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

[Ani Anyanwu]

Michael
 
Commiserations on a tough case - difficult when we have to go through the motions of putting so much energy and resource into saving a life when we know as we go along what the likely outcome would be. Since no one has asked I will ask what I see as the most obvious question here. Realistically do you actually think this patient had any hope of survival? I think (despite what may be said about the original surgeon) he did very well to survive his first operation, but 61 year old super morbidly obese with prior surgical sepsis survive a reop for a dissection in two months???? Actually when I started reading your narration i thought the question to us would be whether anyone would operate and was surprised when I got to the bit where you said you took him emergently to OR!
 
Two questions. First - did you consider not operating? Second - did you at any stage think realistically that your attempt to save this life would be successful and did that change at any point before the final event?
 
I ask these questions because from when i started reading till the end the story read more and more to me like a situation that was not survivable. Indeed I was surprised when you got to the bit of closing the chest as I thought that itself was a great feat, but still then I was convinced he would not survive ICU. I think some patients cannot survive the extensive surgery required to fix this problem and I have a feeling you were operating on one such patient and that his fate was predestined at his first procedure and there is nothing any doctor can do to alter that.
 
Ani
 
 



> To: OpenHeart-L at lists.hsforum.com> From: msfirst at gmail.com> Date: Sun, 25 Nov 2007 18:47:53 -0500> CC: > Subject: [HSF] Ahh, the Holiday Transfer. Would anyone do anything different?> > 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> > > > > > > > > > _______________________________________________> 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> -----------------------------------------
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