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

[Donald Ross]

Michael.
"Stuff happens", to quote one of yours.
Like his stuff, it doesn't necessarily have to happen.
This large yeasty bloke sounds like the one on whom I did cabg X4  
last week, however, as it was done "anaortic" he will not suffer a  
dissection from an aortic intervention.
I apologise for sounding pompous and  commiserate with your terrible  
predicament.
You and your team battle for hours, all the time  with  a gnawing   
knowledge in back of the mind, that your efforts will be futile.
Don

On 26/11/2007, at 10:47 AM, 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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