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

Fri Nov 30 02:47:02 EST 2007

Ani;

See note to Tea. By the way, the Stage 2 Norwoods that I did?last year both look great! The girl from the Chernobyl Heart movie is engaged to be married, last week I recieved an letter with pictures from a Shone's Syndrome I did in Memphis in 1994, she was Ukrainian, still is actually, at any rate she sent pictures of her wedding (12 months ago) and her new baby girl! Shone's that was done in 1994 and now having babies, wonder how she is, I think that answers it. Also on the web page you can see the pictures of the wedding and the letter her grandmother wrote to me. 

Look I am not saying that we are succesful everywhere we go, we have our share of case failures and program failures, but I will say this, our successes are spectacular, and that is what drives us.

Bill

Yes. That Dr Novick was right doesn't mean the Chief was wrong. 

Maybe the Chief knows something we don't (e.g. about the healthcare provision or 
natural history after heart surgery in his country) and what might seem the best 
and successful therapy in one country might not necessarily be the same in 
another. What I would want to know is what is the likelihood that this 
particular 7 month old in his country would remain alive to see his 5th 10th 
15th and 20th birthday after this life saving operation?

Ani

> Date: Thu, 29 Nov 2007 18:24:15 -0800> From: tacuff at swbell.net> Subject: Re: 
[HSF] Ahh, the Holiday Transfer. Would anyone do anything different?> To: 
OpenHeart-L at lists.hsforum.com> CC: > > How about the possibility in this case 
that both the Chief and you were right with different recommendations!> > tea> > 
> ----- Original Message ----> From: "ichfno at aol.com" <ichfno at aol.com>> To: 
OpenHeart-L at lists.hsforum.com> Sent: Thursday, November 29, 2007 10:41:50 AM> 
Subject: Re: [HSF] Ahh, the Holiday Transfer. Would anyone do anything 
different?> > 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, Chie> f 
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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