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

Fri Nov 30 01:58:05 EST 2007

Totally agree

NFA

On Nov 29, 2007 8:24 PM, Tea Acuff <tacuff at swbell.net> wrote:

> 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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