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

Wed Nov 28 22:18:51 EST 2007

So - just dont do something, stand there....

Michael Firstenberg <msfirst at gmail.com>

-----Original Message-----
From: "Tea Acuff" <tacuff at swbell.net>
To: OpenHeart-L at lists.hsforum.com
Sent: 11/28/2007 9:55 PM
Subject: Re: [HSF] Ahh,	the Holiday Transfer.  Would anyone do anything different?

As per some of the other comments, he had a better chance with nothing. Your findings would point to that although it is a calculated quess preop.

tea

----- Original Message ----
From: Michael Firstenberg <msfirst at gmail.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Sunday, November 25, 2007 7:52:57 PM
Subject: Re: [HSF] Ahh, the Holiday Transfer. Would anyone do anything different?

The tear was at the SVG->PDA site going into the arch (as per CT) and  
down a little, but did not appear to involve the native ostium nor  
the valve - the AI appeared to be from being bicuspid/fused.

-michael

On Nov 25, 2007, at 8:44 PM, Tea Acuff wrote:

> What did you find on opening the aorta? Did the dissection go  
> proximal to the grafts? Was the dissection the cause of the AI or  
> was that just the biscupid valve?
>
> tea
>
>
> ----- Original Message ----
> From: Michael Firstenberg <msfirst at gmail.com>
> To: OpenHeart-L at lists.hsforum.com
> Sent: Sunday, November 25, 2007 6:58:39 PM
> Subject: Re: [HSF] Ahh, the Holiday Transfer. Would anyone do  
> anything different?
>
> he was a little wet - but not bleeding to death.
>
>
>
> -michael
>
>
>
>
> On Nov 25, 2007, at 7:48 PM, zzhoumd at pol.net wrote:
>
>>
>> Just wonder if Factor 7 may help.
>>
>> Sent via BlackBerry by AT&T
>>
>> -----Original Message-----
>> From: Michael Firstenberg <msfirst at gmail.com>
>>
>> Date: Sun, 25 Nov 2007 18:47:53
>> To:OpenHeart-L at lists.hsforum.com
>> 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
>>
>>
>>
>>
>>
>>
>>
>>
>>
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