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

Thu Nov 29 11:41:50 EST 2007

Okay, here is my do nothing story for the day. In a former Soviet Union Country at present, presented a child who is 7 months old, 5 KGS, had coarctation repair as newborn, at which time they did not address his MS, but did send to cath lab to balloon his stenotic aortic valve. No gradient after coarc, 60 gradient by echo after balloon, down from 90 gradient measured in lab, left him with 1-2 plus AI. So, now seven months later, has 22 mmHg peak mitral gradient and 1 plus MR, with single pap muscle by echo, 2-3 plus AI and 60 mmHG LVOTO gradient with subvalve 7mm. Massively dialated LA, LV dialated as well, cachectic, can see every rib, breathing 45 times/minute. Chief at the Institution returns from Moscow, tells mother child should go home to die, operation is not possible, even though we have scheduled child for an operation. Mother says, I cannot do nothing, I must do everything possible for my only child. Mother refuses advice of Chief, child goes to operating room, Chief makes entire surgical team sign note stating that we know he has advised against surgery that is doomed to failure. We all sign!

Child is in ICU, 0.08 epi, 0.75 milrinone, sternum closed, cvp 12, BP 95/68. Did Ross-Konno, spilt single pap muscle and opened both commissures, no LVOTO gradient, Mitral down to 4 mmHg, mild MR, no AI, no residual VSD, sometimes you just can't do nothing!

WNovick MD

If you reflect on your story, sometimes nothing is the hardest thing to do. 
It does have the advantage, however, that one is able to reverse the choice with 
better information or a change in the situation to change your odds...possibly 
including the arrival of a "better" surgeon or better plan. 
tea 

----- Original Message ----
From: Michael Firstenberg <msfirst at gmail.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Wednesday, November 28, 2007 9:18:51 PM
Subject: RE: [HSF] Ahh, the Holiday Transfer. Would anyone do anything 
different?

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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