[HSF] Ahh, the Holiday Transfer. Would anyone do anything different?

[Michael Firstenberg]

The wonders of holiday in the U.S. is that we (academic medical  
centers) seem to get all of transfers.
This was my case from yesterday and would be very interested in  
comments (besides shipping to a better surgeon......).

61 year/old, hypertensive, diabetic, severe abdominal obesity (BMI  
48, 300 lbs, around 5' 4')
presents to outside hospital with refractory chest/back pain,  
radiating to legs.
CT Angio - aortic dissection, just about the valve to the iliacs.
   head/visceral/renal/femorals off true lumen (but very small)
Surgery resident from outside hospital calls me for transfer (on  
cardizem drip for BP control, no beta-blockers, not working, should  
we heparinize...... discussion for another time!!!)
"oh, I forgot to mention, he had a CABGx4 in June of this year)

My response - esmolol and ship quickly
Upon arrival, still having pain, BP OK, neuro intact, faint femoral  
pulses, strong radials (no A-line)
Reviewed still with our local Cardiology CT expert (lucky he was in  
house)
- confirm dx
- all grafts patent, LIMA-LAD, SVG->PDA, SVG->Dx, SVG->Om
- 3 proximals coming off the ascending aorta
  - LIMA lateral to sternum

Taken emergently to OR
Axillary cannulation (nice artery)
Wire in right femoral vein (ugly groin, lots of fat, yeastly)
Intra-op TEE shows bicuspid aortic valve with mild/mod AI.
Open the chest (they missed midline on the CABG and went through a  
bunch of ribs on the right- close to the RIMA)
Got in OK
tons of mediastinal fat plastered to pericardium, plastered to  
epicardial fat.
NO, and I mean NO identifiable planes!
Finally found aorta after about an hr of digging - found old  
cannulation site
aorta looks ugly as I exposed.
Finally found SVG to PDA graft - completely plastered to small right  
atrium
cannulated right vein - went on, cooled
could not find "the heart/apex/etc) to vent - fortunately arrested  
without fibbing (LV didnt look too bad on TEE while cooling)
Cooled to 18C (didnt even look for the LIMA - way laterally and  
everything was a mess) -> kept feeding heart with cold blood
Finally got around aorta - circ arrest, opened up, trimmed to hemi- 
arch - contained rupture, tear at right vein graft site
found "something to sew to" distally in arch (30 min of circ arrest  
time)
went back on, started warming - blood coming from grafts, left main  
and right (all good, I assumed)
aortic valve - bicuspid ->fused, but leaflets normal -> separated  
left and non-cor leaflets and appeared to co-apt ok and hold water  
went closed
    (mobilzing for AVR would have been very difficult - at least for  
me!)
On/off circ arrest, low flow, etc to fix leaks, mobilize, visualize,  
etc....
Bioglue to proximal aorta layers and dissection plane.
Sewed proximal
root vent - cardiopledgia
Sewed on very scarred, friable SVG buttons (got the right mobilzed  
off the RA once empty and repaired/resected tear)

Took of x-clamp - slowly developed junction rhythm as warming more
came off pump eventually with lots of drugs, inhaled nitric
over an hour de-airing
TEE - still mild AI
  - felt addressing would be futile
  - 6 hours on pump.....30 min DHCA, 4 hr cross clamp (on and off)
Anesthesia up and down with tons of drugs/fluids/products/bicarb
big chest - wet lungs, hard to ventilate, very unstable, up/down  
acidosis......(thought making urine???)
Very coagulopathic (would have liked to have had Aprotinin) but used  
TA.....
Tons of products (INR>6, PTT unmeasurable, ACT after protamine>999,  
platelts=18), but not bleeding too bad
re-enforced graft site and potential space to co-seal, flow-seal,  
fibrilar, NuKnit, anything that I was allowed to leave in the chest
  (although no potential space - other than right pleural space - to  
bleed into)
Closed chest (modified weave and lots of wires through ribs)
meta-stable

went out to talk to family.......called back in....became brady  
cardiac as getting ready to move to bed....pulseless.....
chest open - heart dead.....open CPR....intra-cardiac epi/vaso...
TEE showed LV empty......(rupture into left chest?  abd?  something  
else?)

"the end"

Please comment as I know many of you have been there (either on-line  
or in private)..........


(fyi, this is the second post-CABG dissection we got this week - the  
first one was only a month out and the redo was much easier)

-michael