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

Sun Nov 25 19:10:07 EST 2007

One more question, Mike.  When you said you "kept feeding the heart  
cold blood," how did you do that?  Did you put multi-perfusion  
catheter limbs down the vein grafts and coronary ostia, did you put a  
retrograde catheter in the coronary sinus, or both?  Once, when faced  
with such a horrible case, I circ arrested, then opened the right  
atrium and directly cannulated the coronary sinus inside a pursestring  
stitch.  I think this gave better protection than relying on systemic  
hypothermia and topical cold.

Ed Bender, MD

On Nov 25, 2007, at 6:51 PM, Michael Firstenberg wrote:

> Could not get ahold of the surgeon (who I know and see every once in  
> a while).  Got called from a 2nd year GenSurg resident from the  
> hospital he was admitted to (not the one where he had his  
> surgery)....... she knew NOTHING about the management of aortic  
> dissection - had him on cardizem, no betablockers, she was going to  
> heparinize him (not sure why???), and didnt think his prior CABG was  
> an issue.   Thank you ACGME 80 hour work week.
>
>
> -michael
>
>
> On Nov 25, 2007, at 7:34 PM, Edward Bender wrote:
>
>> Its not just the academic centers.  Even our lowly community  
>> hospital gets transfers from other community hospitals (surgeon and/ 
>> or cardiologist is out of town or its after 5pm or its a weekend).   
>> Luckily, a case like that is pretty rare for us.  Unfortunately,  
>> when you said the patient had had a recent CABG, I thought the  
>> etiology was either a graft proximal, a clamp injury, or the aortic  
>> cannulation site.  Did you try shaming the surgeon of record into  
>> re-thinking the transfer?
>>
>> Ed Bender, MD
>>
>>
>> On Nov 25, 2007, at 5:47 PM, Michael Firstenberg wrote:
>>
>>> 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
>>>
>>>
>>>
>>>
>>>
>>>
>>>
>>>
>>>
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