patients, I have been perfusing
the pulmonary artery via a sidebranch from the arterial cannula. One of
our transplant surgeons is also perfusing the lungs during heart
transplantation.  At the same time, in conjunction with Dr. Buffalo and
Edgar from Brazil, we are doing experimental studies in pigs comparing
perfusion versus no perfusion of lungs during CPB.

In summary, we need to avoid ischemia at all cost for all organs.
Ischemia reperfusion injury is a difficult and complex subject, whose
treatment may be best by preventing it all together, instead of treating
it after it occurs.

Tomas

-----Original Message-----
From: openheart-l-bounces at lists.hsforum.com
[mailto:openheart-l-bounces at lists.hsforum.com] On Behalf Of Tea Acuff
Sent: Tuesday, March 13, 2007 10:33 AM
To: OpenHeart-L at lists.hsforum.com
Subject: Re: [HSF] CABG/Mitral Repair

TRALI?
tea

----- Original Message ----
From: "jbflegejr at aol.com" <jbflegejr at aol.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Tuesday, March 13, 2007 7:06:05 AM
Subject: Re: [HSF] CABG/Mitral Repair

Could this be TRALI? John Flege

-----Original Message-----
From: ebender001 at charter.net
To: OpenHeart-L at hsforum.com
Sent: Mon, 12 Mar 2007 10:27 PM
Subject: [HSF] CABG/Mitral Repair

    Ten days ago a 52 year old obese diabetic female was admitted with 
unstable angina and class 3-4 heart failure. She had cardiac cath 
showing a 25% EF, and tight LAD and Circ stenoses. LV gram also showed 
severe MR. No right heart cath was performed. Echo showed severe MR 
with a dilated annulus and central regurg. There was no flail. Her 
creatinine went from 1.6 to 3.6 in three days, then came back down to 
1.3. She had been in pulmonary edema, and this resolved with diuretics. 
After waiting until her creatinine improved as above, this past Friday 
I did 2 vessel CABG and mitral annuloplasty with a 24 ETLogix ring and 
a couple of cleft closures. No post-op MR on TEE. In the OR her initial 
PA pressures were a little more than one-half systemic (systolic BP 
around 100). After the operation her PA pressures were 30-15 with a 
systemic BP of 120/70. Over the next 24 hours, she whited out both 
lungs, her PA pressures have once again become high, she has required 
very high doses of pressors. Any beta agonist drug causes horrific 
ventricular and supraventricular arrhythmias (even with ongoing 
cordarone and lidocaine). I have her on inocor, vasopressin, and 
levophed. A balloon pump was also placed. Repeat echo shows LVEF about 
40%, no MR, trace AI, and a dilated RV. Her CVP is 20-25. I dialed in 
Nitric oxide with some initial improvement in PA pressures, but not 
long-lasting. Short of VAD therapy, anybody have any other tricks? 

Ed Bender, MD 
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