[HSF] Moderate Gradient Aortic Stenosis with patent LIMA,GEA

[erdinç naseri]

Hal,
my technique for the redo cases is as follows:
1.Left groin preparation of the femoralartery and vein( complete mobilization and encircling.( R groin for IABP)
2.Direct arterial cannulation with regular cannulae.Direct venous cannulation with carpentier's cannulae( without TEE,it goes directly to SVC on soft guidewire) and normothermic CPB( normal gravity dependent venous reservior)
3.Incision up to sternum.
4.Resternotomy with Lebsche knife from below to midsternum and from above by regular sternum saw( never have used oscillating saw)
5.Drop the temperature slowly( to prevent VF)
6.OPen both pleura and don't touch the adhesed epicardium.
7.Put retrograde cardiplegia cannulae through Ra wall ,if not possible then bicaval cannulation and change the venousinflow and put directly via R atriotomy.
8.Put L heart vent either through PA or if not possible transatrially to LA(technique described  a few days ago)
9.ısolate ascending aorta for clamping and antegrade cardioplegia.
10.Drop the temperature to the planned temp.
Erdinc> From: Hgrmd at aol.com> Date: Sat, 26 May 2007 11:29:25 -0400> Subject: Re: [HSF] Moderate Gradient Aortic Stenosis with patent LIMA,GEA> To: OpenHeart-L at lists.hsforum.com> CC: > > Tohru,> Unfortunately, I'm from the 3rd world country, Arkansas, and don't know > the "Katana" collection. However, would like to know. > Anyway, for this technique, the prerequisite is vacuum-assisted venous > drainage. First, I expose the anterior surface of the common femoral artery and > vein. Heparinize. Through 6-0 Prolene pursestrings, insert a 16 gauge > needle followed by a J-wire. In the artery, by TEE look for the J-wire in the > descending aorta. The wire should pass easily. If it doesn't, and you can't > see it on TEE, DO NOT PROCEED. Obviously, that's how iatrogenic dissections > can occur. Dilators are then passed over the wire. Finally, the aortic > cannula is passed over the wire. It's size ranges between 16-24 Fr, depending on > the size of the patient (the perfusionist tells me what size is optimal). The > venous cannula is an Edwards device designed by Carpentier. It has holes at > the end and about 20 cm proximally, so that blood is drained from the SVC > and IVC. When positioning the venous cannula, it is important to ask the > anesthesiologist to give you the bicaval view so that you can see the wire go up > the SVC. Otherwise, it can go into the RV or deadend into the RA appendage. > All of this takes less than 15 minutes. Next, open the sternotomy scar and > remove the wires. Next, go on CPB and maintain normothermia. You then > divide the sternum with an oscillating saw. Adhesions underneath the sternum are > divided with cautery. Next, place a small retractor and mobilize the left > innominate vein. Avoiding tension of its adhesions will prevent it was being > shredded as the sternotomy is progressively opened. Place the regular > retractor (I use a Cosgrove). Now is the fun part: dissecting out the collapsed > heart. Start at the diaphragmatic surface of the RV and then proceed up to > the RA and ascending aorta. This part of the case is a breeze with a collapsed > heart. No longer do you have to stop and repair a little divot in the right > atrium. Those can be addressed prior to coming off bypass. I then place an > aortic needle vent and retrograde cannula. Now, I let the temp drift for > short clamp times, or lower to 28 C for big cases. The clamp is then applied > and the case goes like any other case. In general the time between going on > bypass and applying the cross clamp is less than 30 minutes, and is often > around 20 minutes. > For those of you who say this is bad, since it adds to CPB time, and that > it's better to do redos the way you've been doing them the last 20 years, I > say try it once and draw your own conclusions.> Hal> > > > ************************************** See what's free at http://www.aol.com.> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L at lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by the OpenHeart-L are subject to the policies and > disclaimers posted at:> http://www.hsforum.com/listdisclaim> -----------------------------------------